Role of dietary iron and fat on vitamin E deficiency anemia of infancy

Biology of Anemia: A Public Health Perspective

Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.

Feeding a diet devoid of choline to lactating rodents restricts growth and lymphocyte development in offspring

The nutrient choline is necessary for membrane synthesis and methyl donation, with increased requirements during lactation. The majority of immune development occurs postnatally, but the importance of choline supply for immune development during this critical period is unknown. The objective of this study was to determine the importance of maternal supply of choline during suckling on immune function in their offspring among rodents. At parturition, Sprague-Dawley dams were randomised to either a choline-devoid (ChD; n 7) or choline-sufficient (ChS, 1 g/kg choline; n 10) diet with their offspring euthanised at 3 weeks of age. In a second experiment, offspring were weaned to a ChS diet until 10 weeks of age (ChD-ChS, n 5 and ChS-ChS, n 9). Splenocytes were isolated, and parameters of immune function were measured. The ChD offspring received less choline in breast milk and had lower final body and organ weight compared with ChS offspring (P<0·05), but this effect disappeared by week 10 with choline supplementation from weaning. ChD offspring had a higher proportion of T cells expressing activation markers (CD71 or CD28) and a lower proportion of total B cells (CD45RA+) and responded less to T cell stimulation (lower stimulation index and less IFN-γ production) ex vivo (P<0·05). ChD-ChS offspring had a lower proportion of total and activated CD4+ T cells, and produced less IL-6 after mitogen stimulation compared with cells from ChS-ChS (P<0·05). Our study suggests that choline is required in the suckling diet to facilitate immune development, and choline deprivation during this critical period has lasting effects on T cell function later in life.

Nutrient deficiencies in the premature infant

Premature infants are a population prone to nutrient deficiencies. Because the early diet of these infants is entirely amenable to intervention, understanding the pathophysiology behind these deficiencies is important for both the neonatologists who care for them acutely and for pediatricians who are responsible for their care through childhood. This article reviews the normal accretion of nutrients in the fetus, discusses specific nutrient deficiencies that are exacerbated in the postnatal period, and identifies key areas for future research.

Effects of vitamin E supplementation during erythropoietin treatment of the anaemia of prematurity

AIMS

To evaluate the effects of vitamin E supplementation on haemoglobin concentration and the requirement for transfusion in premature infants treated with erythropoietin and iron.

METHODS

Randomised, double blind, placebo controlled trial. Thirty infants </=32 weeks gestation and </=1250 g birth weight, who were defined as stable based on minimal requirements for respiratory support and phlebotomy, and absence of major congenital anomalies were enrolled. All were treated with erythropoietin and iron, and were randomised to receive, in addition, either vitamin E 50 IU/day or placebo for eight weeks or until discharge, whichever came first.

RESULTS

Despite higher vitamin E (alpha-tocopherol) levels in the experimental group in weeks 3 (49.0 v 28.1 micro mol/l) and 8 (66.2 v 38.5 micro mol/l), there were no differences in haemoglobin, reticulocyte count, iron concentration, or transfusion requirement.

CONCLUSIONS

Oral vitamin E supplementation at 50 IU/day does not increase the response of preterm infants to erythropoietin and iron. Vitamin E obtained through standard nutrition may have been sufficient or higher doses may be required.

Vitamin E supplementation for prevention of morbidity and mortality in preterm infants

BACKGROUND

Treating very low birth weight (VLBW) infants with pharmacologic doses of vitamin E as an antioxidant agent has been proposed for preventing or limiting retinopathy of prematurity, intracranial hemorrhage, hemolytic anemia, and chronic lung disease. However, excessive doses of vitamin E may result in side effects.

OBJECTIVES

The aim of this systematic review was to assess the effects of vitamin E supplementation on morbidity and mortality in preterm infants.

SEARCH STRATEGY

We searched MEDLINE (October 2002), EMBASE (March 2002), the Cochrane Controlled Trials Register (CCTR) from the Cochrane Library, 2003, Issue 1, and personal files for clinical trials assessing vitamin E in preterm infants.

