What is Dry Needling?

Patient Presentation
A 19-year-old female athlete came to clinic for her health supervision visit during the summer. She was a discus thrower completing at the NCAA Division I level. Overall her freshman year had gone well and she had no general medical concerns. She said that she had no specific injuries or problems with her training, but she said in retrospect she probably didn’t listen to her coach as well as she should have and overtrained early. She relayed that early in the preseason winter/spring she had had some upper back/lower cervical pain in her right side (throwing side). She had worked with the university physicians and trainers with a program of stretching, heat, and massage. “I had this one place that we couldn’t quite fix. They tried pressure on that too but it didn’t work. They then stuck some needles into the muscle a few times. That along with the other stuff, plus listening to my coach more, eventually stopped the pain in that spot.”

The pertinent physical exam showed a healthy muscular female with normal vital signs.
She had a normal examination including both shoulders and arms with no specific tight muscles or pain elicited on exam.

The diagnosis of a healthy female was made. The physician discussed how important it was to listen to her coaches regarding her training and to really do the physical therapy when it was recommended. “The pain in my shoulder and back was really bad for a while. It was hard and irritating to do my classes and regular activities. I don’t want to do that again. My coach has us doing a summer program and is checking in on us a few times a week. Believe me, I’m doing what they say including the physical therapy,” she said.

Myofascial pain is pain from muscle or fascia, and usually associated with myofascial trigger points which are “…a highly localized, hyperirritable spot in a palpable, taut band of skeletal muscle fibers.” Trigger points are common reasons people, especially adults, seek relief in primary care or pain clinic settings. Athletes may also complain of pain caused by them. They are treated in a variety of ways, none of which used as a single method is successful for all individuals. Muscle “…stretching, massage, ischemic compression, laser therapy, transcutaneous electrical nerve stimulation, biofeedback, and pharmacological treatment…” are some options.

Learning Point
“With dry needling, a solid needle is passed through the skin into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue to relieve or stimulate myofascial trigger points. The practitioner palpates the trigger point, places the need into the position over the target area on the skin, and taps or flicks the top of the needle to penetrate the skin. The needle may be inserted into a muscle to elicit a local twitch response, or into other connective tissue to elicit tissue relaxation. The needle is removed and placed into neighboring areas or allowed to remain in place for two minutes until the trigger-point sensitivity decreases.” It is called “dry” needling as the needles are solid and do not inject any fluid. Dry needling is also called Western acupuncture, medical acupuncture and intramuscular stimulation.

Dry needling is different than acupuncture. Dry needling is based on Western anatomy and physiological principles. Its mechanism is not understood, but may disrupt the trigger points, modulate nerves or some other effect. This appears to be the treatment the patient above had. Acupuncture is meant to stimulate acupoints and meridians in the body to help with the body’s energy flow. The underlying mechanism of its effect is not understood but may be due to changes in chemical and electrical activity within the body or other mechanisms. Acupuncture is also used for pain management and may be helpful in back, neck and osteoarthritis/knee pain. It is also used for some other problems such as nausea due to chemotherapy.

For acupuncture, the Federal Drug Administration “…requires that needles be sterile, non-toxic, and labeled for single use by qualified practitioners only.” Dry needling has similar requirements. Both are safe when performed by experienced practitioners using appropriate methods. Potential dry needling complications include bleeding or bruising in the site and pain are relatively common. Syncope can also occur. Less common complications include infection (local or deep usually with common skin organisms), injury to nerve, pneumothorax or cardiac tamponade.

Dry needling is offered by physicians (including pain and rehabilitation specialists), physical therapists and other similar health care practitioners. Efficacy data is difficult as randomized controlled trials do not represent real life situations and in most cases multiple interventions are being offered or have been tried by individuals. Dry needling may be used as part of a comprehensive strategy which could include exercise, soft tissue mobilization, postural interventions, ergonomic interventions and education about pain. A systemic review and meta-analysis concluded that while the data was low- to moderate- quality, dry needling was more effective than no treatment and sham dry needling for both shorter and intermediate term end points for pain relief and other functional outcomes.

