facts and opinion Iron-Deficiency Anemia: How Long Must It Be With Us? A N N A M . SESSO, M D , F A A P , and J O H N SILVERIO, M D , F A A P Iron-deficiency anemia persists in the face of a simple solution. T h e plight of the infant and younger child is emphasized; the needs of the menstruating and pregnant w o m a n are also considered. A t least 50 years have passed since endemic goiter posed a significant problem in the United States, and a t least 30 years have transpired since scurvy and rickets were prevalent. Once these illnesses were recognized as being caused b y dietary deficiencies, they were quickly eliminated. W h e n will the same be true for irondeficiency anemia? T h e simple addition of iodine to table salt, vitamin C to almost all fruit drinks, and vitamin D to milk was enough to eradicate goiter, scurvy, and rickets, respectively. T h e simple addition of an easily absorbed iron salt to the diet early in life should eradicate anemia. W h a t are the reasons for its persistence? This disorder often starts in infancy. Before birth, the fetus takes what it needs from the mother’s nutrient stores; it is quite efficient in getting enough iron, even if the mother’s blood is iron deficient. A t birth the infant’s normal endowment of hemoglobin ranges from 14 to 2 2 g/lOO ml. But for some time after birth the mechanism regulating the infant’s erythropoiesis (the production of red blood corpuscles) does not function fully. During the first few weeks of life, more red blood cells die than can be replaced, so the number of circulating cells gradually declines. Production of new red cells by the bone marrow is insignificant until about 2 months of age. W i t h growth, vascular volume increases, and the hemoglobin mass is diluted. T h e growth of muscle, in particular, requires iron for myoglobin. T h e need for iron is perhaps never greater than January/February 1975 JOGN Nursing
during the first year of life.1 T h e premature infant may be more anemic because he has an insufficient maternal endowment of iron (most iron reserves are obtained by the fetus during the last 2 months of gestation), and he has a greater rate of growth than a term infant.2 A n infant is generally considered anemic when the hemoglobin concentration is below 10 g / l W ml or the hematocrit is less than 31%; however, our personal experience is that levels of 1 1 g/lOO ml and 3 3 % are more realistic and certainly more satisfactory.3
How Much Iron Does the Infant Need? In 1969, the Committee on Nutrition of the American Academy of Pediatrics (AAP) recommended 1.5 mg/kg/day of iron for all infant^.^ T h e recommended iron supplement could be supplied by fortified baby cereal, iron-enriched milk, o r medicinal iron. T h e Committee specifically felt that the 0.5 mg iron/liter provided by ordinary cow’s milk was insufficient for such children, especially during the rapid growth in the first year of life. Recommendations of the National Academy of Sciences are shown in Table 1. Until recently, the most important source of iron in the diet of the American infant was cereal fortified with organic iron salts during processing. Although such cereals contained 8.6 to 22 mg iron/dry ounce, many of the infants fed on them continued to exhibit iron-deficiency anemia. T h e big problem was that iron
37
in the form in which it is added to cereals (i.e., as the organic pyrophosphate) is not well absorbed, while iron in a readily absorbable form (inorganic ferrous sulfate) cannot be added to cereals without making them rancid within a short period of time after manufacture. (Ferrous sulfate is a pro-oxidant; it easily converts fatty acids in cereals to a number of organic acids.) This problem does not occur in the case of milk formulas. Evidence from many studies has shown that the ironcontaining formula offers easily absorbed iron (ferrous sulfate) very early in infancy, which is a great advantage. Iron-fortified milk is recommended by the A A P to prevent iron deficiency on a large scale. In 1971, the A A P Committee on Nutrition recommended that when proprietary formulas are prescribed, iron-supplemented ones should be the rule until 12 months of age.5 T h e Committee also recommended that iron-fortified whole cow’s milk or evaporated milk should be made available for all persons beyond the infant stage. T h e intent was to have the mother use them with the infant cereals when the proprietary infant formula was stopped (usually at about 6 months of age). Unfortunately, although these milks did become available in some localities, they were not well accepted. T h e y often had an objectionable color and odor when used in cooking o r with coffee.