SELECTION CRITERIA

We selected trials analyzing primary outcomes (mortality or combined long-term morbidity) or secondary outcomes (other morbidity) in infants with gestational age less than 37 weeks or birth weight less than 2500 grams. The intervention was allocation to routine supplementation with vitamin E in the treatment group versus placebo, no treatment or another type, dose or route of administration of vitamin E.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration and of the Cochrane Neonatal Review Group.

MAIN RESULTS

Twenty-six randomized clinical trials fulfilled entry criteria. No study assessed combined long-term morbidity. Routine vitamin E supplementation significantly reduced the risk of germinal/intraventricular hemorrhage (typical relative risk [RR] 0.85, 95% confidence interval [CI] 0.73, 0.99), increased the risk of sepsis (typical RR 1.52, CI 1.13, 2.04) and increased hemoglobin concentration by a small amount, but did not significantly affect mortality and other morbidity. In VLBW infants, vitamin E supplementation increased the risk of sepsis, and reduced the risk of severe retinopathy and blindness among those examined. Subgroup analyses in VLBW infants showed (1) an association between serum tocopherol levels greater than 3.5 mg/dl and increased risk of sepsis and reduced risk for severe retinopathy among those examined; and (2) an association between intravenous, high-dose administration of vitamin E and increased risk of sepsis.

REVIEWER'S CONCLUSIONS

Vitamin E supplementation in preterm infants reduced the risk of intracranial hemorrhage but increased the risk of sepsis. In very low birth weight infants it increased the risk of sepsis, and reduced the risk of severe retinopathy and blindness among those examined. Evidence does not support the routine use of vitamin E supplementation by intravenous route at high doses, or aiming at serum tocopherol levels greater than 3.5 mg/dl.

Nutrient requirements for preterm infant formulas

Achieving appropriate growth and nutrient accretion of preterm and low birth weight (LBW) infants is often difficult during hospitalization because of metabolic and gastrointestinal immaturity and other complicating medical conditions. Advances in the care of preterm-LBW infants, including improved nutrition, have reduced mortality rates for these infants from 9.6 to 6.2% from 1983 to 1997. The Food and Drug Administration (FDA) has responsibility for ensuring the safety and nutritional quality of infant formulas based on current scientific knowledge. Consequently, under FDA contract, an ad hoc Expert Panel was convened by the Life Sciences Research Office of the American Society for Nutritional Sciences to make recommendations for the nutrient content of formulas for preterm-LBW infants based on current scientific knowledge and expert opinion. Recommendations were developed from different criteria than that used for recommendations for term infant formula. To ensure nutrient adequacy, the Panel considered intrauterine accretion rate, organ development, factorial estimates of requirements, nutrient interactions and supplemental feeding studies. Consideration was also given to long-term developmental outcome. Some recommendations were based on current use in domestic preterm formula. Included were recommendations for nutrients not required in formula for term infants such as lactose and arginine. Recommendations, examples, and sample calculations were based on a 1000 g preterm infant consuming 120 kcal/kg and 150 mL/d of an 810 kcal/L formula. A summary of recommendations for energy and 45 nutrient components of enteral formulas for preterm-LBW infants are presented. Recommendations for five nutrient:nutrient ratios are also presented. In addition, critical areas for future research on the nutritional requirements specific for preterm-LBW infants are identified.

Neonatal iron nutrition

Preterm infants are prone to iron deficiency. Their total body iron content at birth is low and gets further depleted by clinical practices such as uncompensated phlebotomy losses and exogenous erythropoietin administration during the neonatal period. Early iron deficiency appears to adversely affect cognitive development in human infants. To maintain iron sufficiency and meet the iron demands of catch-up postnatal growth, iron supplementation is prudent in preterm infants. A dose of 2-4 mg/kg/day is recommended for preterm infants who are fed exclusively human milk. A dose of 6 mg/kg/day or more is needed with the use of exogenous erythropoietin or to correct preexisting iron deficiency. However, due to the poor antioxidant capabilities of preterm infants and the potential role of iron in several oxidant-related perinatal disorders, indiscriminate iron supplementation should be avoided.

