Sir.—The recent report "Critical Malnutrition in Breast-fed Infants" (Journal 132:885-887, 1978) presented three cases of severe malnutrition in breast-fed infants. The authors implied that these cases represent primary inadequacy of lactation, while they have understated the more likely causes.
In case 1, the probable factor responsible for undernutrition was the initial four-hour feeding interval. Breast milk has a finer curd than formula and is absorbed faster, indicating that breast-fed babies should nurse at least every three hours for proper nutrition.1.2
In case 2, insufficient nutrition was probably due to the accumulative effects of the combination of oxycodone, aspirin, phenacetin, and caffeine (Percodan) in the breast milk, which caused sleepiness, lack of crying, and decreased vigor of nursing. A review of drugs in breast milk by one of us (L.W.) showed that there is no information on this drug in breast milk.3 However, this case would make us