Rampant Anemia in Preschoolers Some form of iron enrichment is certainly necessary for the preschool child. Most children this age consume limited quantities of iron-containing foods, particularly meat and eggs. Iron-deficiency anemia is still rampant in children from 1 to 3 years of age.O An incidence of anemia as high as 64% was found in an urban ghetto area where children had hemoglobin levels between 9 and 10.5 g/100 ml and hematocrits less than 32%. These children did not include those with pica, bacterial infection, o r parasite infestation.7 Between November 1968 and July
38
Table 1. Recommended Daily Dietary Allowances (1968) Age Infants 0-1 yr Children 1-10 yr Pregnancy Lactation
Iron (mg) 6-15 10-15 18 18
From Recommended Dietary Allowances, Publication #1964, Food and Nutrition Board, National Academy of Sciences, Washington, D. C.
1969, Owen, Nelsen, and Garry studied randomly selected children from 1 to 6 years of age from 15 states. Seven percent were obviously anemic and 45% had iron deficiency, based on both iron saturation and iron-binding capacity. T h e y were from all socioeconomic groups.8 Iron deficiency in preschool and young school-age children causes irritability and apathy, and, most authors feel, underachievement in school and poor somatic growth. More recent studies associate the growth limitation with overall nutritional deficiency.? Beller and Howell studied irondeficient 4- to 6-year-old children in their investigation, assessing their learning ability by psychometric testing. T h e y chose nondeficient siblings close in age as controls. Both groups were about equal on the standard intelligence tests and on the StanfordBinet and Goodenough Draw-A-Man tests. But there were differences. T h e anemic group saw less of the total visual field when presented with a dominant stimulus. Anemic boys were slower in starting a task and were more repetitive and perseverating in their play. Anemic girls were unable to organize or integrate their play as well, nor could they sustain attention in complex activities. Clearly, the iron deficiency affected the children? ability to attend and to concentrateboth important in learning. Learning improved when the iron deficiency was c ~ r r e c t e d . ~ 3
Usual Diet Is Iron-Deficient in Pregnancy, Menstruation W h a t about the nutritional status of
the adult in this, the supposedly best nourished country of the world? Do w e get enough iron? Surveys indicate that the ordinary diet gives us an average of 6 mg iron/1,000 cal, an amount which easily meets the estimated 5- to 16-mg daily requirement of the nonanemic American male and the nonpregnant, nonmenstruating American female and even the 8.5- to 23-mg daily requirement of the adolescent American male. O n the other hand, the normally menstruating woman loses from 10 to 60 ml of blood every month (average flow, about 40 ml), and if she has a hemoglobin level in the neighborhood of 12 g/lOO ml, her monthly loss of iron is about 16 mg. This may elevate the daily requirement to an amount that would be difficult to provide in the usual diet. In pregnancy the need is further increased, to between 17 and 37.5 mg/day.1° There is substantial agreement that the usual diet is deficient for the pregnant woman. A recent 10-state nutrition survey by the A A P found the average pregnant woman of all socioeconomic circumstances and all ethnic groups to have an insufficient dietary intake to supply herself and her unborn child with the required nutrients, including iron.ll H o w should these special groups be treated? For the infant, the answer is the iron-fortified proprietary formula, as recommended by the A A P Committee on Nutrition. Later in life, either the formula must be continued or other food products must be fortified. T h e Food and Drug Administration recently suggested adding larger amounts of iron to enriched white bread; this change has not been implemented-pending public hearings. Many protested this action. Some of the most vociferous expressed the concern that persons with Parkinson’s disease would be made worse by such a diet. Others felt that persons with iron storage disease would have a greater problem. Still others were worried about sickle cell disease and thalassemia, which affect a substantial number of persons in the United States.13J4 January/February 1975 JOGN Nursing
Hence, the total problem is in no way solved. But a t least we k n o w h o w to protect o u r infants and young children. For them, iron-deficiency anemia should go the w a y of goiter, scurvy, and rickets. All w e need d o is to continue to educate mothers on the infant’s need f o r extra iron and to supply it via the formula, a t least during the first year of life.
References 1. Filer, L. J. Jr: “The Case for Iron Supplements in Infant Feeding Regimens.” Hosp Practice 6:79-92, June 1971 2. Gorten, M. K., and E. R. Cross: “Iron Metabolism in Premature Infants.” J Pediatr 64:509, 1964 3. Project Headstart Health Services
Guide for Project Directors and Health Personnel, Office of Eco4.
5.
6.