The role of vitamins in the prevention and control of anaemia

OBJECTIVE

While iron deficiency is regarded as the major cause of nutritional anaemia, changes in vitamins A, B12, C and E, folic acid and riboflavin status have also been linked to its development and control. This paper provides a systematic review of vitamin supplementation trials relating to the control of nutritional anaemia.

METHODS

A MEDLINE search was used to find reports of vitamin supplementation trials that reported changes in anaemia or iron status.

RESULTS

Vitamin A can improve haematological indicators and enhance the efficacy of iron supplementation. Both folate and vitamin B12 can cure and prevent megaloblastic anaemia. Riboflavin enhances the haematological response to iron, and its deficiency may account for a significant proportion of anaemia in many populations. Vitamin C enhances the absorption of dietary iron, although population-based data showing its efficacy in reducing anaemia or iron deficiency are lacking. Vitamin E supplementation given to preterm infants has not reduced the severity of the anaemia of prematurity. Vitamin B6 effectively treats sideroblastic anaemia. Multivitamin supplementation may raise haemoglobin (Hb) concentration, but few studies have isolated the effect of multivitamins from iron on haematological status.

CONCLUSIONS

In general, the public health impact of vitamin supplementation in controlling anaemia is not clear. Neither are the complex interactions involving multiple vitamins in haematopoiesis sufficiently understood to explain the observed variability in haematological responses to vitamins by age, population, vitamin mixture and dosages. Further research is needed to understand the roles of individual and combined vitamin deficiencies on anaemia to design appropriate micronutrient interventions to prevent anaemia.

Simple high-performance liquid chromatographic method for determination of alpha-tocopherol in human plasma

A simple high-performance liquid chromatographic method using UV detection was developed for the determination of alpha-tocopherol in human plasma. The method entailed direct injection of the plasma sample after deproteinization using acetonitrile-tetrahydrofuran (3:2). The mobile phase comprised methanol-tetrahydrofuran (94:6) and analysis was run at a flow-rate of 1.5 ml/min with the detector operating at 292 nm. A Crestpak C18S (5 microm, 250 mm x 4.6 mm ID) was used for the chromatographic separation. The method had a mean recovery of 93%, while the within-day and between-day coefficients of variation and percentage errors were all less than 7%. The speed, specificity, sensitivity and reproducibility of this method make it particularly suitable for routine determination of alpha-tocopherol in human plasma. Moreover, only a small sample plasma volume (100 microl) is required for the analysis.

Severe hemolytic anemia associated with vitamin E deficiency in infants with cystic fibrosis. Implications for neonatal screening

Three infants are described with cystic fibrosis (CF) and malnutrition leading to severe anemia beginning as early as 6 weeks of age. Laboratory studies demonstrated high reticulocyte counts, negative Coombs' tests, abnormal peroxide hemolysis test results, and biochemical evidence of vitamin E deficiency. Oral administration of alpha-tocopherol resulted in rapid correction of the in vitro hemolysis and improvement of in vivo hematologic indices. Investigation of these patients supports the conclusion that the hemolytic anemia of infancy in CF is caused by vitamin E deficiency and should be treated promptly with 50 IU/day of vitamin E. Because two of the three patients were identified in a CF screening/surveillance program, we can estimate that the frequency of clinically significant anemia in CF infants is 4%. Our observations demonstrate a potential advantage of CF neonatal screening for individual patients susceptible to vitamin E-deficient hemolytic anemia and suggest that confirmatory follow-up diagnostic studies, such as sweat tests, should be performed by 4 to 6 weeks of age.

