Misplaced iron in kwashiorkor.

OBJECTIVES: To determine the presence of radical promoting iron (non-protein-bound or loosely bound or free iron) in the plasma of children with kwashiorkor. DESIGN: The bleomycin assay was employed for the quantitation of free or loosely bound iron. SETTING: The Red Cross War Memorial Children's Hospital, Cape Town, Tertiary Care. SUBJECTS: Fifty children on admission with kwashiorkor: six with marasmus and twelve healthy well-nourished controls. RESULTS: Non-protein-bound iron was detected in the plasma of 58% of children with kwashiorkor but was absent in marasmic and healthy well-nourished children. CONCLUSIONS: The presence of radical promoting iron supports the hypothesis that a free radical injury probably plays a role in the pathogenesis of kwashiorkor and its removal may improve mortality.

An evaluation of the Ramco kit for serum ferritin assay.

The determination of serum ferritin levels may be of diagnostic importance in medicine. To establish whether values obtained using a commercially available kit (Ramco) were adequate for this purpose, a comparison was undertaken using a two-site immunoradiometric assay that had been developed and standardized in our laboratories. Over the range 6 micrograms/l to greater than 2 000 micrograms/l there was a correlation coefficient between the two methods of 0,8284 (P less than 0.001). It is concluded that the Ramco kit is suitable for use in clinical practice.

Free erythrocyte protoporphyrin levels in the first year of life.

Free erythrocyte protoporphyrin (FEP) levels were measured in 161 infants judged not to be iron-deficient. In addition to high mean FEP levels in cord blood, a significant number of infants had FEP levels in excess of 120 micrograms/dl red blood cells during the first 6 months of life. These levels are comparable to those found in iron-deficient adults. It is concluded that the clinical significance of an FEP level in excess of 120 micrograms/dl and its value as a marker of early iron deficiency during the first 6 months of life require further study. FEP values in excess of 120 micrograms/dl were not observed in infants aged 7-12 months.

Iron fortification of infant milk formula: the effect on iron status and immune function.

We conducted a randomized double-blind trial of a cow's milk infant formula with increased iron fortification in order to confirm its safety and to measure its effects on iron status and immune function. A group of full-term, well nourished and healthy infants was followed from the age of 3 months to 1 year. A control group of 74 infants was given a commercially available infant formula containing 8.3 mg Fe/100g. The test group of 75 infants received a similar formula with 40 mg Fe/100 g. The formula with the extra iron proved to be safe and, when compared with the control group, the children in the test group had significantly improved iron status as reflected by the proportion of children classed as normal (25 of 61 cf. 44 of 65; p less than 0.003), and by the mean values of the haemoglobin concentration (11.5 cf. 11.9 g/dl; p = 0.04), red cell distribution width (15.5% cf. 14.4%; p = 0.0005), red cell zinc protoporphyrin (3.4 cf. 4.0 micrograms/g Hb; p = 0.04) and ferritin (29 cf. 17.3 micrograms/l; p = 0.004). The extra iron fortification depressed zinc concentration in plasma (90.6 cf. 83.5 micrograms/l; p = 0.05). There was no significant difference between the two groups for laboratory measures of immune function or for incidence of infection. No adverse effects such as infection could be attributed to the increased iron. We conclude that iron fortification of cow's milk infant formula may be safely increased to 40 mg/100 g (i.e. by a factor of 4.8 over the common concentration of 8.3 mg/100 g), but that this has less than the expected effect on iron status. Further studies are required to define (a) the long-term role of facilitators of iron absorption such as ascorbic acid, (b) the interaction of iron with absorption of divalent trace elements such as zinc, and (c) the effect of iron status on immune function and susceptibility to infection.

Lead absorption in Cape children: a preliminary report.

There is little information on environmental lead absorption in childhood in southern Africa. The concentration of lead in the dentine of shed teeth was measured as a cumulative marker of long-term absorption in 80 children attending a Cape Town dental clinic. Blood lead levels were determined in 226 children, 114 from the Red Cross War Memorial Children's Hospital, Cape Town, 23 from Ciskei and 89 from a dental clinic. This small survey reports on the precision of laboratory technique and indicates that some children living in urban Cape Town have accumulated lead to an extent comparable to that in large Western cities.

Ferritin levels in human milk.

