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DOI: 10.1542/peds.2009-1906
; originally published online March 15, 2010; 2010;125;e973Pediatrics
Sangita Basnet, Michael Schneider, Avihu Gazit, Gurpreet Mander and Allan Doctor
A Review−−Fresh Goat's Milk for Infants: Myths and Realities
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Fresh Goat’s Milk for Infants: Myths and Realities—A
Review
abstract
Many infants are exclusively fed unmodified goat’s milk as a result of
cultural beliefs as well as exposure to false online information. Anec-
dotal reports have described a host of morbidities associated with that
practice, including severe electrolyte abnormalities, metabolic acido-
sis, megaloblastic anemia, allergic reactions including life-threatening
anaphylactic shock, hemolytic uremic syndrome, and infections. We
describe here an infant who was fed raw goat’s milk and sustained
intracranial infarctions in the setting of severe azotemia and hyper-
natremia, and we provide a comprehensive review of the conse-
quences associated with this dangerous practice. Pediatrics 2010;125:
e973–e977
AUTHORS: Sangita Basnet, MD, FAAP,
a
Michael Schneider,
MD,
a
Avihu Gazit, MD,
b
Gurpreet Mander, MD, FAAP,
a
and
Allan Doctor, MD
b
a
Department of Pediatrics, Southern Illinois University School of
Medicine, Springfield, Illinois; and
b
Department of Pediatrics,
Washington University School of Medicine, St Louis, Missouri
KEY WORDS
goat’s milk, infant feeding, hypernatremia
ABBREVIATION
G-tube— gastrostomy tube
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1906
doi:10.1542/peds.2009-1906
Accepted for publication Dec 15, 2009
Address correspondence to Sangita Basnet, MD, FAAP, Southern
Illinois University School of Medicine, Department of Pediatrics,
Division of Pediatric Critical Care, PO Box 19676, Springfield, IL
62794-9676. E-mail: sbasnet@siumed.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
CASE REPORTS
PEDIATRICS Volume 125, Number 4, April 2010 e973
at Siu School Of Medicine on May 24, 2012pediatrics.aappublications.orgDownloaded from
The developed world does not lack nu-
tritious food; nevertheless, infants
may still suffer from inadequate and
inappropriate nutrition because of pa-
rental and cultural beliefs. Further-
more, easy access to the Internet ex-
poses women to false information in
regards to alternative foods for their
infants, such as raw goat’s milk, that
may cause severe morbidity and even
death. We describe here the case of an
infant with severe electrolyte imbal-
ance, renal dysfunction, and stroke as
a result of being fed goat’s milk.
CASE REPORT
A 5-month-old white boy with CHARGE
(coloboma, heart defect, atresia choa-
nae, retarded growth and develop-
ment, genital hypoplasia, ear anoma-
lies/deafness) association from an
Amish family was admitted to the PICU
from an outside emergency depart-
ment after presenting with respiratory
failure that required endotracheal
tube placement and mechanical venti-
lation. He had a 1-day history of in-
creased work of breathing and de-
pressed level of consciousness that
was preceded by a 4-day history of di-
arrhea. His past medical history was
significant for tracheoesophageal fis-
tula repair with gastrostomy tube (G-
tube) placement, multiple esophageal
dilatations, and repair of choanal atre-
sia. He also had a history of atrial and
ventricular septal defects. In the neo-
natal period, because of parental con-
sanguinity, testing for plasma amino
acids and urine organic acids and the
state-expanded tandem mass spec-
troscopy screen were performed; no
abnormalities were found. There had
been no previous episodes of acidosis
or hypernatremia.