Questions for Further Discussion
1. Where can you find good, scientific resources about complimentary and alternative medicine?
2. What complimentary and alternative medicine methods do you employ in your clinical practice and why?
2. How is acupuncture different than acupressure?
3. Where are your local resources for dry needling and acupuncture?
4. What complimentary and alternative medicine methods do you employ in your clinical practice and why?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Non-Drug Pain Management and Acupuncture.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Acupuncture: In Depth. NCCIH. https://nccih.nih.gov/health/acupuncture/introduction. Published January 1, 2008. Accessed March 6, 2020.

Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med JABFM. 2010;23(5):640-646. doi:10.3122/jabfm.2010.05.090296

Zhuang Y, Xing J, Li J, Zeng B-Y, Liang F. Chapter One – History of Acupuncture Research. In: Zeng B-Y, Zhao K, Liang F-R, eds. International Review of Neurobiology. Vol 111. Neurobiology of Acupuncture. Academic Press; 2013:1-23. doi:10.1016/B978-0-12-411545-3.00001-8

Gonzalez-Lopez-Arza MV, Sautreuil P, Varela-Donoso E, Rodriguez-Mansilla J, Garrido-Ardila E. Epidemiological data on acupuncture and physical and rehabilitation medicine in the European Union. J Tradit Chin Med. 2015;35(4):478-482. doi:10.1016/S0254-6272(15)30128-X

Gattie E, Cleland JA, Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133-149. doi:10.2519/jospt.2017.7096

Kim DC, Glenzer S, Johnson A, Nimityongskul P. Deep Infection Following Dry Needling in a Young Athlete: An Underreported Complication of an Increasingly Prevalent Modality: A Case Report. JBJS Case Connect. 2018;8(3):e73. doi:10.2106/JBJS.CC.18.00097

Dommerholt J. How have the views on myofascial pain and its treatment evolved in the past 20 years? From spray and stretch and injections to pain science, dry needling and fascial treatments. Pain Manag. March 2020. doi:10.2217/pmt-2019-0055

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Long Does Neonatal Galactorrhea Last?

Patient Presentation
A 34-day-old male came to clinic for his well-child visit. He was the third child and the family had no concerns except for clear to white discharge from both breasts when touched or palpated. This occurred frequently and a small amount was produced. The breasts did not appear red, indurated or painful. The galactorrhea had been noted at his 1 week visit and the family had been told that it should disappear with more time. His neonatal screening test was normal including for hypothyroidism. His family denied him taking any medications. They also denied using or taking any medications in the home except for the mother’s prenatal vitamins. The family did have emollient creams but all were standard brands with usual ingredients. Specifically there were no known hormone exposures. The past medical history revealed a term male without significant prenatal or natal history.

The pertinent physical exam showed normal vital signs and growth parameters around the 50th percentile. He had palpable breast tissue under the areolas bilaterally that was about 2-3 cm in size. There were no irregularities of the tissue such as a discreet mass and the tissue seemed proportional between the two breasts. With minimal palpation, a small amount of a thin, whitish discharge without odor could be produced bilaterally. There was no surrounding erythema or edema and the infant did not seemed bothered by the palpation. The rest of his examination was normal.

The diagnosis of of a healthy male with bilateral galactorrhea was made. The pediatrician thought this was a little long to have galactorrhea due to maternal hormones, but also thought that the infant did not have neonatal mastitis, abscess, or breast mass. The infant also didn’t appear to in an environment where there were medications or exogenous hormones as the cause. His neonatal screening test was normal and he didn’t appear to have any stigmata of midline defects or genetic syndromes. Pediatric endocrinology was consulted and recommended to monitor the infant without further evaluation because this was bilateral and spontaneous in an otherwise healthy infant. It was thought this was still within the normal time period for transplacental maternal hormones as the cause.

The patient’s clinical course showed athis 2 month visit the family said that the discharge had stopped about 1 week after the last appointment and the breasts had decreased in size since that time.