Ferritin was detected and quantitated in breast milk from 24 mothers of healthy fullterm infants 3 days, 7 days, 6 weeks and 3 months after delivery. Highest concentrations were found at day 3 and demonstrated a marked decline at day 7, with negligible levels at 6 weeks and 3 months. The values in breast milk were compared with mother's serum ferritin concentration at delivery and a significant but weak correlation (r = 0.475, P less than 0.05) was found between the paired values of maternal serum ferritin at delivery and breast milk ferritin at day 3. The possible biological significance of ferritin in breast milk is discussed.

Plasma free iron: a possible cause of oedema in kwashiorkor.

BACKGROUND: Oedema is a sine qua non for the diagnosis of kwashiorkor yet the mechanisms leading to oedema remain ill defined. AIMS: To relate the plasma concentration of radical promoting 'free' iron to the degree of oedema in patients with kwashiorkor. SETTING: University teaching hospital. PATIENTS: Fifteen children with kwashiorkor, nine of whom had severe and six of whom had a moderate degree of oedema. METHODS: Plasma 'free' iron was measured as bleomycin detectable iron (BDI) and related to severity of oedema and plasma albumin concentration. RESULTS: BDI was significantly higher in the patients with severe oedema (20.5 v 6.75 mumol/l) whereas the albumin concentrations were similar (16 v 17 g/l). BDI was no longer present in any patients 30 days after admission. CONCLUSIONS: 'Free' circulating iron may contribute to the oedema of kwashiorkor, and its sequestration could hasten recovery and decrease morbidity and mortality.

Diagnosis of iron deficiency: mean corpuscular hemoglobin (MCH) as a predictor of iron deficiency in infants.

Hematologic variables were measured in 240 apparently healthy infants ranging from 1-12 months of age attending a well baby clinic. There were 20 infants for each month of age. Hematologic parameters were measured in each infant by Coulter Counter Model S. Serum iron, total iron binding capacity, free erythrocyte protoporphyrin (FEP) and serum ferritin levels were measured in most infants. Their weights together with their serum iron, total iron binding capacity, and serum ferritin were judged to be independent variables of iron status, whereas the hematologic variables were considered to be response variables indicative of iron status. The correlation coefficients among these variables, after excluding redundant variables and transforming to logarithms, were computed. Canonical correlation analysis was applied to the matrix of correlation coefficients to yield the linear function of the independent variables most highly correlated with a linear function of the response variables. The linear function of the response variables was found to be well approximated by the logarithm of the mean corpuscular haemoglobin, which was highly correlated with each of the independent variables.

Measurement of zinc and copper levels in breast milk.

Zinc and copper levels in breast milk were measured to assess the accuracy of the analysis and to obtain a range of values for the local population. Samples were collected 7 days after delivery from 48 well-nourished mothers who had given birth to healthy full-term infants. The method was found to be accurate and reproducible provided precautionary measures were taken to avoid sample contamination. A wide variation in values was found in samples from different mothers, however, ranging from 155 to 680 microgram/dl for zinc and from 27 to 90 microgram/dl for copper.

Blood lead levels in preschool children in Cape Town.

Blood lead levels were assessed in 293 children aged between 4 and 6 years attending preschool centres in metropolitan Cape Town in order to establish the degree of lead absorption. Anthropometric data, blood count, zinc protoporphyrin and blood lead level were obtained for each child. A questionnaire was used to determine socio-economic status, dietary habits and history of pica. Thirteen children, or 4,4% of those sampled, had blood levels of greater than or equal to 30 micrograms/dl. The majority of these children lived in close proximity to one another in a socially deprived inner urban environment. Environmental sampling for lead was carried out in the homes of children with the highest blood levels as well as in the homes of a matched control group with low levels living in the same area. The only difference was a significantly higher incidence of pica in the children with high levels.

Reference values for serum copper, ceruloplasmin and zinc and haematological indices for healthy nulliparous females.

Reference serum copper, ceruloplasmin and zinc values were established for 100 healthy white nulliparous students aged 18-23 years resident in Cape Town who had been taking low-dosage triphasic contraceptives for a minimum period of 3 months, and in 100 female students not taking contraceptives. The mean serum copper values were 26.5 +/- 4.2 mumol/l and 16.9 +/- 2.7 mumol/l for those taking and not taking oral contraceptives respectively; corresponding values for ceruloplasmin were 181 +/- 43.9 IU/ml and 110 +/- 22.7 IU/ml respectively. Both differences were statistically significant. Serum zinc values for those on contraceptives were 14.1 +/- 2.1 mumol/l and for the others 14.7 +/- 2.0 mumol/l. There were no differences in the haematological parameters except for a significantly higher mean corpuscular volume in females taking oral contraceptives. Of possible clinical significance in this student population are prevalence rates of 2.2% for anaemia (haemoglobin value less than 11.5 g/dl), 7% for iron deficiency (serum ferritin less than 12 micrograms/l) and 6.6% for iron depletion (serum ferritin 12-20 micrograms/l).