The infant’s respiratory distress
seemed principally to be the result of
severe metabolic acidosis with respi-
ratory compensation. A comprehen-
sive metabolic panel revealed aci-
demia, severe hypernatremia, and
azotemia, with significant hyperosmo-
larity. He had hyperchloremia, hyper-
phosphatemia, hyperuricemia, and an
elevated creatinine kinase level. Re-
sults of lactic acid and liver function
tests were within normal limits. Urinal-
ysis was significant for proteinuria, he-
maturia, and glucosuria. A complete
blood count showed leukocytosis with
left shift but was otherwise unremark-
able. Abnormal initial serum labora-
tory values are shown in Table 1.
On arrival to the PICU, the infant was
pharmacologically sedated and on me-
chanical ventilation with a hemody-
namic profile that was normal for his
age. His respiratory rate was in the 80
breaths per minute range. His capil-
lary refill time was prolonged. Results
of his chest radiograph were normal
except for minimal right perihilar infil-
trates. An echocardiogram on admis-
sion revealed normal segmental anat-
omy and left ventricular systolic
function, a small patent foramen ovale,
and tiny atrial and ventricular septal
defects.
Nutritional history revealed that the in-
fant was initially fed breast milk
through a G-tube. However, for 3 to 4
weeks before admission, he had been
exclusively fed raw goat’s milk be-
cause his mother was unable to pump
sufficient volume.
The infant’s hypernatremia and dehy-
dration were corrected slowly over 96
hours to reduce the risk of cerebral
edema and central pontine or extra-
pontine myelinolysis, which can occur
rarely.1–3 He required substantial
amounts of intravenous bicarbonate
to correct the metabolic acidosis, with
his serum level normalizing after 4
days of replacement. He also required
intravenous boluses and intermittent
supplementation of calcium, magne-
sium, potassium, and albumin. He was
started on low-sodium, low-protein
formula through his G-tube on the sec-
ond hospital day. His serum amino ac-
ids, urine organic acids, carnitine pro-
file, ammonia levels, and lactate level
were not diagnostic of an inborn error
of intermediary metabolism; the acido-
sis quickly corrected and has not
recurred.
Renal ultrasound showed normal ar-
chitecture and anatomy and demon-
strated a normal Doppler flow signal in
the renal veins. A renal duplex scan
showed no evidence of renal artery oc-
clusive disease and normal intrarenal
vascular perfusion. The ongoing losses
of electrolytes and bicarbonate were
attributed to acute tubular necrosis.
The infant’s serum urea nitrogen and
creatinine slowly normalized.
MRI of his brain showed acute and sub-
acute infarcts within the left posterior
cerebral artery territory and right
temporo-occipital periventricular white
matter and chronic infarctions involv-
ing bilateral occipital lobes (Fig 1).
There was no history of seizures or
neurologic deficits, and there was no
seizure activity noted during hospital-
ization. A hypercoagulability workup,
including protein C, protein S, and an-
tithrombin levels, was normal. The
TABLE 1 Initial Serum Laboratory Values at
Presentation
Blood Test Result Reference
Range
pH (arterial) 6.90 7.35–7.45
PCO
2
, mm Hg 13 35–45
HCO
3
, mmol/L 3 18–23
Sodium, mmol/L 176 135–147
Chloride, mmol/L 154 96–107
Anion gap 18 4–16
Measured osmolarity,
mOsm/kg
384 262–286
Serum urea nitrogen,
mg/dL
112 10–25
Creatinine, mg/dL 2.1 0.7–1.3
Calcium, mg/dL 7.2 9–11
Ionized calcium,
mmol/L
1.35 1.10–1.30
Glucose, mg/dL 132 70–109
Uric acid, mg/dL 13.5 3.4–7.4
Creatinine kinase, U/L 1000 0–200
Phosphorus, mg/dL 9.6 3.5–6.7
e974 BASNET et al at Siu School Of Medicine on May 24, 2012pediatrics.aappublications.orgDownloaded from
strokes were attributed, therefore, to
severe hypernatremic dehydration.
The infant had severe respiratory dis-
tress on extubation, was diagnosed
with having severe tracheomalacia,
and underwent tracheostomy. Cardiac
angiography demonstrated a vascular
ring that was subsequently repaired.