Galactorrhea is a milky discharge from the breast in a non-lactating female.

Neonatal galactorrhea is sometimes called “Witch’s Milk” based on ideas from the 17th century or earlier that witches would steal the milk for use in their magic. Infant breasts were often compressed to express the fluid and prevent its collection. During the 19th century, reports of breast inflammation and even abscess were reported because of this practice and it was strongly discouraged, and continues to not be recommended today.

Enlargement of neonatal breasts and galactorrhea, both for males and females, is felt to be usually due to transplacental maternal hormone stimulation and fetal hormones. This stimulation decreases rapidly after birth, but for some infants breast enlargement continues with or without galactorrhea. The ongoing cause is not totally certain.

Galactorrhea is most often seen in term infants as premature infants have little breast tissue and therefore breast enlargement and/or galactorrhea are not seen usually.

Nipple discharge that is usually benign is described as “bilateral, not spontaneous, and occurs with breast manipulation or stimulation, whereas suspicious discharge is usually unilateral, spontaneous and persistent. Bloody breast discharge is potentially worrisome for breast cancer however, pediatric breast cancer is exceedingly rare, and bloody discharge can be see due to stimulation and irritation.

Mastitis or breast abscess are again not very common in infants and children. However, with signs or symptoms of infection these problems must be considered. Neonatal mastitis has a high rate of concurrent bacteremia and usually is treated with systemic antibiotics. A review can be found here.

Prolactin is produced in the anterior pituitary lobe due to dopamine signaling. Prolactin then acts on the mammary gland to increase tissue and produce milk. It also has several other functions on the gonads, adipose tissue, insulin secretion and immune system. “…[S]tress, suckling, estrogens, [thyroid releasing hormone], vasoactive intestinal polypeptide… and oxytocin… act as stimulants of prolactin release directly into the anterior [pituitary] or by reducing the inhibitory action of dopamine.”

Causes of galactorrhea in the pediatric population include:

  • Transplacental maternal hormone
  • Hypothyroidism
  • Hyperprolactinemia
    • Pituitary adenomas
    • Polycystic ovarian syndrome
    • Estrogen
    • Oxytocin
    • Thyroid releasing hormone
    • Stress
    • Suckling
    • Vasoactive peptide
  • Medications
    • Antidopamineric
    • Antidepressants
    • Antipsychotics – a common cause
    • Anticonvulsants
    • Antiandrogens
    • Antihypertensives
    • Cholinomimetics
    • Estrogen
    • Opioids
    • Prokinetic agents
  • Other
    • Obesity (probably partly due to increased lipid conversion to estrogen)
    • Marijuana
    • Self-stimulation of breast tissue
    • Cancer – rare

Learning Point
Neonatal galactorrhea can last longer than usually thought. In a study of healthy newborns (N=640) examined from birth up to 12 weeks of age, 5.9% (N=38 infants) were found to have galactorrhea at some point. All of these infants were term infants and 55% were female. The incidence of galactorrhea was most common in the first 2 weeks of life (6.2% of 552 examinations), but still occurred at 2-5 weeks (3% of 265 examinations) and at 6-10 weeks (1.8% of 167 examinations) with decreasing incidence. One infant was examined at 12 weeks and still had persistent galactorrhea.

Questions for Further Discussion
1. What is in the differential diagnosis of breast masses in the pediatric population? A review can be found here
2. What are common problems associated with pituitary function?
3. What are other common parental concerns regarding neonatal breasts?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Breast Diseases and Pituitary Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Madlon-Kay DJ. “Witch’s milk”. Galactorrhea in the newborn. Am J Dis Child 1960. 1986;140(3):252-253. doi:10.1001/archpedi.1986.02140170078035

Weimann E. Clinical management of nipple discharge in neonates and children. J Paediatr Child Health. 2003;39(2):155-156. doi:10.1046/j.1440-1754.2003.00118.x

