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PEDIATRICS (ISSN 0031 4005). Copyright © 1981 by the

American Academy of Pediatrics.

PEDIATRICS Vol. 68 No. 3 September 1 981 435

AMERICAN ACADEMY OF PEDIATRICS

Committee on Nutrition

Nutrition and Lactation

Lactation is a continuation of intrauterine gesta-

tion. In both processes, maternal diet plays an

active role in the provision of nutrients, maternal

nutritional stores and endocrine adaptations serve

to buffer the short-term variations in maternal flu-

tritional intake, blood flow plays an overriding role

in nutrient transfer to the fetus and newborn infant,

and the nutrient demands of the recipient are the

highest of any stage in human development.

Human milk is remarkable in its variability. Re-

cent data suggest that the variability often improves

the nutrient composition as part of a complex adap-

tation to the infant’s specific needs. A comprehen-

sive survey of the literature on lactation and human

milk is provided in two review articles.” 2

NUTRIENTS

Lipids

Milk lipids provide the major fraction of calories

in human milk, yet they are the most variable

constituent.3 Preceding a nursing, the fluid phase of

milk stored within the gland resembles skimmed

milk. During the course of a nursing, the contraction

of smooth muscle launches the fat droplets. Thisdraught reflex is essential for caloric adequacy for

the breast-fed infant.2

Women living under unfavorable socioeconomic

conditions have reduced total milk lipid.46 There is

evidence that supplementing the diets of these

women leads to increased milk fat. Under controlled

metabolic ward conditions, a high-caloric, high-fat

diet can be demonstrated to increase milk fat pro-

duction.7 The distribution of the spectrum of fatty

acids in human milk also is responsive to dietary

changes.7’3

Women who are malnourished also produce an

excess of 12:0 and 14:0 fatty acids.’4 Women ingest-

ing a diet with a high content of polyunsaturated

fat have high levels of unsaturated fat in milk,

especially linoleic acid (18:2).�’� Breast-fed infants

of mothers on a vegetable oil diet have high plasma

levels of linoleic acid (18:2).813

Protein

Colostrum, the milk produced by women in the

first five days post partum, is richer in protein than

milk collected after 30 days of lactation.15’6 The

quantitative and qualitative changes are summa-

rized in Table 1. The “whey” proteins make up the

largest fraction of human milk proteins. By defmi-

tion, they are milk proteins that do not precipitate

in the stomach. Lactofemn and secretory IgA play

a role in the control of susceptibility to gastrointes-

tinal disease in the nursing infant.’ The caseins are

proteins that give milk its characteristic, white ap-

pearance. The micelles of casein coagulate under

the conditions found in the stomach and precipitate

as curds. The older literature indicates that 40% of

human milk protein precipitates under gastric con-

ditions.’5 Recent literature shows that many whey

proteins precipitate with “casein.” 16 The addition

of a skimmed milk supplement sufficient to increase

protein intake of an energy-adequate diet from 25

to 100 gm of protein per day increased milk yield

from severely malnourished women.’7 Total milk

protein concentration was unchanged. The increase

of dietary protein from 25 to 100 gm per day was

associated with increased infant weight gain which

became evident by the third or fourth day and was

sustained throughout a four-week study period.

This study confirmed the findings of previous in-

vestigators.18”9

Carbohydrate

Lactose is the dominant sugar in human milk.’

Synthesis of this sugar takes place at the wall of

the Golgi apparatus. This mechanism effectively

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436 NUTRITION AND LACTATION

traps carbohydrate in the Golgi spaces from which

lactose is released into the alveolar lumen. Although

the concentration of lactose is less variable than

that of other nutrients, the total production is re-

duced in malnourished mothers.’7

Water

Water is by mass and volume the major nutrient

in milk and comprises between 85% and 95% of the

total volume. The total milk volume varies with the

age of the infant and is related closely to maternal

lactose production.’ Folklore says an increased wa-

ter intake increases milk production, but several

investigations have shown that in fact, forcing fluid

intake above that required by normal thirst impairs

milk production.20’2’

Salt

The trapping of lactose within the Golgi spaces

creates an electrochemical difference that is respon-

sible for the transport of sodium and potassium into

milk. The salt concentration of colostrum is higher

than that of mature milk.2224 No relationship has

been demonstrated between maternal salt intake

and human milk sodium concentration.