The infant was discharged from the
hospital with a tracheostomy and me-
chanical ventilatory assistance. How-
ever, he is gaining weight on regular
infant formula, and his electrolyte lev-
els have normalized without the need
for supplementation.
DISCUSSION
The first case in the literature to report
concerns with goat’s milk feeding in
infants described a 7-month-old boy
who had been fed for 6 months on
goat’s milk, weighed only 4 lb, and was
thought to have died of malnutrition
because “goat’s milk is lighter than
skimmed milk.”4The author ridiculed
the physician who made the diagnosis
saying that after cow’s milk, “goat’s
milk closely approximates to that of a
woman.”
As a result of information technology,
it is very easy for parents to read and
be influenced by false and potentially
dangerous information. A Google
search of the terms “goat’s milk” and
“infant” and “benefits” yielded 9490
hits; these pages provide information
such as “[g]oat’s milk is the ideal food
for babies....Beneficial for the treat-
ment of asthma, eczema, migraines,
stomach ulcers, liver complaints and
chronic catarrh, goat’s milk also helps
babies with colic, habitual vomiting
and those not gaining weight.”5This
same site suggests that the first few
feeds be given at half strength, in-
creased to two thirds, then three quar-
ters, reaching full strength in 2 to 3
days’ time mixed with honey (another
concerning recommendation).
The infant in this report presented
with severe hypernatremia and
azotemia in addition to other electro-
lyte abnormalities. Goat’s milk con-
tains 50 mg of sodium and 3.56 g of
protein per 100 mL, approximately 3
times that in human milk (17 mg and
1.03 g per 100 mL, respectively).6The
estimated requirements of sodium
and protein for infants ⬍6 months old
are 100 to 200 mg/day and 9 to 11
g/day, respectively.7The infant de-
scribed here was receiving ⬃500 mg/
day of sodium and 30 g/day of protein,
with a total intake of 32 oz of goat’s
milk per day. The immature kidneys in
very young infants have difficulty han-
dling the byproducts of foods with a
high renal solute load.8Sodium excre-
tion capacity matures more slowly
than glomerular filtration rate and
does not attain full capacity until the
second year of life.9Therefore, infants
fed fresh goat’s milk are at substantive
risk for hypernatremia and azotemia,
particularly in the face of dehydration
(as in the case described here), which
may in turn result in major central ner-
vous system pathology, including dif-
fuse encephalopathy, intraparenchy-
mal hemorrhage, or thromboses10 as
manifested in our patient.
Metabolic acidosis has been described
in infants fed undiluted goat’s milk.11–13
Our patient presented with severe
metabolic acidosis with increased an-
ion gap, which seemed out of propor-
tion to the dehydration and hyperchlor-
emia alone. The high protein content of
goat’s milk may have contributed to
this problem. Excessive protein load-
ing may result in accumulation of non-
volatile acids and urea,14,15 and it has
been shown that the incidence of met-
abolic acidosis increases with in-
crease in dietary protein intake.16
The main benefit claimed by propo-
nents of fresh goat’s milk for infants is
that it is less allergenic than cow’s
milk and is a suitable substitute for in-
fants who are allergic to the latter.
However, evidence shows that most in-
fants who are allergic to cow’s milk
are also allergic to goat’s milk. In vitro
studies have shown that there is an
extensive cross-reactivity of sera from
individuals who are allergic to cow’s
milk with proteins found in goat’s
milk.17–19 In 1 study, 26 children with
immunoglobulin E–mediated cow’s
milk allergy also had positive skin test
responses to goat’s milk, and 24 of 26
had positive double-blind, placebo-
FIGURE 1
Acute stroke: restricted diffusion (bright-white signal) of the left occipital lobe (A) and the white
matter along the occipital horn of the right lateral ventricle (B).