Simultaneous determination of retinol, alpha-tocopherol and retinyl palmitate in plasma of premature newborns by reversed-phase high-performance liquid chromatography

A reversed-phase high-performance liquid chromatographic method is described for the simultaneous determination of retinol, alpha-tocopherol and retinyl palmitate in plasma. Plasma containing an internal standard (tocol) was deproteinized with ethanol, then extracted with n-hexane. The organic layer was removed and evaporated under a nitrogen stream, and chromatographed on a reversed-phase RP-18 column using a water/acetonitrile-ethyl acetate/2-propanol gradient solvent system over 15 min at 305 nm. The recovery exceeded 93%. The detection limit was 0.1 microgram/ml for retinol, 1.3 micrograms/ml for alpha-tocopherol and 0.95 micrograms/ml for retinyl palmitate. The reproducibility, precision (expressed as coefficients of variation) and accuracy were less than 8% for all analytes. The small sample requirement, the simplicity of extraction, the short run-time and the good reproducibility make this procedure particularly useful for monitoring retinol and alpha-tocopherol supplementation in premature newborns.

Empiric red cell transfusion in asymptomatic preterm infants

In a prospective randomized trial, asymptomatic very low-birth-weight infants in a neonatal intensive care unit were either electively transfused with red cells to maintain capillary haematocrit greater than 0.35 l/1 (group 1; n = 9), or were not transfused (group 2; n = 10). Individuals from both groups were excluded if they subsequently received non-elective transfusions, necessitated by their clinical condition. Electively transfused infants gained weight more rapidly than their non-transfused counterparts, but the duration of hospitalization was not shortened. Criteria of morbidity, such as patent ductus murmurs, apnoea and failure to thrive, were similar in both groups. We conclude that in the absence of clinical indications, transfusion to achieve a hematocrit greater than 0.35 l/1 as an empiric procedure, improves weight gain but the risks of transfusion are likely to outweigh the benefits.

Cardiomyopathy of copper deficiency: effect of vitamin E supplementation

The present study was undertaken to determine whether the intraperitoneal injection of vitamin E to copper-(Cu) deficient rats fed fructose will protect the animals against the severity of Cu deficiency. Cu-deficient and adequate rats were fed a diet containing 62% carbohydrate as fructose. Half the Cu-deficient rats fed fructose were injected daily with vitamin E. Vitamin E treated rats were not protected against the lethal consequences of the interaction between Cu and fructose. These data provide evidence that the cardiomyopathy of Cu deficiency in rats consuming a fructose-based diet cannot be ameliorated by vitamin E supplementation.

Placental transfer and tissue distribution of vitamin E in pregnant rabbits

alpha-Tocopherol (vitamin E) is widely prescribed in neonatal intensive care units, in large doses and by different schedules, for the prevention of retrolental fibroplasia, intraventricular haemorrhage, bronchopulmonary dysplasia, and haemolytic anaemia. Since the efficacy of the drug in premature newborns seems related to early administration, the physicochemical characteristics of the drug itself and available formulations limit the major therapeutic aim of promptly raising levels of vitamin E in premature babies during the early hours of life. It has thus been suggested that vitamin E be given to the mother before delivery to produce higher drug concentrations in the newborn. To see whether this would work, the tissue distribution and transplacental transfer of vitamin E were studied in six pregnant rabbits at steady-state after an i.v. bolus + infusion to give a mean venous blood concentration of about 325 mumol l-1 of alpha-tocopherol acetate, corresponding to about 30 mumol l-1 of alpha-tocopherol. Endogenous levels were measured in six control pregnant rabbits. In treated animals alpha-tocopherol was increased in liver, spleen, placenta, lung, mammary gland, blood, and bile but not in brain, heart, fat, muscle or adrenals probably because distribution into these tissues is very slow. Vitamin E levels in the placenta of treated mothers were 15 times those of control rabbits, but the vitamin was not detectable in amniotic fluid and only very low levels were found in fetal blood. These findings do not indicate any advantage of giving mothers alpha-tocopherol acetate before delivery.