Calcium and Phosphorus

Milk calcium and phosphorus have mean concen-

trations of 34 and 14 mg/100 ml, respectively.24

Balance studies indicate that the lactating woman

must receive 1.5 to 2 gm of calcium per day to

absorb the 0.3 to 0.5 gm/day secreted in her breast

milk.25 On usual levels of dietary intake, the mother

TABLE 1 . Protein in Human Milk

Fraction Colostrum(mg/mi)

Mature Milk(mg/mi)

Casein . . . 1.9Lactofemn 3.0 1.7a-Lactalbumin 2.2 1.6Secretory IgA 3.0 1.4Lysozyme 0.3 0.4Serum albumin 0.3 0.4

TABLE 2. Minerals in Human Milk

is losing about 250 mg/day more than she is ab-

sorbing.26’27 Older clinical literature documents

cases of osteomalacia and tetany in mothers who

nursed for long periods while on inadequate

diets.m� Clinical reports also document the occur-

rence of rickets in breast-fed infants.25”#{176}’3’ Measure-

ments of total calcium and phosphorus in the

milk of mothers with rachitic infants, however,

revealed no significant alterations in mineral com-

position.25”#{176}’3’ Studies of maternal intakes of dietary

calcium and phosphorus revealed no correlation

with milk concentrations (Table �

Iron

The normal infant at birth has a store of approx-

imately 75 mg of iron per kg.45 Theoretical calcula-

tions and practical experience indicate that this is

adequate to meet erythrocyte iron needs during the

first four to six months of 1ife.4�8 Breast milksupplies about 0.3 mg of iron per liter.36’49 At the

usual rate of intake, many authorities believe that

supplemental iron is essential during the second six

months of breast feeding.�”4�#{176} Supplementing the

diet with iron-fortified cereals during the second six

months of infancy may meet these iron needs.47

Other authors argue that 210 mg of an elemental

iron supplement should be given during the first

year of life to prevent iron deficiency.5’ The iron in

human milk is better absorbed than that from other

milks.�35’5155 Maternal iron stores do not influence

milk iron concentrations.�’47 Iron-deficient anemic

Indian and African women had no reduction in milk

iron, and iron supplements during lactation did not

increase milk iron.32’47

Zinc

Colostrum has a zinc concentration of 4.6 mg/

liter37; at 6 months of age, the concentration in

human milk falls to 0.9 mg/liter�; and, at 1 year of

age, average milk zinc is 0.45 mg/liter.� At 6 months

of age, breast-fed infants have serum and hair zinc

concentrations equivalent to those of adults. For-

mula-fed infants have lower serum and hair zinc

Mineral Concentration

ThroughoutFacilitated

BioavailabilityEffect of Maternal Mineral

Intake on Milk ContentLactation

Sodium Declines2224 Unknown None (unpublished)Calcium Unchanged24 Unknown None32IronZinc

Unchanged24Declines37’�

Facilitated�’35Facilitated39’40

None�’1’None36’�

CopperManganese

Unchanged37Declines�42

UnknownUnknown

None�’4’Yes36

Selenium Unknown Unknown UnknownIodine Declines43 Unknown Yes43Fluoride Unknown Unknown None�


AMERICAN ACADEMY OF PEDIATRICS 437

concentrations despite intakes up to 5.8 mg/liter

from cow’s milk formula.� This observation con-

firms earlier experiments that indicate zinc is better

absorbed from human milk than from cow’s milk.