7.
nomic Opportunity, Washington, D.C. American Academy of Pediatrics Committee on Nutrition: “Iron Balance and Requirements in Infancy.” Pediatrics 43: 134, 1969 American Academy of Pediatrics Committee on Nutrition: “Iron-Fortified Formulas.” Pediatrics 47:786, 1971 “Iron-Deficiency Anemia in Infants and Preschool Children.” Dairy Council Digest 43 (1) :1-5, JanjFeb 1972 Howell, D. A., and E. K. Beller:
“Variability in Iron Therapy in Mildly Anemic Children.” Proceedings of the International Congress of Pediatrics, Section on Nutrition and Gastroenterology, Vienna, Austria, 29 Aug-4 Sept, 1971 8. Owen, G. M., C . E. Nelsen, and P. J. Garry: “Nutritional Status of Preschool Children: Hemoglobin, Hematocrit, and Plasma Iron Values.” J Pediatr 76:761, 1970 9. Beller, E. K., and D. A. Howell: “A Study of Anemia and Mental Functioning in Underprivileged Children.” Proceedings of the International Congress of Pediatrics, Section on Nutrition and Gastroenterology, Vienna, Austria, 29 Aug-4 Sept, 1971 10. Moore, C. V.: “Prevention of Iron Deficiency,” in Iron: A Total Clinical Learning Experience. New York, Medcom, 1972, pp 69-71 11. American Academy of Pediatrics, statement of the Committee on Nutrition: “The Ten-State Nutrition Survey-A Pediatric Perspective.” Newsletter Suppl January 1973 12. “Bread: H o w Much Iron Is Safe?” Med World News Jan 4, 1974, p 15 13. Norman, C.: “Iron Enrichment.” Nutr Today Nov/Dec 1973, p 16 14. Wintrobe, M. M.: “The Proposed Increase in the Iron-Fortification of Wheat Products.” Nutr Today Nov/ Dec 1973, pp 18-20 Address reprint requests to John Silverio, MD, Director of Clinical Nutrition, Wyeth Laboratories, Box 8299, Philadelphia, PA 19101.
Doctor Sesso is in the Department of Pediatrics at Mercy Catholic Medical Center, Misericordia Division, Philadelphia, Pennsylvania.
Doctor Silverio is Assistant Professor of Pediatrics at the University of Pennsylvania, Philadelphia, and is Director of Clinical Nutrition at W y e t h Laboratories, Radnor, Pennsylvania.
MANAGEMENT CONFERENCE FOR SUPERVISORS IN CHICAGO The 2nd National Hospital Nursing Supervisor Management Conference sponsored by Hospital Topics is scheduled for June 19-22, 1975, at the Palmer H o u s e in Chicago. It is designed to help supervisors manage “people problems” at work. Registration fee is $50 in advance; $75 at the time of the conference. For further information write to Gordon M. Marshall, Conference Manager, 734 Siesta Key Circle, Sarasota, FL 33581, (813) 349-7445.
January/February 1975 JOGN Nursing
39
during the first year of life.1 T h e premature infant may be more anemic because he has an insufficient maternal endowment of iron (most iron reserves are obtained by the fetus during the last 2 months of gestation), and he has a greater rate of growth than a term infant.2 A n infant is generally considered anemic when the hemoglobin concentration is below 10 g / l W ml or the hematocrit is less than 31%; however, our personal experience is that levels of 1 1 g/lOO ml and 3 3 % are more realistic and certainly more satisfactory.3
How Much Iron Does the Infant Need? In 1969, the Committee on Nutrition of the American Academy of Pediatrics (AAP) recommended 1.5 mg/kg/day of iron for all infant^.^ T h e recommended iron supplement could be supplied by fortified baby cereal, iron-enriched milk, o r medicinal iron. T h e Committee specifically felt that the 0.5 mg iron/liter provided by ordinary cow’s milk was insufficient for such children, especially during the rapid growth in the first year of life. Recommendations of the National Academy of Sciences are shown in Table 1. Until recently, the most important source of iron in the diet of the American infant was cereal fortified with organic iron salts during processing. Although such cereals contained 8.6 to 22 mg iron/dry ounce, many of the infants fed on them continued to exhibit iron-deficiency anemia. T h e big problem was that iron
37
in the form in which it is added to cereals (i.e., as the organic pyrophosphate) is not well absorbed, while iron in a readily absorbable form (inorganic ferrous sulfate) cannot be added to cereals without making them rancid within a short period of time after manufacture. (Ferrous sulfate is a pro-oxidant; it easily converts fatty acids in cereals to a number of organic acids.) This problem does not occur in the case of milk formulas. Evidence from many studies has shown that the ironcontaining formula offers easily absorbed iron (ferrous sulfate) very early in infancy, which is a great advantage. Iron-fortified milk is recommended by the A A P to prevent iron deficiency on a large scale. In 1971, the A A P Committee on Nutrition recommended that when proprietary formulas are prescribed, iron-supplemented ones should be the rule until 12 months of age.5 T h e Committee also recommended that iron-fortified whole cow’s milk or evaporated milk should be made available for all persons beyond the infant stage. T h e intent was to have the mother use them with the infant cereals when the proprietary infant formula was stopped (usually at about 6 months of age). Unfortunately, although these milks did become available in some localities, they were not well accepted. T h e y often had an objectionable color and odor when used in cooking o r with coffee.