Maternal and fetal plasma vitamin E to total lipid ratio and fetal RBC antioxidant function during gestational development

Placental transfer of vitamin E was investigated from 19 to 35 weeks of gestation by analysis of fetal and maternal blood samples for total tocopherol, total lipids, and fetal red blood cell antioxidant reserves. Fifty-two fetal blood samples were obtained under ultrasonographic guide by percutaneous umbilical blood sampling. Thirteen were from fetuses with gestational age less than or equal to 22 weeks (x serum vitamin E = 0.4 +/- 0.14 mg/dl), 12 were from fetuses at 23-27 weeks gestation (x serum vitamin E = 0.4 +/- 0.21 mg/dl), and 27 were from fetuses with gestational age 28-38 weeks (x serum level = 0.37 +/- 0.18). Total lipid levels ranged from 140 to 216 mg/dl. Maternal plasma vitamin E concentrations correlated significantly with concurrent values in the fetus. There were no significant differences in serum vitamin E levels or vitamin E to total lipid ratio in samples from early, mid, or late gestation in either the mother or fetus. Red blood cell antioxidant reserve on samples from 18 fetuses were grossly abnormal by three different functional assays. On the basis of these data, placental transfer of vitamin E appears to be relatively constant through advancing gestation. Red blood cell antioxidant reserve is uniformly low.

Retinopathy of prematurity: prevalence and treatment over a 20 year period at Pennsylvania Hospital

This paper presents the results of a 20 year survey of ROP among less than or equal to 2000 g BW infants cared for at Pennsylvania Hospital. It relates changes in perinatal care and nutrition, survival rates, and serial serum E levels with incidence and severity of ROP. It includes our protocol for monitoring E nutrition so as to optimize its effectiveness at physiologic serum levels for prophylaxis for ROP. Also presented are the promising results of our experience with vitamin E at pharmacologic serum levels as a treatment for severe ROP (defined as in the Cryo ROP Trial). These indicate the need for a multicenter trial to assess the effect of pharmacologic Vitamin E therapy as an alternative or supplement to therapy of severe ROP with laser or cryo surgery.

The effect of vitamin E on lipid peroxidation in the copper-deficient rat

The present study was designed to determine whether the supplementation of vitamin E in the copper-deficient diet would ameliorate the severity of copper deficiency in fructose-fed rats. Lipid peroxidation was measured in the livers and hearts of rats fed a copper-deficient diet (0.6 microg Cu/g) containing 62% fructose with adequate vitamin E (0.1 g/kg diet) or supplemented with vitamin E (1.0 g/kg diet). Hepatic lipid peroxidation was significantly reduced by vitamin E supplementation compared with the unsupplemented adequate rats. In contrast, myocardial lipid peroxidation was unaffected by the level of vitamin E. Regardless of vitamin E supplementation, all copper-deficient rats exhibited severe signs of copper deficiency, and some of the vitamin E-supplemented rats died of this deficiency. These findings suggest that although vitamin E provided protection against peroxidation in the liver, it did not protect the animals against the severity of copper deficiency induced by fructose consumption.

Iron nutrition in childhood: the interplay of genes, development and environment

The state of a child's iron nutrition depends on his genetic endowment, the stage of development he has reached and the environment in which he lives. Genetic disorders lead more commonly to iron overload than to deficiency. Generally interplay between genes and environment is apparently of little importance when considering iron deficiency; are we missing something? The greatest demands for iron are at the time of most rapid growth, i.e. during infancy and puberty, but during early infancy body stores can meet the demand without a need for dietary iron. Oxygen, diet and microbes are the important environmental factors related to iron nutrition. The relationship of oxygen toxicity to iron nutrition in the newborn has received only fleeting study, the availability of iron from many foods is unclear; the clinical significance of iron overload and deficiency in the evolution of an infection is also unclear despite a wealth of in vitro observation. I am not convinced that the bottle fed baby should receive iron in his diet during the first 4-6 months of life. Thereafter, while the concept of universal unselective supplementation causes some uneasiness there are considerable epidemiological arguments for fortification of food with iron.