Prevention of iron deficiency in preterm neonates during infancy.

The preterm infant inevitably develops iron deficiency unless supplementary iron is given. Oral iron supplementation is preferred in ideal social circumstances but, where compliance with such therapy is uncertain, intramuscular iron dextran may be a more effective treatment. A study was conducted to compare the effectiveness of two methods of preventing iron deficiency of prematurity. One group of healthy premature infants was given oral iron 2 mg/kg/d until the age of 6 months. The second similar group was given 100 mg as intramuscular iron dextran (Imferon; Fisons) between the ages of 6 and 8 weeks. Both kinds of supplementary iron appeared to have benefited the majority of infants in this trial.

Reference concentrations of serum selenium and manganese in healthy nulliparas.

Reference serum selenium and manganese concentrations were established for healthy nulliparas aged 18-23 years resident in Cape Town. Measurements were determined for selenium in 100 female students who had been taking low-dosage triphasic contraceptive medication for a minimum of 3 months and in 100 female students who were not on contraceptive therapy. Manganese concentrations were determined for 25 female students from each group. The mean serum selenium concentrations were 0.988 +/- 0.189 micrograms/l (78 +/- 15 micrograms/dl) and 0.925 +/- 0.177 mumol/l (73 +/- 14 micrograms/l) respectively for females taking and not taking oral contraceptives. The corresponding concentrations for manganese were 21.84 +/- 9.82 nmol/l (1.20 +/- 0.54 micrograms/l) and 21.66 +/- 7.64 nmol/l (1.19 +/- 0.42 micrograms/l) respectively. The differences in selenium were statistically significant (P = 0.0231) but not for manganese (P = 0.910).

Red blood cell antioxidant enzyme concentrations in kwashiorkor and marasmus.

Kwashiorkor may occur when an imbalance between pro- and antioxidants in malnourished children results in an excess of free radicals. The concentrations of the antioxidant enzymes catalase (CAT), superoxide dismutase (SOD), reduced glutathione (GSH) and glutathione peroxidase (GPX) were measured in erythrocytes of 22 children with kwashiorkor on admission to hospital and repeated on days 5, 10 and 30 of recovery. The concentrations were compared with those in 22 children with marasmus and in 20 children who were normally nourished but had infective illness necessitating their hospitalization. CAT and SOD were similar in all groups and did not change during recovery. GSH and GPX were significantly lower in kwashiorkor than in the other groups. Concentrations of thiobarbituric acid-reactive substances (TBARS), a marker of lipid peroxidation, were significantly elevated in children with kwashiorkor. During clinical recovery, GSH but not GPX concentrations rose despite an increase in plasma selenium levels and decreased concentrations of TBARS. These findings suggest that the antioxidant status of children with kwashiorkor differs from that of well nourished and marasmic children. Whether these differences are the cause of the consequence of the clinical picture is unresolved.

Antibacterial activity of amniotic fluid.

The antibacterial activity of amniotic fluid against Escherichia coli in the last month of pregnancy was reduced in an unselected sample of mothers delivering in Cape Town. Amniotic fluid zinc, required for normal antibacterial activity, was also reduced. These findings offer an explanation for the high incidence of amniotic fluid infection previously reported.

Serum zinc and copper levels in healthy middle and higher socio-economic class infants in Cape Town. A longitudinal study during the 1st year of life.

Serum zinc and copper levels were measured using a flame atomic absorption technique in 55 healthy infants and their middle and upper socio-economic class mothers at delivery, and also longitudinally in the infants during the first 12 months of life. Mean cord serum zinc levels (99.50 +/- 27.63 micrograms/100 ml) were 1.5 times higher than maternal serum levels at birth (66.3 +/- 21.0 micrograms/100 ml). The mean serum zinc levels showed no significant change (P greater than 0.05) at each of the study periods. However, the mean serum zinc levels at birth were significantly higher (P less than 0.05), than those after 6 weeks. The infants' levels remained within the normal adult range at all the study periods. The mean cord serum copper levels (34.46 +/- 12.60 micrograms/100 ml) were about one-sixth of the mean maternal serum copper levels at delivery (217.7 +/- 64.39 micrograms/100 ml). The mean serum copper levels increased significantly (P less than 0.05) from birth to 12 months of age. Mean serum copper levels similar to those of normal adults were reached at 12-24 weeks.

