Hyperkalemia from 6 floz of cow's whole milk per day?

[dchz]

Mods: sorry if this is the wrong forum. But I was hoping to consult some experienced peds hivemind.

My daughter is 9 months old, born at 39 weeks of gestation, meeting all developmental milestones. 25%ile for weight, 50%ile for height.

Bedtime routine: We feed her solids at approx 5PM. And 6 oz of formula (enfamil gentle ease) at 7PM before bed. We feed her as much as she will eat during the day with a good mix of solids (veggies, fruits, combination of cooked solids) and breast milk (supplemented with formula since my wife is producing less and less).

Lately, I've noticed my daughter would wake up 2-3 times at night, feed 5 ozs of formula, and then go right back to sleep. She also had a growth spurt in height recently so I noticed she has been losing a lot of baby fat, her ribs are almost visible. She is crawling a lot but not quite standing by herself yet.

From my observations, it feels like she's not getting enough calories. So I've decided to increase the caloric density of her foods before bedtime. I pressure cook beef and mushrooms and the puree it so her 5 pm solid feeds have more protein and fat. For her 7 PM formula feed, instead of mixing the formula with water, I have substituted 6 oz of water with 6 oz of cows whole milk to increase calorie density. This is the ONLY cow milk she receives in a whole 24 hour period.

I did this for several days and my daughter sleeps through the whole night for 10-12 hours without waking. At my daughter's 9 months appointment, the pediatrician said I should not mix formula with whole milk, as it will cause hyperkalemia. He states that I should not give her cow's milk until 12 months of age. Upon hearing this, I have stopped mixing the formula with whole milk and just went back to water.

However, the logic of it is bugging the crap out of me:

It's almost impossible to cause hyperkalemia with PO intake in adults, what about a 9 month old nephron that makes them more susceptible to hyper K?

What happens between 9 to 12 months in an infant that makes it's ok to give them cows milk?

Does this mean that a 29 week premature baby has to wait until 14 months before she can have cow's milk?

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[SurfingDoctor]

Mods: sorry if this is the wrong forum. But I was hoping to consult some experienced peds hivemind.

My daughter is 9 months old, born at 39 weeks of gestation, meeting all developmental milestones. 25%ile for weight, 50%ile for height.

Bedtime routine: We feed her solids at approx 5PM. And 6 oz of formula (enfamil gentle ease) at 7PM before bed. We feed her as much as she will eat during the day with a good mix of solids (veggies, fruits, combination of cooked solids) and breast milk (supplemented with formula since my wife is producing less and less).

Lately, I've noticed my daughter would wake up 2-3 times at night, feed 5 ozs of formula, and then go right back to sleep. She also had a growth spurt in height recently so I noticed she has been losing a lot of baby fat, her ribs are almost visible. She is crawling a lot but not quite standing by herself yet.

From my observations, it feels like she's not getting enough calories. So I've decided to increase the caloric density of her foods before bedtime. I pressure cook beef and mushrooms and the puree it so her 5 pm solid feeds have more protein and fat. For her 7 PM formula feed, instead of mixing the formula with water, I have substituted 6 oz of water with 6 oz of cows whole milk to increase calorie density. This is the ONLY cow milk she receives in a whole 24 hour period.

I did this for several days and my daughter sleeps through the whole night for 10-12 hours without waking. At my daughter's 9 months appointment, the pediatrician said I should not mix formula with whole milk, as it will cause hyperkalemia. He states that I should not give her cow's milk until 12 months of age. Upon hearing this, I have stopped mixing the formula with whole milk and just went back to water.

However, the logic of it is bugging the crap out of me:

It's almost impossible to cause hyperkalemia with PO intake in adults, what about a 9 month old nephron that makes them more susceptible to hyper K?

What happens between 9 to 12 months in an infant that makes it's ok to give them cows milk?