Jain S, Sharma P, Mukherjee A, Bal C, Kumar R. “Witch’s milk” and 99mTc-pertechnetate uptake in neonatal breast tissue: an uncommon but not unexpected finding. Clin Nucl Med. 2013;38(7):586-587. doi:10.1097/RLU.0b013e318292aaba

Fernandez TF, Ashraf AP. An Unusual Case of Galactorrhea With Normal Serum Prolactin. Clin Pediatr (Phila). 2018;57(2):238-240. doi:10.1177/0009922816685821

Michail M, Ioannis K, Charoula M, Alexandra T, Eleftheria H. Clinical manifestations, evaluation and management of hyperprolactinemia in adolescent and young girls: a brief review. Acta Bio Medica Atenei Parm. 2019;90(1):149-157. doi:10.23750/abm.v90i1.8142

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Potential Complications of Tattooing?

Patient Presentation
A 15-year-old male came to clinic with his mother after she had noticed some redness and swelling around his ankle the previous day. He had been experimenting with giving himself a tattoo using pins and pen ink 3 days previously. He said that he had done this alone and had not shared any pins or needles with anyone. He said he had taken new pins from a container from his mother’s sewing basket, and had cleaned them by a match flame and then by sitting in alcohol. He had cleaned his skin with an iodine solution. He stated that, “It didn’t hurt too much and I think I did a good job with the small design. I’m not sure how much I like it though now.” He had re-cleaned the site afterwards and a few times a day since. The next day though it was redder but hadn’t really spread. His mother noticed the redness the night before. He denied wanting to hurt himself in any way including having no history of substance abuse, mental health issues or self-harm. He was doing well in school with the same social group. “I’m a pretty good artist and just wanted to see if I could give myself a small tattoo,” he stated.
The social history showed that his mother was a nurse and had been very upset when she found out about it. The past medical history showed that he was fully immunized.

The pertinent physical exam showed a healthy male with normal vital signs. There was a 2 cm black geometric drawing just about the lateral malleolus on the right ankle. There was a surrounding 3-4 cm ring of erythema but no significant swelling or induration. There was no streaking up the leg. There was full range of motion in the ankle and knee.

The diagnosis of a mild allergic local reaction vs mild cellulitis was made. Oral antibiotics were started. This incident was felt to be a very low risk of bloodborne pathogen exposure and so testing was not done at that time. He was also felt to not have significant psychosocial risk factors for self-harm or other high-risk behaviors. During confidential questioning the pediatrician confirmed the adolescent’s story The pediatrician discussed body art and the potential risks of tattoos. “Amateur tattoos have the highest risks of problems. Please don’t do that again or in the future. If you are going to get one in the future, please use a licensed business. They are professionals and can do it right if that is what you want to do. Remember tattoos are permanent and can be beautiful if done right. But there are real risks too. Please use your artistic talents in a different medium than tattoos for right now.” Three months later the adolescent had not done further tattooing but was doing ink drawings inspired by graphic artists.

“Tattooing of skin via deposition of pigment particles and ink ingredients in the dermis changes normal skin into abnormal skin. Fortunately, this often causes no harm and no disease, although with important exceptions.” Tattoos can be inadvertent from road dirt, gunpowder, pencil graphite etc., but most are desired. Tattoos are common in many cultures and over time..They have been increasing in popularity in the United States over the past few years particularly with a younger, wider and more diverse population.

Newsweek reported an 18-country study in 2018 which showed 46% of Americans have a tattoo and the US and Sweden tied for the highest median number of tattoos at 4. Of those 14-29, 36% had a tattoo. Unfortunately many adolescents and young adults are not aware of the potential complications.

“If tattoos are placed in licensed parlors, infections are less likely to occur after tattooing than if they are placed by unlicensed individuals.” “Unfortunately, many tattoos are placed by amateurs, which makes the process much riskier. In these cases, antiseptic process may not be followed, leading to potential skin infections and transmission of bloodborne illnesses, such as hepatitis C or HIV.” Common sense recommendations if someone wishes to have a tattoo placed are to use a licensed business, and follow all appropriate after-care instructions scrupulously.