This is because of a 50% better bioavailabiity of

zinc in human milk (Table 2).�#{176}Dietary investiga-

tions indicate that a majority of North American

women do not meet the 25 mg/day standard of

intake suggested by the Recommended Dietary Al-

37,� No difference in milk zinc concentra-

tions was detected when a group of women who had

intakes in excess of the Recommended Dietary Al-

lowances were compared with a group of women

whose diet provided one-half this amount.� No

relationship has been detected between maternal

serum, hair, and milk zinc concentrations.37�

Copper

When the infant is between 6 and 12 weeks of

age, human milk has an average copper concentra-

tion of 0.3 mg/liter.37’49 Milk copper concentration

averages 0.5 mg/liter during the first weeks of lac-

tation.� There is no decrease in concentration after

2 weeks of age.37 No relationship between maternal

dietary intake and milk copper concentration has

been observed.3�

Manganese

Human milk contains approximately 20 �tg/liter

of manganese.37 With the possible exception of an

elevated level at two weeks of lacthtion,�’42 the

concentrations of manganese are constant, even

after 1’/2 years of milk production. There is no

relationship between maternal diet and serum level,

hair concentration, or milk content of American

women. A relationship between diet and milk man-

ganese levels has been reported in Finnish women.36

Selenium

Selenium is of interest in infant nutrition because

of its role in the requirement for vitamin E. The

mean concentrations in human milk have been

reported to be 30 pg/liter in Germany,� and 20 �g/

liter in the United States.37 The selenium in human

milk was three times higher than that in commercial

infant formulas.�

Iodine

Human milk contains a total of about 100 �zg of

iodine per liter during mature milk production. The

use of iodized salt by the mother was associated

with levels of twice this concentration. Colostrum

has an iodine concentration of about 200 jzg/liter.43

There is a milk-to-plasma gradient for inorganic

iodine that is greater than i0.�

Breast-feeding for six months has been reported

to mitigate the impact of congenital cretinism on

physical and mental development.�#{176} This is ex-

plained largely by the transfer of thyroid hormones

in breast milk. The studies of the Montreal screen-

ing program for congenital hypothyroidism have

not confirmed that breast-feeding provided protec-

tion in 12 infants with thyroid insufficiency diag-

nosed and treated by 6 weeks of age.6’

Fluoride

The fluoride concentration of human milk col-

lected on the fourth and fifty days post partum

averages 50 gig/liter. This is one half the concentra-

tion found in whole cow’s milk.� When milk col-

lected from women living in a low fluoride area was

compared to milk from women in an area where the

drinking water was fluoridated, the mean concen-

trations did not differ significantly. Fluoridation of

drinking water is not associated with a major in-

crease in human milk fluoride concentrations.

Vitamin D

Fifty years ago, rickets was observed commonly

in breast-fed infants who were seen at public hos-

pitals in the United States.62 This continues to be

true among mothers who, because of social or reli-

gious practices, do not drink vitamin D-fortified

milk.63 A daily supplement of approximately 1,000

lU/day of vitamin D given to lactating mothers

prevents rickets in breast-fed infants. The effect is

in proportion to the total quantity of vitamin D

ingested by the lactating mother (Table 3)#{149}62

Early bioassays could not document nutritionally

adequate quantities ofvitamin D in human milk.71’72

Current advances in vitamin D chemistry have

revealed that cholecalciferol and 25-hydroxychole-

calciferol are in the lipid fraction of human milk. A

sulfated fraction also is present in the aqueous

phase.7�76 Japanese investigators report that water-

soluble vitamin D sulfate is as potent as the lipid-

soluble form in the prevention or healing of rickets

in rats.73 They further report that the total vitaminD potency in human milk was bioassayed to be 750

lU/liter, most of which was accounted for by the

sulfated form of the vitamin. This work requires

confirmation before new recommendations can be

made regarding vitamin D supplementation of the

breast-fed infant.

Vitamin K

Hemorrhagic disease of newborn infants is a dis-


TABLE

Vi-

tamin

In Malnour-

ished

Yes25”'2UnknownUnknown

Unknown

In WellNourished

UnknownNone””'5

Yes””””

Yes7#{176}


order associated with prolonged prothrombin times

and reduced blood prothrombin levels (Table 3). It

is prevented effectively by the administration of 100

;ig of vitamin K soon after delivery. The mother

does not provide for the vitamin K requirements of

the fetus or her nursing infant (Table 3).�”� Cow’s

milk formula contains vitamin K. Newborn infants

who receive a cow’s milk formula have a reduction

in prothrombin time (and therefore increased pro-

thrombin level) equivalent within 24 hours to that

observed in infants receiving vitamin K supplement.

