Health and nutrition of loggerhead sea turtles (Caretta caretta) in the southeastern United States.

Loggerhead sea turtles (Caretta caretta) are opportunistic carnivores that feed primarily on benthic invertebrates and fish. Sea turtle rehabilitation requires provision of a species-specific, balanced diet that supplies nutrition similar to that of a wild diet; this can be challenging because free-ranging loggerheads' diets vary depending on their life stage and geographic location, with predominant prey species dictated by local availability. The goal of this study was to better understand the nutritional needs of subadult and adult loggerheads in rehabilitation. This was accomplished by conducting a retrospective survey of stomach contents identified during gross necropsy of 153 deceased loggerheads that stranded in coastal Georgia, USA. A total of 288 different forage items were identified; the most frequently observed prey items belong to the subphylum Crustacea (N = 131), followed by bony fish (Osteichthyes; N = 45), gastropod mollusks (N = 40), bivalve mollusks (N = 23), and Atlantic horseshoe crabs (Limulus polyphemus; N = 15). The proportions of certain prey items differed significantly with turtle size; adult turtles ate proportionately more gastropods (p = 0.001), and subadults ate proportionately more fish (p = 0.01). Stomach contents information was used to determine common local prey items (blue crab, cannonball jellyfish, horseshoe crab, whelk), which were evaluated for nutritional content. Additionally, we compared hematology and plasma biochemistry profiles (including proteins, trace minerals, and vitamins) between four cohorts of loggerhead turtles, including free-ranging subadults and adults, nesting females, and loggerheads undergoing rehabilitation. This information was applied to inform a regionally specific, formulated diet for tube feeding, and a supplement containing vitamins and minerals for captive loggerheads, to more closely approximate the nutritional content of their natural diet. Assessing the regional and temporal variability in loggerhead diets is an important component in their effective conservation because resultant data can be used to help understand the impacts of environmental perturbations on benthic food webs.

Adequacy of Infant Formula With Protein Content of 1.6 g/100 kcal for Infants Between 3 and 12 Months.

OBJECTIVES: Infant formulas provide more protein than breast milk. High protein intakes may place infants at risk of later obesity. The present study tested whether a formula with protein content below the regulatory level supports normal growth from age 3 months. METHODS: Randomized double-blind trial enrolled healthy infants less than age 3 months. At 3 months, formula-fed infants were assigned to experimental (EXPL, 1.61 g protein/100 kcal; modified bovine whey proteins with caseinoglycomacropeptide removed) or control (CTRL 2.15 g protein/100 kcal; unmodified bovine milk protein with a whey/casein ratio of 60/40) formula; breast-fed (BF) infants were enrolled in a reference group. Complementary foods were allowed in small amounts from 4 to 6 months and unrestricted after 6 months. RESULTS: Weight gain (g/day) from 3 to 6 months was similar in the EXPL and CTRL groups (EXPL-CTRL -0.84 g/day; 95% confidence interval -2.25 to 0.57) and faster in the EXPL and CTRL groups than in the BF group. Weight analyzed longitudinally from 4 to 12 months was lower in the EXPL group than in the CTRL group (P = 0.031) but higher than in the BF group (P < 0.0001). Longitudinal analysis of odds ratios from 4 to 12 months indicated fewer infants with weight >85th percentile in the EXPL group than in the CTRL group (P = 0.015). Length z scores were lower than, and body mass index z scores were similar to, World Health Organization Standards in all of the groups. Serum biochemical parameters in the EXPL group reflected lower protein intake and were closer to parameters in the BF infants than in the CTRL group. CONCLUSIONS: A formula with 1.61 g of protein/100 kcal supports normal growth of infants after age 3 months. This protein content is adequate if provided from a high-quality source.

PHARMACOKINETICS OF TRAMADOL AND O-DESMETHYLTRAMADOL IN LOGGERHEAD SEA TURTLES (CARETTA CARETTA).

