Cali-Harvard Nutrition Project. I. Megaloblastic anemia in kwashiorkor

Hematologic and bone marrow changes in children with protein-energy malnutrition

BACKGROUND

All systems in an organism are affected by protein-energy malnutrition (PEM), but one of the worst affected is the hematopoietic system. Today PEM remains a very serious problem in developing countries. We examined the relationships between clinical features, hematological, and bone marrow changes with severe PEM from Turkey.

METHOD

We evaluated 34 (11 females and 23 males) consecutive cases of severe PEM, with no underlying diseases aged 3-20 months. The clinical nutritional conditions of the patients were determined using the Wellcome-Trust PEM classification. Ten of the patients were in the Marasmic-Kwashiorkor (M-K) group, 10 were in the Kwashiorkor (KW) group, and 14 were in the Marasmic (M) group. Full blood count, protein, albumin, serum iron (SI), iron-binding capacity (TIBC), ferritin, vitamin B12, folic acid, complement-3 (C3), complement-4 (C4), and bone marrow were investigated in all groups.

RESULTS

Anemia was detected in 97% of patients. We determined serum iron levels were low in 67.6% of the patients, TS levels were low in 76.4% of the patients and ferritin levels were low in 20.5%. The level of vitamin B12 was normal in all patients. Bone marrow analysis showed erythroid series hypoplasia in 28.5% of patients in the M group, 50% in the KW group, and 30% in the M-K group. Marrow iron was absent in 58.8% of patients.

CONCLUSION

The most common hematologic change in the children with PEM was anemia and major cause of anemia was iron deficiency in this study. Patients with severe PEM have normal Vit B12 and serum folate levels. Most of the patients with severe PEM had normal cellularity with megaloblastic and dysplastic changes in bone marrow due to the inadequate and imbalanced intake of protein and energy.

The folic acid activity of some milk foods for babies

Folic acid activity was determined for National Dried Milk and for 5 proprietary dried milk foods for babies, for a proprietary liquid milk baby food and for 8 brands of tinned evaporated milk. For comparison, values were determined for mature breast milk, for raw bulk cow's milk, for bottled pasteurized cow's milk and for goat's milk.

Human milk and raw and pasteurized cow's milk all had much the same folate activity, equivalent to about 54 µg folic acid/1. Values for goat's milk were much lower, around 6 µg/1.

Values for the reconstituted baby milks ranged from 9 to 65 µg/1, though only 2 of the products had markedly lower values than breast milk. The question is discussed whether the folic acid requirement in infants can be met by formulas based on cow's milk without having recourse to folic acid supplementation.

Plasma and red blood cell folate in breastfed infants

We have studied growth, red blood cell status and folate concentrations in plasma and red cells in a group of 35 breastfed infants during the first year of life. Folic acid supplementation was not given to the mothers during pregnancy or lactation, and none of them developed megaloblastic anaemia. The growth and red blood cell status of the infants were both normal. At birth, and throughout the period of observation, the folate concentrations in plasma and red cells were significantly higher than in the adult reference material. A positive correlation between plasma and red cell folate was demonstrated. During the latter part of pregnancy and lactation the foetuses and infants seem to be protected against folate deficiency. We regard the folate status of normal breastfed infants as optimal. The optimal supply of the vitamin in artificial nutrition should be the amount of folate necessary to maintain plasma and red cell folate concentrations similar to those found in breastfed infants.