Continuing care for the preterm infant after dismissal from the neonatal intensive care unit

As more low-birth-weight babies survive, primary-care physicians are facing the responsibility of providing continuing care for those who have been dismissed from neonatal intensive-care units. Premature infants often require outpatient care for bronchopulmonary dysplasia, apnea, retinopathy of prematurity, intraventricular hemorrhage, hearing loss, hypothyroxinemia, anemia, neurodevelopmental sequelae, assessment of growth and nutrition, immunizations, and psychosocial stress. In this review, we present guidelines for the primary-care physician for the management of these conditions in preterm infants.

The early anaemia of the premature infant: is there a place for vitamin E supplementation?

1. The efficacy of oral vitamin E supplementation in preventing the early anaemia of the premature infant was assessed in a 10-week double-blind trial. Forty-two babies received either a placebo or 5 or 15 mg supplementary vitamin E/d with oral feeding. No infant received less than the recommended vitamin E:polyunsaturated fatty acid (E:PUFA) value of 0.6. No iron supplement was given. 2. Weekly full blood counts were taken, and plasma vitamin E assay and in vitro haemolysis tests performed on blood sampled on day 1, and also at 6 and 10 weeks of age. All blood withdrawn and transfused and all feeds were documented. 3. Thirty-six (86%) of the babies had a plasma vitamin E level at birth below the accepted adult norm, i.e. less than 5200 micrograms/l. At 6 weeks of age thirty-three (79%) and at 10 weeks thirty-five (83%) of the babies had levels within the normal adult range. No baby showed either clinical or haematological evidence of a vitamin E deficiency state during the trial. 4. It is concluded that in the absence of Fe supplementation and observing the minimum recommended E:PUFA value, contemporary feeding practices allow for the absorption of sufficient vitamin E by the premature baby to prevent the development of an early haemolytic anaemia. 5. No significant relation was found between plasma vitamin E levels and the degree of peroxide haemolysis.

Controversies in neonatal nutrition

The assessment of growth parameters remains one of the most practical and valuable tools to estimate nutritional status in neonates. Growth assessment in full-term infants is performed by using charts developed by the National Center for Health and Statistics. The assessment of post-natal growth in premature infants is controversial and can be performed by using either intrauterine or extrauterine standards. The selection of appropriate growth charts should be based on clinical, demographic, ethnic, and socioeconomic similarities of the population used for reference. Daily energy intakes ranging from 100 to 120 kcal/kg/day have been recommended for full-term infants, while higher intakes ranging from 114 to 181 kcal/kg/day have been recommended for premature neonates. Full-term infants should be nursed or nipple fed on demand; however, premature infants should ideally be tube fed by intermittent gastric feeding (gavage). Continuous gastric and transpyloric feedings are indicated in selected infants. Human milk is a preferred food for full-term infants during the first six months of life; however, this precept does not suggest that all infants who are exclusively breast-fed will grow adequately. Preterm human milk is also a preferred food for the low birthweight infant, provided nutritional supplements are used. It is unclear whether the supplementation of vitamin D, iron, and fluoride in full-term breast-fed infants should be started at birth, at the time of initiation of solid foods, or at the age of six months. The routine supplementation of multivitamins, folic acid, and vitamin E to all low birthweight infants is controversial. Most investigators suggest vitamin supplementation be given until the intake of formula or breast milk is sufficient to meet daily requirements. Vitamin E appears to exert a protective effect in premature infants against the development of severe retinopathy. The supplementation of vitamin E should be dependent upon the serum vitamin E concentration. It is controversial whether iron supplementation for premature infants should be initiated soon after birth or at two months of age, or whether higher doses of iron should be given to very low birthweight infants. If iron supplementation is started at birth, vitamin E status should be closely monitored. Although the optimal intakes of calcium and phosphorus in infant feedings have not been firmly established, the levels of calcium and phosphorus in human milk appear to be inadequate for the growing low birthweight infant.(ABSTRACT TRUNCATED AT 400 WORDS)

Improved neurologic function after long-term correction of vitamin E deficiency in children with chronic cholestasis