CASE REPORTS
PEDIATRICS Volume 125, Number 4, April 2010 e975
at Siu School Of Medicine on May 24, 2012pediatrics.aappublications.orgDownloaded from
controlled, oral food challenges with
fresh goat’s milk.20 There have been
case reports of severe life-threatening
anaphylactic reactions after the inges-
tion of commercial goat’s milk prepa-
ration in infants with documented
cow’s milk protein allergy.21 Further-
more, infants and young children may
have signs, symptoms, and serology
positive for goat’s milk without being
allergic to cow’s milk.22–25 In a retro-
spective study, children presented
with severe allergic reactions, includ-
ing anaphylaxis, after consumption of
goat’s milk products but tolerated
cow’s milk products.26
Folate deficiency with anemia in in-
fants fed homemade formula based on
goat’s milk has been described.27,28 In
fact, “goat’s milk anemia” was the
name given to the macrocytic hyper-
chromic megaloblastic anemia ob-
served in infants fed goat’s milk in Eu-
rope during the 1920s and 1930s.29 The
anemia was thought to be more severe
than that associated with exclusive
cow’s milk feeding and was cured by
giving supplements of liver extracts.
The concentration of folate in goat’s
milk is 6
g/L in comparison to human
breast milk, which contains 50
g/L.30
Infants younger than 6 months of age
need 65
g/day of folate, and the rec-
ommended daily allowance increases
with age.30
There have been reports of infections
such as Q fever, toxoplasmosis, and
brucellosis associated with feeding
raw goat’s milk.31–33 Consumption of un-
pasteurized goat’s milk has also been
implicated in the development of Esch-
erichia coli O157:H7–associated hemo-
lytic uremic syndrome.34,35 Although
raw goat’s milk is a proven vehicle for
pathogen transmission, the belief per-
sists that raw dairy products are
healthier and that pasteurized prod-
ucts are less beneficial and even
harmful.5
Although infants should not be fed un-
modified, raw goat’s milk, goat’s milk
infant formula may be a suitable alter-
native to cow’s milk formula. A study
performed in New Zealand showed
that there was no difference in weight
gain between healthy neonates fed ei-
ther formulas.36 Sixty-two infants were
randomly assigned to either goat’s
milk formula or cow’s milk formula
from within 72 hours of birth until
168 days of age. There was no statisti-
cally significant difference in average
weight gain in the goat’s milk formula
group versus the cow’s milk formula
group (309 g [95% confidence interval:
⫺49 to 668]). Furthermore, although
infants fed goat’s milk formula had
higher bowel motion frequency (2.4 vs
1.7 bowel motions per day), both for-
mulas resulted in similar bowel mo-
tion consistency and periods of crying
and were deemed safe and well toler-
ated. However, the authors cautioned
feeding it to infants with documented
allergy to cow’s milk infant formula.
CONCLUSIONS
An exclusive, unmodified goat’s milk
diet can cause significant morbidity
and even mortality in infants, including
electrolyte imbalances, metabolic aci-
dosis, folate deficiency, and species-
specific and nonspecific antigenicity.
Unpasteurized goat milk has its ad-
ditional infectious risks. However,
information supporting this practice
abounds on the Internet and in specific
cultures. Our case report and literature
review support the need to strongly ad-
vocate against this practice.
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CASE REPORTS
PEDIATRICS Volume 125, Number 4, April 2010 e977
at Siu School Of Medicine on May 24, 2012pediatrics.aappublications.orgDownloaded from
DOI: 10.1542/peds.2009-1906
; originally published online March 15, 2010; 2010;125;e973Pediatrics
Sangita Basnet, Michael Schneider, Avihu Gazit, Gurpreet Mander and Allan Doctor
A Review−−Fresh Goat's Milk for Infants: Myths and Realities
Services
Updated Information &
tml
http://pediatrics.aappublications.org/content/125/4/e973.full.h
including high resolution figures, can be found at:
References
tml#ref-list-1
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at:
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