Serum zinc and copper levels in healthy South African women at term and during the first year after childbirth.

Serum zinc and copper levels were measured longitudinally in 55 healthy middle and upper socio-economic group white mothers living in Cape Town from the birth of the baby to 12 months after parturition. Mean maternal serum zinc levels showed a significant rise (P less than 0.05) from delivery (66.34 +/- 21.07 micrograms/100 ml) to 12 weeks (87.88 +/- 15.93 micrograms/100 ml), but no further changes were detected at 24, 36 and 52 weeks after parturition. The mean maternal serum copper levels decreased from 217.73 +/- 64.34 micrograms/100 ml at delivery to 141.65 +/- 45.60 micrograms/100 ml at 12 weeks (P less than 0.05); they remained constant at all the other sampling periods. No differences (P greater than 0.05) were noted at all the different sampling periods between mean serum zinc levels of primiparous and multiparous mothers, but mean serum copper levels were significantly higher (P less than 0.05) in the primiparas. The mean serum zinc and copper levels of healthy white South African mothers at delivery and 12 months after parturition correspond with those for Northern American mothers. Normal non-pregnant adult serum zinc and copper levels were attained within 12 weeks of delivery.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations in children with kwashiorkor in the acute stage and during refeeding.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations were measured in 22 children with kwashiorkor on admission to hospital and on days 5, 10 and 30 of refeeding. Twenty similarly aged, healthy, well nourished children served as controls. The mean (SEM) zinc, copper and selenium concentrations of 7.5 (0.93), 10.8 (0.64) and 0.29 (0.02) mumol/l, respectively, in the children with kwashiorkor on admission were all significantly lower than the values of 13.7 (0.66), 25.6 (1.72) and 0.72 (0.04) mumol/l in the controls. In contrast, the erythrocyte manganese level of 1.67 (0.09) micrograms/gHb and the median ferritin concentration of 293 micrograms/dl were significantly higher than in the controls. After 30 days there was full clinical recovery with significant weight gain and a return of the plasma albumin, caeruloplasmin, copper and ferritin to normal. However, manganese remained elevated and zinc and selenium concentrations remained significantly low. Our results suggest that nutritional rehabilitation of children with kwashiorkor is incomplete by 30 days and cannot be judged purely by a return of the plasma proteins to normal. Addition of selected trace elements to the diet may hasten full recovery.

Bone marrow and chelatable iron in patients with protein energy malnutrition.

OBJECTIVES: To examine the iron status of malnourished children by comparing bone marrow iron deposits in children with protein energy malnutrition with those in well-nourished controls, and measuring chelatable urinary iron excretion in children with kwashiorkor. DESIGN: Bone marrow iron was assessed histologically in postmortem specimens from children with kwashiorkor or marasmus, and from controls. Twenty-four-hour urinary iron was measured in children with severe kwashiorkor, half of whom received 10 mg/kg of intramuscular desferrioxamine (DFO) on admission. SETTING: Red Cross War Memorial Children's Hospital, Cape Town. SUBJECTS: Thirteen children with kwashiorkor, 6 with marasmus and 16 well-nourished children underwent bone marrow examination. Urinary iron excretion was assayed in 17 children with kwashiorkor. RESULTS: Stainable iron was present in the bone marrow of half the children with kwashiorkor but in only 1 child in each of the other groups. The median iron excretion was 945.5 micrograms/24 hours in the DFO group compared with 28.5 micrograms/24 hours in the non-DFO group. CONCLUSIONS: There is an apparent excess of iron which may predispose to bacterial infections and free radical-mediated injury in children with kwashiorkor.

Zinc and copper levels in the breast-milk of Cape Town mothers.

Zinc and copper levels were measured longitudinally in the breast-milk of 55 healthy South African women from the middle and upper socio-economic classes. The mean foremilk zinc levels showed a significant fall (P less than 0,05) from 652,9 +/- 240,7 micrograms/dl at 3 days after delivery to 413,3 +/- 143,0 micrograms/dl at 7 days and 228,1 +/- 136,1 micrograms/dl at 6 weeks. Lower foremilk zinc levels were obtained at 36 weeks (64,3 +/- 50,0 micrograms/dl). In contrast, foremilk copper levels were low at 3 days (57,0 +/- 74,8 micrograms/dl), with a gradual decline to very low levels (28,0 +/- 29,7 micrograms/dl) at 36 weeks. No differences were detected between the fore- and hindmilk zinc and copper levels at any stage of lactation studied (P greater than 0,05).