The objective of this study was to determine the pharmacokinetics of two orally administered doses of tramadol (5 and 10 mg/kg) and its major metabolite (O-desmethyltramadol) (M1) in loggerhead sea turtles (Caretta caretta). After oral administration, the half-life of tramadol administered at 5 and 10 mg/kg was 20.35 and 22.67 hr, whereas the half-life of M1 was 10.23 and 11.26 hr, respectively. The maximum concentration (Cmax) for tramadol after oral administration at 5 mg/kg and 10 mg/kg was 373 and 719 ng/ml, whereas that of M1 was 655 and 1,376 ng/ml, respectively. Tramadol administered orally to loggerhead sea turtles at both dosages provided measurable plasma concentrations of tramadol and O-desmethyltramadol for several days with no adverse effects. Plasma concentrations of tramadol and O-desmethyltramadol remained ≥100 ng/ml for at least 48 and 72 hr when tramadol was administered at 10 mg/kg.

Vitamin D supplementation of breastfed infants: a randomized dose-response trial.

BACKGROUND: Breastfed infants require supplementation with vitamin D (vD), but little is known about the necessary dose. This double blind trial evaluated four different doses of vD. METHODS: Exclusively breastfed infants (N = 213) were randomized at 1 mo to one of four doses, which they received through 9 mo while receiving no formula. The supplements provided daily 200 IU, 400 IU, 600 IU, or 800 IU of vD. The primary endpoint was plasma 25(OH)D level, and secondary outcomes were plasma parathyroid hormone and calcium, and illness incidence. The study was conducted during winter at 41° N. RESULTS: Most infants had low (<50 nmol/l) 25(OH)D levels at 1 mo, but with supplementation levels rose. Overall, levels of 25(OH)D differed significantly in proportion to vD dose. There were no effects of vD on illness incidence or growth. Low levels were common, with 7.8% of levels being <50 nmol/l and 15 infants having 2 to 4 low levels. CONCLUSION: The four doses of vD produced different plasma levels of 25(OH)D. The higher doses were somewhat more efficacious in maintaining vD sufficiency in breastfed infants. The findings support the recommended dose of 400 IU/d, and stress the need to start supplementation at birth.

Phosphorylation of alfalfa mosaic virus movement protein in vivo.

The 32-kDa movement protein, P3, of alfalfa mosaic virus (AMV) is essential for cell-to-cell spread of the virus in plants. P3 shares many properties with other virus movement proteins (MPs); however, it is not known if P3 is posttranslationally modified by phosphorylation, which is important for the function of other MPs. When expressed in Nicotiana tabacum, P3 accumulated primarily in the cell walls of older leaves or in the cytosol of younger leaves. When expressed in Pischia pastoris, P3 accumulated primarily in a soluble form. Metabolic labeling indicated that a portion of P3 was phosphorylated in both tobacco and yeast, suggesting that phosphorylation regulates the function of this protein as it does for other virus MPs.

Low-protein formula slows weight gain in infants of overweight mothers.

OBJECTIVES: Infant formulas provide more protein than breast milk. High protein intakes, as well as maternal obesity, are risk factors for later obesity. The present study tested whether a formula with lower protein content slows weight gain of infants of overweight mothers (body mass index [BMI] >25 kg/m). METHODS: In a randomized double-blind study infants of overweight mothers received from 3 months an experimental (EXPL) formula with 1.65 g of protein/100 kcal (62.8 kcal/100 mL) and containing probiotics, or a control (CTRL) formula with 2.7 g of protein/100 kcal (65.6 kcal/100 mL). Breast-fed infants were studied concurrently. Primary assessment was between 3 and 6 months, although formulas were fed until 12 months. Biomarkers of protein metabolism (blood urea nitrogen, insulin growth factor-1, insulinogenic amino acids) were measured. RESULTS: Infants fed the low-protein EXPL formula gained less weight between 3 and 6 months (-1.77 g/day, P=0.024) than infants fed the CTRL formula. In the subgroup of infants of mothers with BMI>30 kg/m the difference was -4.21 g/day (P=0.017). Weight (P=0.011) and BMI (P=0.027) of EXPL infants remained lower than that of CTRL infants until 2 years but were similar to that of breast-fed infants. Blood urea nitrogen, insulin growth factor-1, and insulinogenic amino acids at 6 months were significantly lower in EXPL compared with CTRL. CONCLUSIONS: A low-protein formula with probiotics slowed weight gain between 3 and 6 months in infants of overweight mothers. Weight gain and biomarkers were more like those of breast-fed infants.