The breast-fed infant or the infant who is fasted in

the perinatal period must rely on a vitamin K

supplement to restore the prolonged prothrombin

time observed at birth.77

Vitamin A

Colostrum is rich in vitamin A. Despite adequate

maternal vitamin A intake and serum concentra-

tion, the milk content of the vitamin decreases

during the course of lactation from 2,000 to 250 �ig/

liter�’78’79 The vitamin A concentration of colostrum

or milk can be increased about fourfold by acute

loading of the mother with excessive supplements

(Table 3) � The ratio of milk/serum concentra-

tion is approximately 0.6. The effect of increased

dietary vitamin A reflects the dependence of milk

concentrations ofalimentary intake. Efforts to build

up the liver reserves by prenatal supplementation,�

by a long-term supplement,�#{176} or by administration

3. Fat-Soluble Vitamins in Human Milk

Recogniz- Effect of Maternal Effect ofable Supplements Dietary

Clinical Intake onDeficiency Milk

Content

UnknownNone”65

Yes”9

Unknown

D Yes25”'2K Yes”’A UnknownE Unknown

of carotene”�’69 did not increase milk vitamin Aconcentrations.

Vitamin E

Vitamin E concentration is greatest in colostrum,

averaging 13.3 mg/liter,79 and it is approximately

equal to maternal plasma levels.8’ Concentrations

in milk decrease to half at two weeks post partum

and to one-fourth at one month post partum.79

Breast-fed infants have an increase in vitamin E

blood level from 3.8 to 14.6 mg/liter during the first

six days of life. Concentrations thereafter parallel

the maternal serum levels. Unless a supplement is

provided, formula-fed infants have a persistence of

low serum levels for at least six months.8’

Vitamin C

Higher concentrations of vitamin C exist in the

plasma and in leukocytes of cord blood than are

found in the mother. This is true even when mater-

nal blood levels are extremely low.82 Balance studies

carried out during lactation suggest that the mother

provides milk ascorbic acid at her own expense.�

The older literature claims that scurvy is rare in

breast-fed infants (Table 4).”' Seasonal fluctuations

in milk concentration reflect the availability of vi-

tamin C in the diet.�”’79’�” Milk concentrations reflect

the intake of ascorbic acid among subjects on a

reduced intake33’�’9’ The subjects respond to ad-

ministration of vitamin supplements in proportion

to the intake; milk levels increase from 24 to 61 mg/

liter when the supplement provided is 200 mg/day.�”

Thiamine (B1)

Infantile beriberi has been observed in breast-fed

infants when unfortified, machine-milled rice was

the main cereal in maternal diets. The addition of

thiamine provided dramatic relief to the infants.�

Milk thiamine concentrations from women on this

diet reveal a drastic reduction in vitamin content.”7

TABLE 4. Water-Soluble Vitamins in Human Milk

Vitamin Recognizable Effect of Maternal Effect ofClinical

Deficiency

Supplements Dietary Intake

on Milk

ContentIn Malnour- In Wellished Nourished

Ascorbic acid Rare�’ Yes�” No”� Yes””Thiamine Yes85 Yes�’ Yes””�” Yes87Riboflavin Unknown Yes�” Yes”�”'””'””'”#{176} Yes””9’Niacin Unknown Yes”� Yes�””'” Yes”’Pantothenic acid Unknown Yes33 No”� Yes9’Pyridoxine Unknown Yes33 Yes”’ UnknownBiotin Yes92 Yes� No”” UnknownFolate Unknown Yes� No* No”3”'’Cyanocobalamin Rare95 Yes�’ Yes”’ Yes”5

* M. R. Thomas, S. M. Sneed, C. Wei, et a!, unpublished data, 1981.



In normal women, milk thiamine is increased from

an average 20 pg/liter in colostrum to 140 �tg/liter

in mature milk.””’�’ Concentrations of milk from

poorly nourished women have shown the same in-

crease during lactation.89 In both well nourished �“‘�“

and poorly nourished mothers.� milk concentra-

tions respond to thiamine supplementation (Table

4)#{149}86��

Riboflavin (B2)

Riboflavin resembles thiamine in the relationship

between dietary intake and milk vitamin concentra-

tion. The concentration in colostrum is approxi-

mately 200 �tg/liter compared to 370 �tg/liter in

mature milk.”�97 The concentrations tend to fall to

lower levels with prolonged lactation.”9 The concen-

tration in milk reflects the average dietary

intake.””9’ The administration of riboflavin either

as a loading dose”” or as a continuing supplement”�’8”

results in the elevation of milk concentrations as

high as 2,000 �.tg/liter (Table 4).�”’�#{176}

Niacin

Milk niacin levels are reduced in colostrum to 750

�tg/liter and increase during the first two weeks of

lactation to three times this level. In mature milk

production, dietary niacin intake influences milk

concentration (Table 4),91 The bioavailabiity of

niacin can be reduced on a corn diet and will result

in reduced milk concentrations despite apparently

adequate maternal vitamin intake.”’� Supplemen-

tary intakes of the vitamin increase milk concentra-

tion acutely”7 and produce sustained effects.”�”'9

Milk contains sufficient tryptophan which is con-

vertible to niacin to protect the infant against niacin

deficiency.