We studied the effect of long-term correction of vitamin E deficiency on neurologic function in 14 children with chronic cholestasis. Vitamin E repletion was achieved in all, either by large oral doses (up to 120 IU per kilogram of body weight per day) or by intramuscular administration of dl-alpha-tocopherol (0.8 to 2.0 IU per kilogram per day). With early institution of therapy, neurologic function remained normal in two asymptomatic children below the age of three years after 15 and 18 months of therapy. Neurologic function became normal in three symptomatic children below age three after 18 to 32 months of therapy. Restitution of neurologic function was more limited in nine symptomatic children 5 to 17 1/2 years old after 18 to 48 months of therapy. We conclude that vitamin E repletion therapy should be initiated at an early age in children with chronic cholestasis complicated by vitamin E deficiency, to prevent irreversible neurologic injury.

Infant nutrition and supplements

Today, American consumers believe they need more and better nutrients than their diets provide. Consequently, consumers spend approximately three billion dollars each year on vitamin and nutrition products. Vitamin and/or mineral supplements are relatively inexpensive and available without a prescription; therefore, it is understandable that they are used by a substantial portion of the population. However, the last 50 years have witnessed a steadily increasing understanding of vitamins and trace mineral biochemistry and its role in human nutrition and intermediary metabolism. It has not been shown conclusively that normal breastfed infants of well nourished mothers need any specific vitamin and mineral supplements, with the exception of iron and fluoride. The use of vitamin D supplements remains controversial. Preterm infants may require supplements of vitamin E, iron, and folic acid because of their rapid rate of growth and less complete, intestinal absorption.

Total parenteral nutrition in children

This article first focuses on the indications for total parenteral nutrition and the effect of its use on the outcome of various nutrient-depleting diseases in infants and children. This is followed by a discussion of some of the newer nutrient additions to total parenteral nutrition regimens, such as biotin, carnitine, zinc, copper, iron, and others.

Vitamin E status in preterm infants fed human milk or infant formula

Vitamin E status was assessed in 36 infants with birth weights less than 1500 gm who were assigned randomly to receive one of three sources of nutrition: milk obtained from mothers of preterm infants (preterm milk), mature human milk, or infant formula. Infants in each dietary group were further assigned randomly to receive iron supplementation (2 mg/kg/day) beginning at 2 weeks or to receive no iron supplementation. All infants received a standard multivitamin, providing 4.1 mg alpha-tocopherol daily. Serum vitamin E concentrations at 6 weeks were significantly related both to type of milk (P less than 0.0001) and to iron supplementation (P less than 0.05). Infants fed preterm milk had significantly higher serum vitamin E levels than did infants fed mature human milk, and both groups had significantly higher levels than did those fed formula. Ratios of serum vitamin E/total lipid were also significantly greater for infants fed human milks than for those fed formula. The addition of iron to all three diets resulted in significantly lower serum vitamin E levels at 6 weeks (P less than 0.05); however, only in the group fed formula was there evidence of vitamin E deficiency. Preterm milk with routine multivitamin supplementation uniformly resulted in vitamin E sufficiency in VLBW infants whether or not iron was administered.

Anemia of prematurity: determinants of the erythropoietin response

This study was undertaken to determine the factors that are important in determining the erythropoietin response in low-birth-weight infants during the period of so-called anemia of prematurity. In the first weeks of life oxygen consumption in a group of 21 infants gradually increased as hemoglobin level fell. The magnitude of the erythropoietin response inversely varied with the central venous oxygen tension (P-vO2) (r = -0.55, P less than 0.001). When the P-vO2 declined to less than 30 torr, erythropoietin values were uniformly increased above the "normal" range (defined as the values associated with P-vO2 greater than 38 torr). Erythropoietin values varied inversely with hemoglobin but in general did not exceed the values observed for normal adult men. The erythropoietin values in the infants were remarkably lower at any given hemoglobin level when compared with those of older children with anemia resulting from bone marrow failure. In general, elevations of erythropoietin were seen when the hemoglobin concentration declined to less than 10.0 gm/dl. Change in heart rate did not appear to be a reliable indicator of the presence of anemia; rather, it correlated best with oxygen consumption.