Factors influencing survivorship of rehabilitating green sea turtles (Chelonia mydas) with fibropapillomatosis.

Marine turtle fibropapillomatosis (FP) is a debilitating, infectious neoplastic disease that has reached epizootic proportions in several tropical and subtropical populations of green turtles (Chelonia mydas). FP represents an important health concern in sea turtle rehabilitation facilities. The objectives of this study were to describe the observed epidemiology, biology, and survival rates of turtles affected by FP (FP+ turtles) in a rehabilitation environment; to evaluate clinical parameters as predictors of survival in affected rehabilitating turtles; and to provide information about case progression scenarios and potential outcomes for FP+ sea turtle patients. A retrospective case series analysis was performed using the medical records of the Georgia Sea Turtle Center (GSTC), Jekyll Island, Georgia, USA, during 2009-2013. Information evaluated included signalment, morphometrics, presenting complaint, time to FP onset, tumor score (0-3), co-morbid conditions, diagnostic test results, therapeutic interventions, and case outcomes. Overall, FP was present in 27/362 (7.5%) of all sea turtles admitted to the GSTC for rehabilitation, either upon admittance or during their rehabilitation. Of these, 25 were green and 2 were Kemp's ridley turtles. Of 10 turtles that had only plaque-like FP lesions, 60% had natural tumor regression, all were released, and they were significantly more likely to survive than those with classic FP (P = 0.02 [0.27-0.75, 95% CI]). Turtles without ocular FP were eight times more likely to survive than those with ocular FP (odds ratio = 8.75, P = 0.032 [1.21-63.43, 95% CI]). Laser-mediated tumor removal surgery is the treatment of choice for FP+ patients at the GSTC; number of surgeries was not significantly related to case outcome.

The WHO growth standards: strengths and limitations.

PURPOSE OF REVIEW: To describe the creation of the World Health Organization Child Growth Standards (WHO standards) released in 2006, to show their main features and to compare them with existing charts. RECENT FINDINGS: The WHO standards are the first globally representative growth standards. They describe the growth of children worldwide who are living in favorable circumstances. The WHO standards are well suited for intercountry comparisons. SUMMARY: Comparison with other charts reveals important differences with implications for child health monitoring. Recent studies comparing the use of the WHO standards to use country-specific growth references suggest that the latter may describe the growth of children more faithfully than the WHO standards. Use of the WHO standards in public health surveys must await the development of specific cutoffs.

Dry cereals fortified with electrolytic iron or ferrous fumarate are equally effective in breast-fed infants.

Precooked, instant (dry) infant cereals in the US are fortified with electrolytic iron, a source of low reactivity and suspected low bioavailability. Iron from ferrous fumarate is presumed to be more available. In this study, we compared a dry infant rice cereal (Cereal L) fortified with electrolytic iron (54.5 mg iron/100 g cereal) to a similar cereal (Cereal M) fortified with ferrous fumarate (52.2 mg Fe/100 g) for efficacy in maintaining iron status and preventing iron deficiency (ID) in breast-fed infants. Ascorbic acid was included in both cereals. In this prospective, randomized double-blind trial, exclusively breast-fed infants were enrolled at 1 mo and iron status was determined periodically. At 4 mo, 3 infants had ID anemia and were excluded. Ninety-five infants were randomized at 4 mo, and 69 (36 Cereal L, 33 Cereal M) completed the intervention at 9 mo. From 4 to 9 mo, they consumed daily one of the study cereals. With each cereal, 2 infants had mild ID, a prevalence of 4.2%, but no infant developed ID anemia. There were no differences in iron status between study groups. Iron intake from the study cereals was (mean ± SD) 1.21 ± 0.31 mg⋅kg(-1)⋅d(-1) from Cereal L and 1.07 ± 0.40 mg⋅kg(-1)⋅d(-1) from Cereal M. Eleven infants had low birth iron endowment (plasma ferritin < 55 µg/L at 2 mo) and 54% of these infants had ID with or without anemia by 4 mo. We conclude that electrolytic iron and ferrous fumarate were equally efficacious as fortificants of this infant cereal.

Practical Management of Iron Overload Disorder (IOD) in Black Rhinoceros (BR; Diceros bicornis).

Critically endangered black rhinoceros (BR) under human care are predisposed to non-hemochromatosis Iron Overload Disorder (IOD). Over the last 30 years, BR have been documented with diseases that have either been induced by or exacerbated by IOD, prompting significant efforts to investigate and address this disorder. IOD is a multi-factorial chronic disease process requiring an evidence-based and integrative long-term approach. While research continues to elucidate the complexities of iron absorption, metabolism, and dysregulation in this species, preventive treatments are recommended and explained herein. The aim of this report is to highlight the accumulated evidence in nutrition, clinical medicine, and behavioral husbandry supporting the successful management of this disorder to ensure optimal animal health, welfare, and longevity for a sustainable black rhinoceros population.

Introduction and Establishment of Raccoon Rabies on Islands: Jekyll Island, Georgia, USA as a Case Study.

The introduction of rabies virus (RABV) to barrier islands, which are often popular tourist destinations with resource-rich habitats and connectivity and proximity to the mainland, is especially concerning because it can easily become endemic due to factors like dense rabies-vector populations (e.g., raccoons [ Procyon lotor]), high inter- and intraspecies contact rates, and anthropogenic activities such as supplemental feeding of feral cats ( Felis catus). In January 2013, a neurologic raccoon found on the Jekyll Island (JI), Georgia, US causeway tested positive for rabies. Mortality investigations of 29 raccoons have been conducted between December 2012-May 2017. The two most common diagnoses were RABV ( n=11) and canine distemper virus (CDV; n=8). Parvoviral enteritis was diagnosed in four raccoons but no coinfections were diagnosed. There was no apparent seasonality for rabies cases, but all CDV cases occurred in spring-fall. Most (64%) rabies submissions came from residential or recreational use areas located near feral cat feeding stations. Jekyll Island is a popular destination where tourists engage in numerous outdoor activities which facilitate human-wildlife interactions. Concerns regarding public and animal health highlight the importance of rabies surveillance, prevention, and control on islands. This is the first report of rabies on JI and emphasizes the importance of disease investigations because the assumption that neurologic raccoons have CDV, an endemic pathogen, can miss the establishment of novel pathogens such as RABV.

Lack of Effect of Graded Doses of Vitamin D on Bone Metabolism of Breastfed Infants.

OBJECTIVE: A range of doses of supplemental vitamin D has been shown to be effective in preventing rickets in breastfed infants, but the effect of different doses of vitamin D on bone metabolism and mineral content has not been delineated. METHODS: In a randomized trial, breastfed infants received from 2 to 9 months daily supplements of vitamin D in doses of 200 IU/d, 400 IU/d, 600 IU/d or 800 IU/d. Measures of bone metabolism (plasma) were determined periodically and bone mineral content (DXA) was determined at study entry and at the end of winter when infants were 5.5 to 9 months old. The main findings have been reported; here we report findings related to bone metabolism. RESULTS: There were no consistent meaningful effects of vitamin D dose on markers of bone metabolism. Some markers showed changes with age. Bone mineral content increased with age but showed no effect of vitamin D dose. CONCLUSION: Vitamin D in daily doses from 200 IU/d to 800 IU/d had no measurable effect on bone mineral content or bone metabolism of breastfed infants.

Weight gain in the first week of life and overweight in adulthood: a cohort study of European American subjects fed infant formula.

BACKGROUND: Successful prevention of obesity and related cardiovascular risk factors requires a clear understanding of its determinants over the life course. Rapid infancy weight gain is associated with childhood obesity, whereas low infancy weight is associated with coronary heart disease. Our aim was to identify during which periods in infancy weight gain is associated with adult obesity. METHODS AND RESULTS: A cohort of European American formula-fed subjects, measured on 7 occasions during infancy as part of several infant formula studies, were contacted at age 20 to 32 years, when they reported usual adult weight and height. A life-course plot was used to identify critical periods of weight gain associated with adulthood overweight (body mass index > or =25 kg/m2). These associations were tested with logistic regressions. Data were available for 653 subjects (72% of eligible subjects). Approximately 32% of them were overweight adults. The period between birth and age 8 days was identified as potentially critical. After adjustment for important confounding factors, weight gain during the first week of life was associated with adulthood overweight status (OR for each 100-g increase 1.28, 95% CI 1.08 to 1.52), as was weight gain during the first 112 days of life (OR 1.04, 95% CI 1.01 to 1.08). Similar results were obtained after standardization with z scores from a reference population. CONCLUSIONS: In formula-fed infants, weight gain during the first week of life may be a critical determinant for the development of obesity several decades later. These results contribute to the understanding of chronic disease programming and suggest new approaches to obesity prevention.

Baseline plasma corticosterone, haematological and biochemical results in nesting and rehabilitating loggerhead sea turtles (Caretta caretta).

The evaluation of hormonal responses to stress in reptiles relies on acquisition of baseline corticosterone concentrations; however, the stress associated with the restraint needed to collect the blood samples can affect the results. The purpose of this study was to determine a time limit for the collection of blood samples to evaluate baseline corticosterone, haematological and biochemical results in nesting (n = 11) and rehabilitating (n = 16) loggerhead sea turtles (Caretta caretta). Blood samples were collected from the dorsal cervical sinus of each turtle immediately after touching the animal (t 0; 0-3 min) and 3 (t 3; 3-6 min), 6 (t 6; 6-9 min; nesting turtles only), 10 (t 10; 10-13 min) and 30 min (t 30; rehabilitating turtles only) after the initial hands-on time. Consistent between the rehabilitating and nesting turtles, there was a subtle yet significant increase in white blood cell counts over time. Despite the fact that white blood cell counts increased during the sampling period, there was no direct correlation between white blood cell count and corticosterone in the sampled turtles. In the nesting turtles, significant elevations in corticosterone were noted between t 0 and t 3 (P = 0.014) and between t 0 and t 6 (P = 0.022). Values at t 10 were not significantly different from those at t 0 (P = 0.102); however, there was a trend for the corticosterone values to continue to increase. These results suggest that sampling of nesting loggerhead sea turtles within 3 min of handling will provide baseline corticosterone concentrations in their natural environment. Significant elevations in corticosterone were also noted in the rehabilitating loggerhead sea turtles between t 0 and t 10 (P = 0.02) and between t 0 and t 30 of sampling (P = 0.0001). These results suggest that sampling of loggerhead sea turtles within 6 min of handling should provide baseline corticosterone concentrations in a rehabilitation setting. The delay in the corticosterone response noted in the rehabilitating turtles may be associated with the daily contact (visual or direct) they have with their human caretakers.

Iron stores of breastfed infants during the first year of life.

The birth iron endowment provides iron for growth in the first months of life. We describe the iron endowment under conditions of low dietary iron supply. Subjects were infants participating in a trial of Vitamin D supplementation from 1 to 9 months. Infants were exclusively breastfed at enrollment but could receive complementary foods from 4 months but not formula. Plasma ferritin (PF) and transferrin receptor (TfR) were determined at 1, 2, 4, 5.5, 7.5, 9 and 12 months. At 1 month PF ranged from 38 to 752 µg/L and was only weakly related to maternal PF. PF declined subsequently and flattened out at 5.5 months. PF of females was significantly higher than PF of males except at 12 months. TfR increased with age and was inversely correlated with PF. PF and TfR tracked strongly until 9 months. Iron deficiency (PF < 10 µg/L) began to appear at 4 months and increased in frequency until 9 months. Infants with ID were born with low iron endowment. We concluded that the birth iron endowment is highly variable in size and a small endowment places infants at risk of iron deficiency before 6 months. Boys have smaller iron endowments and are at greater risk of iron deficiency than girls.