Pantothenic Acid

Human milk pantothenic acid levels increase to

an average concentration of 2 to 3 mg/liter during

the first weeks of lactation.97 In poorly nourished

women with milk concentrations averaging 1 mg/

liter, supplementary vitamin intake has increased

milk content in proportion to the intake (Table

4)#{149}3391 In well nourished North American women

with basal levels of 3 mg/liter, no increase wasdetected after supplementations.”

Pyridoxine (B6)

Fetal pyridoxine levels, as reflected in cord blood,

are about three times the levels found in the ma-

ternal circulation. The pyridoxine level in colostrum

is equivalent to maternal blood levels; mature milklevels are 16 times maternal blood levels.””’� Milk

pyridoxine levels in poorly nourished populations

are lower than those observed in the United

States.33M Supplementary pyridoxine given to these

poorly nourished women resulted in a twofold in-

crease in milk concentrations, 80 to 160 jig/liter

(Table 4).� In North American women, supplemen-

tation with pyridoxine resulted in a statistically

significant increase in milk content from 204 to 237

jig/1iter.�

Biotin

The biotin content of human colostrum is low; it

increases from 1 to 8 jig/liter in mature milk.97

There appears to be a lower content of this vitamin

in the milk of poorly nourished women33 than in the

milk of most North American women.”' Supplemen-

tation of biotin in women with poor nutritional

status resulted in an increase from 1.5 to 5 jig/liter

(Table 4).�’ No effect was observed from supple-

mental biotin�’ in American women whose initial

levels averaged 8 jig/liter.

Folate

Folic acid levels are low in human colostrum, 0.5

jig/liter, and they increase in mature milk.97 Poorly

nourished women with low milk folate levels aver-

aging 2 jig/liter responded to a vitamin supplement

with a peak content at 5.6 jig/liter.33 In lactating

women who develop megaloblastic anemia, folic

acid is excreted preferentially in milk. This affords

protection of the infant hemoglobin concentration

in severe maternal anemia.93”’ In North American

women with milk folate concentrations of 50 jig/

liter, the administration of an oral “one-a-day” sup-

plement was not associated with increased milk

concentrations. (M. R. Thomas, S. M. Sneed, C.

Wei, et al, unpublished data, 1981).

Cyanocobalamin (B12)

Maternal levels ofvitamin B12 are reduced during

the last trimester of pregnancy, but fetal and cord

blood concentrations remain high. Administration

of labeled cyanocobalamin to the mother resulted

in transfer of the vitamin to the fetus. Stores of

maternal liver B,2 are not transferred across the

placenta.’#{176}#{176}Milk vitamin levels range from 50% to

90% of the maternal serum level. The high extrac-

tion occurred in vegetarian women who had lower

serum vitamin levels. Milk vitamin B,2 levels, how-

ever, were not lower than those in nonvegetarian

women control subjects.’#{176}’ When women from a

poorly nourished community received a vitamin B12

supplement, milk concentration increased only

from 0.8 to 1 jig/liter (Table 4).� When well nour-

ished women received a “one-a-day” supplement,


0 28 56 84 1128

7

I(9Li

4

3

EU

I��55(9zLi

50

0

Figure. Growth of normal breast-fed infants during first weeks of life. These infantsreceived some supplements of infant foods or formulas after 28 days of age. Charts providea standard for normal growth during first weeks of life when transition to mature milkproduction �

28 56 84 112 0 28 56 84 112

AGE (days) AGE (days)


milk concentration increased significantly from 0.6

to 1 jig/liter. No change in serum vitamin levels

could be detected in these normal women.�

FAILURE TO THRIVE

Growth is the most practical assessment of nutri-

tional adequacy in childhood. The percentile clas-

sification of lengths and weights of normal breast-

fed infants has been developed by a group of inves-

tigators from Iowa. The data from these measure-

ments on 178 normal, full-term infants are given in

the Figure. As with the more familiar charts, loss of

percentile channels is a cause for careful surveil-

‘#{176}‘

Failure to grow “normally” may be a transient

phenomenon associated with either infantile or ma-

ternal factors, some of which are poorly understood.