Tattoos sometimes can be removed but should be considered permanent before placement. Removal can be attempted including ablative, chemical, and mechanical, removal. Laser treatment is often used currently but has its own set of potential complications including burns. Removal can also be expensive. One study cited $49/square inch of tattoo/laser session. Multiple sessions are usually needed.

Learning Point
Tattoo complaints are not uncommon and occur around the time of tattoo placement or later. These include reactions such as inflammation, irritation, pruritis, or swelling. These can be worse with worse with sun exposure for people.

Tattoo complications include:

  • Infection
    • Potentially the most serious complication
    • Caused because contaminated equipment or ink, inadequate disinfection and secondary during healing due to irritation, pruritis etc.
    • Superficial problems are more common (e.g. impetigo, pustules), but can be worse with cellulitis or abscess problems. Bacteremia, sepsis or complications related to them such as endocarditis, erysipelas, and gangrene.
    • Common skin flora is the most common include Staphylococcus aureus and Streptococcus pyogenes. Other bacterial infections also include Clostridium species, E. coli, Pseudomonas species. Tuberculosis, non-tuberculosis mycobacterium and leprosy have been reported. Tetanus is not common because of vaccination but can occur. Fungus, parasites and spirochetes can also be inoculated.
    • Viral infections are probably of the most concern including bloodborne pathogens of Hepatitis B, Hepatitis C, and HIV. Other viruses causing local disease include Herpes, molluscum, warts and condyloma.
  • Allergic reaction
    • These are frequent and can be caused by inks, chemicals used, equipment or personal protective equipment
    • Long term inflammation, elevation, thickening, scaling, hyperkeratosis and even ulceration, necrosis and scarring.
      Can be more papular, nodular or more plaque-like

    • Latex allergy can be an early or late complication as particles from the tattooists’ latex gloves are introduced into the skin. These can cause problems later when latex is encountered including in foods that can cross-react
  • Neoplasms
    • Described in areas of tattoos and not know if this is causal or coincidence.
    • Tattoos over dermal lesions can make it difficult to monitor for malignant transformation
  • Provoked illness
    • Eczema
    • Psoriasis
    • Sarcoid
  • Other
    • Psychosocial problems
    • Ink problems – photosensitivity, migration, or metabolic conversion
    • Acute vasculitis
    • MRI burn
    • Syncope and falls around the procedure

Questions for Further Discussion
1. How does the American Academy of Dermatology recommend to care for tattoos? See To Learn More below.
2. How should new body piercings be cared for? A review can be found here
3. How old does someone need to be in your location to get a tattoo legally?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Piercing and Tattoos

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Which country has the most people with tattoos? It’s not the U.S. Newsweek. https://www.newsweek.com/which-country-most-people-tattoos-943104. Published May 24, 2018. Accessed March 3, 2020.

Serup J, Carlsen KH, Sepehri M. Tattoo Complaints and Complications: Diagnosis and Clinical Spectrum. Tattooed Skin Health. 2015;48:48-60. doi:10.1159/000369645.

Breuner CC, Levine DA, COMMITTEE ON ADOLESCENCE. Adolescent and Young Adult Tattooing, Piercing, and Scarification. Pediatrics. 2017;140(4). doi:10.1542/peds.2017-1962.

Caring for tattooed skin. https://www.aad.org/public/everyday-care/skin-care-basics/tattoos/caring-for-tattooed-skin. Accessed March 3, 2020.

Tattoos: 7 unexpected skin reactions and what to do about them. https://www.aad.org/public/everyday-care/skin-care-basics/tattoos/tattoo-skin-reactions. Accessed March 3, 2020.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Much Breast Milk Does a Lactating Woman Make?

Patient Presentation
A 4-month-old male came to clinic for his health supervision visit. His mother had no concerns and he was rolling over, smiling, transferring toys, putting them in his mouth and saying many vowel sounds. His mother only noted that he seemed to be more active and at times eating more. “It seems like some days even now I’m just breastfeeding him. He can get really hungry at times,” she said.