Proposed treatment of Duchenne muscular dystrophy with desferrioxamine

The primary disturbance in Duchenne muscular dystrophy (DMD) appears to affect membrane function, and changes characteristic of oxidant-induced damage occur in skeletal muscle and erythrocytes. There is recent evidence that DMD is a functional tocopherol deficiency, with reduced levels of the lipoprotein required to carry tocopherol to tissues. This may explain the parallels between DMD and dietary tocopherol deficiency. Thus DMD should follow the usual experience of other examples of oxidative pathology, where the balance between tocopherol, the main antioxidant in membrane lipids, and non protein-bound iron, an important catalyst of reactions which produce oxidizing free radicals, largely determines whether or not tissue damage occurs. Desferrioxamine prevents oxidant damage in vitro and in vivo by removing this iron, and may therefore be able to reverse the muscle damage of DMD. Recent experience with this drug in long term dialysis patients is consistent with this suggestion.

Vitamin E deficiency during chronic childhood cholestasis: presence of sural nerve lesion prior to 2 1/2 years of age

Vitamin E malabsorption and deficiency during chronic childhood cholestasis has been associated with a progressive ataxic neurologic syndrome. Hyporeflexia, the first sign of neurologic dysfunction, may begin prior to age 2 years, but severe symptoms do not develop until age 5 to 10 years. To establish the age of onset of neuropathologic lesions, we prospectively evaluated four young children with severe cholestasis. Malabsorption and deficiency of vitamin E were documented by low serum vitamin E concentrations, low serum vitamin E to total serum lipids ratios, elevated hydrogen peroxide hemolysis, and impaired absorption of a pharmacologic dose of alpha-tocopherol. Abnormal neurologic findings in two patients were limited to areflexia, ptosis, mild truncal ataxia, and hypotonia; two patients had minimal signs of neurologic dysfunction. Sural nerve histology at age 6 to 25 months revealed a degenerative axonopathy involving large-caliber myelinated fibers, but without quantitative axonal loss. Muscle histology and histochemistry tests yielded normal results. Our study suggests that neurologic injury may occur during the first two years of life in vitamin E-deficient children with cholestatic hepatobiliary disease, obligating aggressive attempts at correcting this deficiency state at a very young age.

Selenium and vitamin E sufficiency in premature infants requiring total parenteral nutrition

A randomized prospective study of LBW infants was undertaken to evaluate the effect of parenteral lipid infusions upon their antioxidant systems. Ten babies received a parenteral nutrition regimen with lipid emulsion, and ten received a regimen without lipid. Although the addition of lipid emulsion to the total parenteral nutrition regimen led to a rise in vitamin E levels, the selenium levels fell in both groups. Neither group showed evidence of deficient antioxidant systems by the peroxide hemolysis test or thiobarbituric acid test. There did not seem to be any adverse effect of the lipid infusion upon the clinical course of the infants except for hyperlipidemia. There was a better weight gain in infants receiving lipid.

Do breast and bottle fed babies require vitamin supplements?

In the present stage of knowledge, the following approach to vitamin supplementation seems reasonable. Breast-fed full-term infants should be supplemented with vitamin D (400 I.U./day). Supplementation of bottle-fed infants will depend upon the vitamin content of the formula which is being used. Pre-term and LBW infants may need higher amounts of vitamin D (800-1 000 I.U./day) and should be supplemented with vitamin E (1-2 I.U./day), C (50 mg/day), B6 (30-60 mcg/day) and folic acid (50-100 mcg/day) when they are being fed formulas with high amounts of PUFA and proteins or with iron. Multivitamin supplementation appears to be acceptable for infants of very low birth weight (less than 1 500 g) until they reach a body weight of at least 2 000 grams or a caloric intake of 300 kcal/day. Finally, the present routine of administering 0.5-1.0 mg of vitamin K at birth to all infants should be continued.