Severe failure to thrive in breast-fed infants is a

recognized clinical entity. Case reports indicate that

the infants usually are brought for treatment when

approximately 30 days old, and they have obvious

malnutrition. Weight at the time of examination

commonly is 20% lower than birth weight. The

infants are said to feed poorly but to appear satis-

fled. Chemical determinations commonly reveal a

reduction in total serum protein and elevated serum

urea nitrogen. The infants respond to supplemental

feedings or maternal support designed to augment

milk production, such as increased maternal caloric

intnke.’#{176}�’#{176}”One of the common characteristics of

these severely ill infants is a lack of pediatric su-

pervision between delivery and the time of the

examination. These case reports emphasize the

need for frequent contact between the mother andphysician during the period of transition to mature

milk production. The initial visit for health evalu-

ation should be two weeks after discharge, and at

appropriate intervals thereafter.

SUPPLEMENTATION

Maternal diet and nutritional status influence the

quantity and quality of human milk. Lactation also

has a profound influence on maternal nutrient phys-

iology. The unique biologic advantages of human

milk justify the promotion of lactation as the nor-

mal method of infant feeding. The variabifity of

milk quality and quantity justify an ongoing assess-

ment of the infant’s weight gain and state of hydra-

tion by the pediatrician as part of the promotion

and supervision of the extension of normal gesta-

tion.

The nutritional needs of the mother during lac-



tation have been summarized by the National Acad-

emy of Sciences in the Recommended Dieta�y Al-

lowances and are shown in Tables 5 and 6.’#{176}”An

increase in intake is recommended for lactating

women to meet the needs for milk production and

protect against deficiencies in maternal nutrients.

When related to caloric intake, the increased re-

quirement is not uniform. A woman at nutritional

risk probably could not meet these recommended

intakes by increasing her usual diet. The milk of

women at nutritional risk may have low nutrient

composition; a vitamin supplement can be demon-

stated to improve the quality of their milk. In North

American women consuming a contemporary diet,

milk composition varies; but low nutrient values are

rare and the administration of vitamin supplements

is probably unnecessary. A deviation from a normal

dietary pattern should lead to a reassessment of

nutrient needs and dietary counseling, and/or a

prescription of multivitamin-multimineral supple-

ments adequate for the special circumstances.

The breast-fed infant requires a vitamin K sup-

plement during the newborn period. There also are

arguments in favor of providing vitamin D and

fluoride as supplements during the first six months

of life; disagreement, however, remains about

whether these nutrients must be provided to all

breast-fed infants. During the latter half of the first

year of life, iron (either in a supplement or in

fortified infant cereals) should be recommended.

Supplementary calories in the form of infant foods

TABLE 5. Daily Requ irements of Lactating Women*

Nutrient Recommended Allowance

Energy +500 kcalProtein +20 gmCalcium +400 mgPhosphorus +400 mgMagnesium +150 mgIron +30-60 mgZinc +10 mgIodine +50 �g

* Calculated from Recommended Daily Allowances.’#{176}”

TABLE 6. Daily Requirements of Lactating Women*

Nutrient Recommended Allowance

Vitamin A +400.0 � REVitamin D +5.0 �gVitamin B +3.0 mg TEVitamin C +40.0 mgThiamin +0.5 mgRiboflavin +0.5 mgNiacin +5.0 mg NEVitamin B6 +0.5 mgFolacin +100.0 jigVitaminB,2 +1.0 jig

* Calculated from Recommended Daily Allowances.’#{176}”

Abbreviations used are: RE, retinol equivalents; TE, to-copherol equivalents; NE, niacin equivalents.

and infant formulas should be started when weight

gain and other findings indicate that the milk sup-

ply is not adequate to meet the needs of continuing

rapid growth.

REFERENCES

COMMIrFEE ON NUTRITION

Lewis A. Barness, MD, Chairman

Peter R. Daliman, MD, Vice-Chairman

Homer Anderson, MD

Platon Jack Collipp, MD

Buford L. Nichols, Jr, MD

W. Allan Walker, MD

Calvin W. Woodruff, MD

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1981;68;435Pediatrics Nichols, Jr, W. Allan Walker and Calvin W. Woodruff

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