Does this mean that a 29 week premature baby has to wait until 14 months before she can have cow's milk?

https://cdn.who.int/media/docs/default-source/nutrition-and-food-safety/complementary-feeding/cf-guidelines/systematic-review-milks-6-11-months.pdf

 

[dchz]

https://cdn.who.int/media/docs/default-source/nutrition-and-food-safety/complementary-feeding/cf-guidelines/systematic-review-milks-6-11-months.pdf

Great evidence!

Are you saying it doesn't matter?

I'm not replacing formula or going cow milk only diet.

So I failed to see how the study applies to my situation other than the already low risks are even lower in my situation since I'm still feeding formula, breast milk, and solids.

 

[SurfingDoctor]

Great evidence!

Are you saying it doesn't matter?

I'm not replacing formula or going cow milk only diet.

So I failed to see how the study applies to my situation other than the already low risks are even lower in my situation since I'm still feeding formula, breast milk, and solids.

I have personally never heard of hyperkalemia from cow’s milk. Cows milk is associated with issues, but not an elevated potassium. I guess I suppose anything is possible but not a common concern.

 

[JW2020]

In terms of what changes between 9-14 months, The gut biome changes drastically after 12 months, which is why we wait to use cows milk until after then. As another example, honey is a serious risk of botulism before 12 months, but then becomes safe after 12 months as the gut flora evolves and can handle/destroy clostridium.

In general, I’ve never heard of someone recommending supplementing cows milk before 12 months. I don’t see how this would cause hyperkalemia, more we think about GI upset and poor absorption. We expect babies to sometimes decrease in percentile transiently as they learn to crawl/walk and burn more calories, and with an age appropriate diet will adjust and growth curve straightens out.

 

[dchz]

In terms of what changes between 9-14 months, The gut biome changes drastically after 12 months, which is why we wait to use cows milk until after then. As another example, honey is a serious risk of botulism before 12 months, but then becomes safe after 12 months as the gut flora evolves and can handle/destroy clostridium.

In general, I’ve never heard of someone recommending supplementing cows milk before 12 months. I don’t see how this would cause hyperkalemia, more we think about GI upset and poor absorption. We expect babies to sometimes decrease in percentile transiently as they learn to crawl/walk and burn more calories, and with an age appropriate diet will adjust and growth curve straightens out.

So far no signs of poor absorption of GI upset.

Feels like I'm in the clear?? I also thought the hyperkalemia comment was WTF?!

 

[oldbearprofessor]

There is no risk of metabolic abnormalities to supplementing a healthy 9 month old with some cow milk as a direct feed except for anemia which can otherwise be assessed and managed. It is not nutritionally optimal however. It was routine to begin some cow milk at 6 months for many years but ultimately the risk of anemia was the main factor that led to a decision by AAP and other US expert groups not to recommend it routinely. In Canada, policy is to allow it at 9-10 months.

Infant nutrition - Canada.ca

Government of Canada tips for providing the proper food and nutrition for babies, older infants and toddlers

www.canada.ca

I concur with this evidence based statement from Canada "If you are making the transition to cow milk as your child’s main milk source, wait until your baby is between 9 and 12 months old. Start with homogenized cow milk (3.25% M.F.). Do not offer skim or partly skimmed milk (1% or 2% M.F.) before 2 years of age."

However, looking at your post, it appears you are taking powder and adding cow milk instead of water to it as a diluent. This would lead to increases in both caloric density and nutrient intake. It's likely the baby would adapt and not become hyperkalemic but I don't recommend that practice as the micronutrient intakes, including potassium, could be quite high doing that. One can slightly increase the caloric density of formula by slightly (e.g.10%) decreasing the amount of water from recommendation but you should discuss with a dietitian as they have calculations for this. In a 9 month old, this wouldn't be usually needed for a healthy baby. Better solution is give more solid foods, such as yogurts at evening dinners.

Finally, the best way to assess growth is via z-score analysis of growth curves for each baby. It's easy to find these online. Many babies normally "thin out" in appearance as they begin to crawl around and are actually not low on calories. Hope this is helpful.