Rampant Anemia in Preschoolers Some form of iron enrichment is certainly necessary for the preschool child. Most children this age consume limited quantities of iron-containing foods, particularly meat and eggs. Iron-deficiency anemia is still rampant in children from 1 to 3 years of age.O An incidence of anemia as high as 64% was found in an urban ghetto area where children had hemoglobin levels between 9 and 10.5 g/100 ml and hematocrits less than 32%. These children did not include those with pica, bacterial infection, o r parasite infestation.7 Between November 1968 and July
38
Table 1. Recommended Daily Dietary Allowances (1968) Age Infants 0-1 yr Children 1-10 yr Pregnancy Lactation
Iron (mg) 6-15 10-15 18 18
From Recommended Dietary Allowances, Publication #1964, Food and Nutrition Board, National Academy of Sciences, Washington, D. C.
1969, Owen, Nelsen, and Garry studied randomly selected children from 1 to 6 years of age from 15 states. Seven percent were obviously anemic and 45% had iron deficiency, based on both iron saturation and iron-binding capacity. T h e y were from all socioeconomic groups.8 Iron deficiency in preschool and young school-age children causes irritability and apathy, and, most authors feel, underachievement in school and poor somatic growth. More recent studies associate the growth limitation with overall nutritional deficiency.? Beller and Howell studied irondeficient 4- to 6-year-old children in their investigation, assessing their learning ability by psychometric testing. T h e y chose nondeficient siblings close in age as controls. Both groups were about equal on the standard intelligence tests and on the StanfordBinet and Goodenough Draw-A-Man tests. But there were differences. T h e anemic group saw less of the total visual field when presented with a dominant stimulus. Anemic boys were slower in starting a task and were more repetitive and perseverating in their play. Anemic girls were unable to organize or integrate their play as well, nor could they sustain attention in complex activities. Clearly, the iron deficiency affected the children? ability to attend and to concentrateboth important in learning. Learning improved when the iron deficiency was c ~ r r e c t e d . ~ 3
Usual Diet Is Iron-Deficient in Pregnancy, Menstruation W h a t about the nutritional status of
the adult in this, the supposedly best nourished country of the world? Do w e get enough iron? Surveys indicate that the ordinary diet gives us an average of 6 mg iron/1,000 cal, an amount which easily meets the estimated 5- to 16-mg daily requirement of the nonanemic American male and the nonpregnant, nonmenstruating American female and even the 8.5- to 23-mg daily requirement of the adolescent American male. O n the other hand, the normally menstruating woman loses from 10 to 60 ml of blood every month (average flow, about 40 ml), and if she has a hemoglobin level in the neighborhood of 12 g/lOO ml, her monthly loss of iron is about 16 mg. This may elevate the daily requirement to an amount that would be difficult to provide in the usual diet. In pregnancy the need is further increased, to between 17 and 37.5 mg/day.1° There is substantial agreement that the usual diet is deficient for the pregnant woman. A recent 10-state nutrition survey by the A A P found the average pregnant woman of all socioeconomic circumstances and all ethnic groups to have an insufficient dietary intake to supply herself and her unborn child with the required nutrients, including iron.ll H o w should these special groups be treated? For the infant, the answer is the iron-fortified proprietary formula, as recommended by the A A P Committee on Nutrition. Later in life, either the formula must be continued or other food products must be fortified. T h e Food and Drug Administration recently suggested adding larger amounts of iron to enriched white bread; this change has not been implemented-pending public hearings. Many protested this action. Some of the most vociferous expressed the concern that persons with Parkinson’s disease would be made worse by such a diet. Others felt that persons with iron storage disease would have a greater problem. Still others were worried about sickle cell disease and thalassemia, which affect a substantial number of persons in the United States.13J4 January/February 1975 JOGN Nursing
Hence, the total problem is in no way solved. But a t least we k n o w h o w to protect o u r infants and young children. For them, iron-deficiency anemia should go the w a y of goiter, scurvy, and rickets. All w e need d o is to continue to educate mothers on the infant’s need f o r extra iron and to supply it via the formula, a t least during the first year of life.
References 1. Filer, L. J. Jr: “The Case for Iron Supplements in Infant Feeding Regimens.” Hosp Practice 6:79-92, June 1971 2. Gorten, M. K., and E. R. Cross: “Iron Metabolism in Premature Infants.” J Pediatr 64:509, 1964 3. Project Headstart Health Services
Guide for Project Directors and Health Personnel, Office of Eco4.
5.
6.
7.
nomic Opportunity, Washington, D.C. American Academy of Pediatrics Committee on Nutrition: “Iron Balance and Requirements in Infancy.” Pediatrics 43: 134, 1969 American Academy of Pediatrics Committee on Nutrition: “Iron-Fortified Formulas.” Pediatrics 47:786, 1971 “Iron-Deficiency Anemia in Infants and Preschool Children.” Dairy Council Digest 43 (1) :1-5, JanjFeb 1972 Howell, D. A., and E. K. Beller:
“Variability in Iron Therapy in Mildly Anemic Children.” Proceedings of the International Congress of Pediatrics, Section on Nutrition and Gastroenterology, Vienna, Austria, 29 Aug-4 Sept, 1971 8. Owen, G. M., C . E. Nelsen, and P. J. Garry: “Nutritional Status of Preschool Children: Hemoglobin, Hematocrit, and Plasma Iron Values.” J Pediatr 76:761, 1970 9. Beller, E. K., and D. A. Howell: “A Study of Anemia and Mental Functioning in Underprivileged Children.” Proceedings of the International Congress of Pediatrics, Section on Nutrition and Gastroenterology, Vienna, Austria, 29 Aug-4 Sept, 1971 10. Moore, C. V.: “Prevention of Iron Deficiency,” in Iron: A Total Clinical Learning Experience. New York, Medcom, 1972, pp 69-71 11. American Academy of Pediatrics, statement of the Committee on Nutrition: “The Ten-State Nutrition Survey-A Pediatric Perspective.” Newsletter Suppl January 1973 12. “Bread: H o w Much Iron Is Safe?” Med World News Jan 4, 1974, p 15 13. Norman, C.: “Iron Enrichment.” Nutr Today Nov/Dec 1973, p 16 14. Wintrobe, M. M.: “The Proposed Increase in the Iron-Fortification of Wheat Products.” Nutr Today Nov/ Dec 1973, pp 18-20 Address reprint requests to John Silverio, MD, Director of Clinical Nutrition, Wyeth Laboratories, Box 8299, Philadelphia, PA 19101.
Doctor Sesso is in the Department of Pediatrics at Mercy Catholic Medical Center, Misericordia Division, Philadelphia, Pennsylvania.
Doctor Silverio is Assistant Professor of Pediatrics at the University of Pennsylvania, Philadelphia, and is Director of Clinical Nutrition at W y e t h Laboratories, Radnor, Pennsylvania.
MANAGEMENT CONFERENCE FOR SUPERVISORS IN CHICAGO The 2nd National Hospital Nursing Supervisor Management Conference sponsored by Hospital Topics is scheduled for June 19-22, 1975, at the Palmer H o u s e in Chicago. It is designed to help supervisors manage “people problems” at work. Registration fee is $50 in advance; $75 at the time of the conference. For further information write to Gordon M. Marshall, Conference Manager, 734 Siesta Key Circle, Sarasota, FL 33581, (813) 349-7445.
January/February 1975 JOGN Nursing
39