The pertinent physical exam showed a smiley infant with a weight of 50%, head circumference of 25% and length of 75%.
His examination was normal and he still had a head lag when pulled from lying to sitting.

The diagnosis of a healthy infant was made. “You have a healthy son. He’s still not ready for solid foods though so you just need to keep breastfeeding him. Are you remembering to have a snack yourself and drink each time he eats?” the pediatrician asked. “Sometimes it seems like feeding him, and me eating, is all I do. I’m always so thirsty and hungry,” the mother replied. “We’ll that sounds pretty normal. You need to eat more to feed him and drink too. Try to keep some healthy snacks ready to go, so you can get one and something to drink before you sit down to feed him. No hot drinks though. You don’t want him to bump you and get burned,” the pediatrician reminded the mother.

After leaving the room, the third year medical student asked, “How much milk does a mother make? It doesn’t seem like it would be enough to make her so hungry?” The pediatrician smiled, “It’s more than you think. If you remember back to your basic science nutrition course, she needs to eat more now than when she was pregnant. It’s about 500 calories a day. That’s about 25-30% more than someone who isn’t pregnant. Then she has to drink all the extra fluid to make the breast milk. I’ve never figured it out but it is gallons she makes over a year; it’s just made fresh a few ounces at a time.”

Each person needs to eat the right about of healthy foods to maintain a healthy body.
This varies based on gender, age, activity, healthy problems, or health status.

Healthy women who are moderately active and not pregnant or lactating need about 1800-2000 calories/day. Pregnant women are advised to keep the calories the same in the first trimester (about 1800 calories/day), increase ~200-300 (about 2200 calories/day)in the second trimester, and then increase ~300-400 in third trimester (about 2400 calories/day). The increase in calories should be met by a normally balanced and varied diet. When pregnant or breastfeeding women should eat a diet rich in protein, omega-3 polyunsaturated fats, calcium, iron and folic acid, along with all the necessary vitamins, minerals, and fiber.

Breastfeeding is recommended throughout at least the first year of life by the American Academy of Pediatrics and up to 24 months by the World Health Organization. Complimentary foods are not recommended until after 6 months of age if the infant is developmentally ready.

Learning Point
Healthy, well-nourished, lactating women are advised to increase their calories by 450-500/day. That is a lot of calories which is turned into ~70 gallons or ~250 liters of breast milk/year. Women who are under- or malnourished will have additional needs and should be advised by their health care providers.

The table below shows the various calculations:

450 extra calories/day 500 extracalories/day
Calories/year 164,250 182,500
Breast milk Produced in Ounces (mLiters)/day 22.5 (0.625) 25 (0.725)
Breast milk Produced in Gallons (Liters)/year 64.1 (238.1) 71.3 (264.6)
Breast milk Produced by Weight in Pounds (Kilograms)/year 535.4 (238.1) 594.9 (264.6)

If a woman did not have access to adequate nutrition, the number of calories/year expended to support the breastfeeding would be the equivalent of losing ~50 pounds.

Questions for Further Discussion
1. What are the breastfeeding rates in your practice, region or country?
2. What factors help initiate breastfeeding after birth?
3. What guidance can help support breastfeeding ?
4. What are the maternal advantages of breastfeeding?
5. What are the infant advantages of breastfeeding?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Pregnancy and Nutrition and Breastfeeding.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

CDC. Diet considerations for breastfeeding mothers. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html. Published February 10, 2020. Accessed February 18, 2020.

Guideline: counselling of women to improve breastfeeding practices. Geneva: World Health Organization; 2018.

American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. https://pediatrics.aappublications.org/content/129/3/e827. Accessed February 18, 2020.

Eating right during pregnancy: MedlinePlus Medical Encyclopedia. https://medlineplus.gov/ency/patientinstructions/000584.htm. Accessed February 18, 2020.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa