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In this communication I wish to report 2 unusual cases of nutritional anemia in young infants and to discuss the problems of therapy to which they gave rise. It should be emphasized that nutritional anemia is a comprehensive term referring to a group of conditions dependent on poor nutrition of the hemopoietic system. Pediatricians in the past have regarded nutritional anemia as synonymous with microcytic anemia due to lack of iron and have therefore considered it as due to faulty nutrition of the child in the sense of a deficiency of iron in the food. The pathologic physiology of nutritional anemia has been made clearer by studies such as those of Minot, Castle and Whipple. Moore1has tersely stated the facts as follows: "The term nutritional anemia should no longer be used to denote the hypochromic anemia of infancy and childhood. Our knowledge of the relationship of essential nutritional

No important differences in hemoglobin and hematocrit values occurred among subgroups of a cohort of 295 healthy, mature infants who were fed various dietary regimens of iron-fortified products, including cereal, whole milk, and corn syrup. Among all infants between the ages of 4 and 27 months, the incidence of hematocrit readings and hemoglobin levels below 30% and 10 g/dl, respectively, was 0.6%, and below 33% and 11 g/dl, respectively, was 3.2%. Because of the low incidence of nutritional anemia after age 4 months, initial screening should be done at 1 to 4 months of age, and selectively thereafter. A formula of evaporated milk and corn syrup plus iron-fortified cereal during early months, then whole milk and a more diversified diet including continued use of iron-fortified cereal during later months of infancy, provides a nutritionally sound and economical diet with sufficient iron. ( JAMA 240:1362-1365, 1978)

To the Editor.— Drs Berg and van Pelt (240:1362, 1978) have made an important observation: children receiving any of a variety of iron-supplemented foods in the first year of life are unlikely to have development of iron deficiency anemia. Readers should contrast their logical and simple method for providing ironfortified foods with the cumbersome and inefficient methods required by most federally funded programs. Every family was given an opportunity to obtain iron-fortified infant foods. In federal programs there is a constant nit-picking over eligibility on the (false) assumption that a child from one poor family is less eligible than a child from another family with a few extra dollars of yearly income. When nutrition problems are resolved, support is often withdrawn. I believe that their conclusions are biased by the nature of the population surveyed. A study of families willing to attend clinic is inherently biased. Families of clinic attenders

• We compared the hematocrit values of 425 black and 164 American Indian children with an equal number of white children who were matched for sex, age, and iron nutrition status based on serum ferritin level. Black children were found to have a mean hematocrit value 0.7% lower than that of white, matched controls. No hematocrit difference was found between American Indian children and their white controls. This finding in blacks is consistent with those of previous series, except the magnitude of the hematocrit difference is smaller. The lower value in blacks may be accounted for by mild thalassemias, which are associated with lower hematocrit values. The use of the same diagnostic criteria for anemia among all races will permit uniform detection of nutritional anemia as well as a greater rate of diagnosis of certain hereditary hemoglobinopathies. ( AJDC 1984;138:824-827)

Interest in disease in ancient times has increased dramatically in the past decade. One difficulty has been a shortage of textbooks to supply up-to-date information. This present work by Steinbock is, therefore, a welcome addition to the library of the paleopathologist, especially because it deals with the kind of tissue most available for study today—bones from the past. The writing is straightforward and simple, the diagrams are informative, the photographs are carefully selected and clearly printed. The author has not been afraid to take a position on debatable issues, and in general I think that his conclusions are sound. For example, in the chapter on anemia, in which the etiology of porotic hyperostosis is discussed, he comes down firmly on the side of nutritional anemia, in most instances, as against thalassemia. By coincidence, the Paleopathology Association held a symposium on this subject in November 1976, in Detroit, and the majority

FOR MANY years, iron, particularly the ferrous form, has been used as a medicinal agent in nutritional anemia and prepartal management. Since ferrous sulfate is relatively inexpensive, quite stable, not unpalatable, and, up to 1947, considered quite harmless, it has enjoyed wide distribution and in tablet form has been dispensed in large numbers with some abandon. This has resulted in easy availability and all too often accidental ingestion by the exploring and inquisitive infant or child. Forbes, 1 in 1947, described postmortem findings in two cases. Thomson, 2 Prain, 3 Thomson, 4 and Smith 5 further documented the clinical and postmortem features of this condition. Spencer, 6 in 1951, reviewed the various problems involved and noted in Great Britain the beginning of branding procedures to the extent that "the drug is dangerous to young children." Duffy and Diehl 7 and Swift and collaborators 8 further established the clinical and postmortem

The extent of anemia was investigated in 1,789 individuals under 21 years of age residing in an inner-city neighborhood. The study group was composed of 56% black, 33% Spanish-speaking, and 11% white individuals. The results reveal that 12.5% of those 10 to 36 months of age, 4.4% of those 3 to 10 years of age, 2.4% of those 10 to 14 years of age, and 13.5% of the girls and 1.2% of the boys 14 to 21 years of age were anemic by hematocrit determination. With the use of hemoglobin determinations, a larger proportion was found to be anemic. Ethnic differences were noted among teen-age girls: white and Spanish-speaking girls were found to be anemic less frequently than black girls of the same age. The results suggest that nutrition counseling and iron supplementation, when indicated, should continue into adolescence.

Hematocrit determinations were performed on 3,016 children in a community with homogeneous socioeconomic and racial characteristics. Striking differences in the occurrence of anemia were found in the age groups studied. Anemia was frequent (14.8%) in infancy, but by preadolescence had declined to 2.6%. However, subsequent compensatory ability was marginal, for after puberty and during pregnancy anemia recurred with considerable frequency. Nearly 25% of pregnant teen-age girls were anemic. Surveys designed to detect nutritional anemia should include the infant and the teen-age girl. Study of only preschool and prepubertal age groups will underestimate the prevalence of nutritional anemia.

The science of nutrition has made sound progress since 1900. With modest beginnings at the turn of the century, nutrition has eradicated or possesses sufficient know-how to eradicate all the classical deficiency diseases prevalent in the first quarter of this century. Thus, rickets, infantile scurvy, and pellagra—all common diseases in the first quarter of this century—for practical purposes have been eliminated as public health problems. 1 Beriberi and ariboflavinosis, which both paraded in this country under a variety of pseudonyms during the first quarter of this century, are now at the beginning of the third quarter relatively rare diseases in the large charity hospitals, thanks to a rising standard of living, health education, vitamin supplementation, and bread, flour, and corn enrichment. 1 Means are available to prevent simple goiter and most nutritional anemia. They should no longer exist in this country, but unfortunately they do. 1 Parallel with this virtual

Nutritional anemia in infancy is not a chronological division of this symptom for a certain age period. It is a dynamic conception based on the recognition of a difference in metabolism, growth and anatomy. The hemoglobin level during infancy varies clinically with circumstances that affect these factors. Thus, normal premature infants, twins and rapidly growing infants have a lower hemoglobin level than normal full-term infants, if no provision is made for their difference in requirements. While nutritional anemia is directly on a dietetic basis, such predisposing factors as rapid rate of growth, hemorrhage and infection are important factors at this period of life. Thus, in the majority of cases it is the increased demand that is placed on the infant chiefly by rapid growth, hemorrhage and infection that results in nutritional anemia rather than a deficiency in iron due to a low intake.

The term nutritional anemia designates a type of anemia especially prevalent among infants of 1 and 2 years, currently thought to be due mainly to lack of iron, which, derived either from stores in the body or from food, is needed for building hemoglobin. The severe form of the disease is seen most frequently among infants who have too long been given an exclusive milk diet, but it is seen also among infants who have been offered a seemingly well balanced diet. In most instances the anemia tends to improve spontaneously, as a rule coincidentally with the increasing acceptance of a well balanced diet, but even in infants who recover spontaneously (i. e., without iron medication) the period of transitory anemia is a critical one, in which the hazards of intercurrent infection and general nutritional disturbances are increased. The evidence produced by recent investigations 1 that there is a higher

THE PATIENT with a skin disorder who expresses the belief that something "may be lacking'' in his system deserves to be taken seriously. Profound nutritional disturbances may exist and may be the cause of certain obscure dermatoses even in the absence of obvious dietary deficiencies or characteristic clinical manifestations. In this brief discussion attention will be focused on two nutritional and metabolic disturbances which have recently been discussed in dermatological literature and several illustrative cases in our experience will be described. MACROCYTIC NUTRITIONAL ANEMIA Stryker and Halbeisen 1 in 1945 called to the attention of dermatologists a relationship between certain dermatoses and nutritional disorders as revealed by a macrocytic anemia. They carried out hematological studies on 179 patients presenting various dermatoses, with a view to determining the presence of a macrocytic anemia. It was pointed out that a routine blood examination including red cell count, white cell count and

Steenbock, Hart and their co-workers have made a series of systematic investigations on the catalytic effect of copper on hemoglobin formation. In Europe a great part of any interest in the present article would be due to the fascinating history of this important discovery. In America, no doubt, all pediatricians are familiar with the facts which led to this contribution to science; however, I shall make a brief survey of these investigations, because sometimes discoveries are not as well known in the country in which they are made as abroad. Let me thus begin with the transport of owls to Athena. The subject of these investigations was interesting to pediatricians, as it dealt with the nutritional anemia due to the exclusive feeding of milk. In the first period of the investigations, rabbits from 4 to 5 weeks of age were placed on a milk diet. After five or six weeks

During the past two decades great advances have been made in the knowledge of nutritional anemia and the relation of dietary deficiencies to formation of blood. This progress was stimulated largely by the clinical and experimental work of Whipple and his colleagues, 1 who evaluated the hemoglobin-producing properties of many foods by feeding them to anemic dogs and who also confirmed the value of inorganic iron in regeneration of hemoglobin. The prevalence of iron deficiency anemia both in adults and in children and the rapid cure by the administration of large doses of iron led to the study of the causes of this type of anemia. In 1928 Ahmann and his associates, 2 in a nutritional survey covering the school children in five counties in Florida, found that approximately 39 per cent of them were anemic. While no particular study was made of the causes of the condition, the authors were of

The older textbooks on therapeutics1list a number of inorganic elements, in addition to iron, which are reputed to be of value in the treatment of anemia. Among these arsenic stands out most prominently, although reference may also be found to the use of salts of manganese, copper, mercury and vanadium. With a clearer appreciation of some of the factors underlying the anemias, the use of this form of therapy has fallen somewhat into disrepute, efforts being devoted more to the use of diets tending to promote the formation of hemoglobin. The work done by Whipple2stands out most prominently in this connection and it paved the way for the discovery by Minot3of the specific value of liver in the treatment of pernicious anemia. The advance that has occurred recently in our methods of treating the anemias is due directly or indirectly in large part to

Macrocytic hyperchromic anemia in infancy is infrequently observed. Faber 1 and Bachman 2 have reviewed 19 previously reported cases. Langmead and Doniach 3 recorded an additional case. Macrocytic hyperchromic anemia in infancy usually is observed in previously healthy infants after an infection of the upper respiratory tract followed by a period of vomiting or diarrhea or both. The patients are noticeably malnourished and fail to gain weight in spite of changes in formulas and addition of various vitamins to the diet. Free hydrochloric acid is nearly always present in the gastric contents, although frequently decreased in amount. Administration of crude liver extract by mouth or injection has frequently been followed by reticulocytosis, rapid rise in the number of red blood cells and gain in weight. Anemia does not recur after it has once been relieved. Because of the comparative rarity of this type of anemia, the case of a child

I. EXTENT OF NUTRITIONAL ANEMIA There is a definite entity among anemias, found mainly in young children, which is due to lack of a sufficient intake of iron and its catalysts and is known generally as nutritional anemia. That this type of anemia is common is shown by the numerous reports in medical journals concerning it. In this paper a new type of carbohydrate for infant feeding is described. It is made from sugar cane, contains considerable amounts of iron and copper and tends to prevent nutritional anemia. A comprehensive study by Mackay 1 of nearly 5,000 samples of blood from the poorer children in London, England, a few years ago showed that 42 per cent of the breast-fed infants and 70 per cent of the artificially fed infants had definite nutritional anemia. Elvehjem, Peterson and Mendenhall, 2 studying 2,000 samples of blood from 750 children at Madison, Wis., found

Interest in the subject of the present study was stimulated on reading Mackay's1report on nutritional anemia in infancy. The conclusions reached in that report, if confirmed, would demand that all children during the first year or two of life receive a fairly large daily supplement of iron. The literature on anemia in infancy has been adequately covered in the aforementioned report, and only additional pertinent contributions will be referred to here. The most intriguing of recent publications are those dealing with the possibility that copper may play a significant role in the synthesis of hemoglobin. The results of the experiments of Elvehjem and Hart2on animals to the effect that, whereas impure inorganic salts of iron cured nutritional anemia, the pure salts failed to do so, unless supplemented by small amounts of copper, have already been applied by clinicians to the treatment of anemia. The most carefully

The influence of copper on the formation of hemoglobin is a problem which has not been completely solved, and the literature abounds in conflicting reports on the subject. Elvehjem 1 has recently summarized the work on the biologic significance of copper, and the reader is referred to this paper for a comprehensive review and bibliography. It has been found that in the experimental nutritional anemia of animals neither iron nor copper alone is effective in producing regeneration of hemoglobin, but when iron is given in combination with a small amount of copper a rapid increase in the hemoglobin content of the blood ensues. The work of Whipple 2 on experimental hemorrhagic anemia in dogs has not entirely confirmed these results. He found that in certain instances a combination of iron and copper was more beneficial than iron alone but that this was not consistently true. It is possible that a

The purpose of this paper is to report the changes in the sedimentation rate of a group of infants and children with nutritional anemia due to a deficiency in iron. It has been generally accepted that dilute suspensions of cells cause accelerated rates of sedimentation and that the speed of sedimentation is inversely proportional to the concentration or the volume of the red blood cells. The present study was undertaken to collect data and to investigate thoroughly the significance of isolated observations of untreated nutritional anemia in which the red blood cells, contrary to this theory, settled at normal rates. In the course of this study it became apparent that such a discrepancy is not uncommon and that, with certain limitations, the periodic determination of the sedimentation rate may be employed as an additional guide in the management of nutritional anemia and also as an aid in the differential diagnosis