Interventional strategies to promote appropriate growth.

Appropriate growth of premature infants can be defined as growth that is not associated with adverse consequences in the short and the long term. Growth failure is associated with neurocognitive impairment. The goal of nutritional management therefore is the achievement of appropriate growth by ensuring that nutrient intakes are maintained at all times at adequate levels. Many impediments stand in the way of this goal. Parenteral administration of nutrients must begin immediately at birth and needs to be continued until enteral nutrition is fully established. While nutritional support is provided by parenteral nutrition, gut priming, also beginning at birth, stimulates the immature gastrointestinal tract to undergo maturation. Human milk is the preferred agent for gut priming because it is more effective and safer than alternative agents. As a source of nutrients, however, human milk is incomplete for the premature infant and requires supplementation (fortification) with nutrients. At the authors' institution, commercial human milk fortifiers and additional sources of protein are being used in efforts to achieve appropriate growth. Data from the authors' institution indicate that nutrient intakes, especially intakes of protein, have improved in recent years and are approaching adequate levels. Accordingly, growth of infants has improved to the point where on average only a mild degree of postnatal growth failure is observed.

Iron supplementation of breastfed infants.

Reported here are three studies performed with the objective of finding ways to improve the iron status of breastfed infants and to prevent iron deficiency (ID). Participating infants were exclusively breastfed until 4 months of age; thereafter, they could receive complementary foods and, in some studies, supplemental formula. In the first study, infants were given medicinal iron between the ages of 1 and 5.5 months. During this period, iron status improved and ID was prevented; however, these benefits did not continue after the intervention ceased. In the second study, infants received medicinal iron or an equivalent amount of iron from an iron-fortified cereal between the ages of 4 and 9 months. Again, iron supplementation largely prevented ID from occurring, while non-anemic ID and ID anemia occurred in the control group as well as in the intervention groups before the intervention began. In the third study, infants received dry cereals fortified with electrolytic iron or with ferrous fumarate between the ages of 4 and 9 months. The cereals were equally effective in providing relative protection from ID. The results of these three studies indicate it is possible to protect breastfed infants from ID and IDA.

Growth charts compared.

Growth assessment of children requires comparison of growth measurements with normative references, usually in the form of growth charts. Traditionally growth charts (growth references) have described the growth of children who were considered normal and were living in a defined geographic area. The new WHO growth charts, on the other hand, are growth standards that aim to represent growth as it occurs worldwide. Moreover, they represent growth as it occurs under optimal circumstances and is thought to be conducive to optimal long-term health. Most growth references are single-country references, exemplified here by charts from the UK, the Netherlands and the USA. By contrast, the Euro-Growth reference and the WHO standard are based on multinational samples. Comparison of these five charts reveals surprisingly large differences that are for the most part unexplained. Differences between the WHO charts and other charts are only partially explained by the use of a prescriptive approach and by the data truncation employed. The large differences between charts probably are of merely trivial consequence when charts are used in monitoring individual children. When charts are used in health assessment of groups of children, the impact of the differences, however, is substantial.

Iron supplementation of breastfed infants from an early age.

BACKGROUND: In breastfed infants, iron deficiency at <6 mo of life, although uncommon, is observed in industrialized countries. Iron supplementation starting at an early age may prevent iron deficiency. OBJECTIVE: The study assessed the effect of early iron supplementation of breastfed infants and tested the hypothesis that iron supplementation enhances iron status. Potential adverse effects (tolerance and growth) were monitored. DESIGN: The prospective, placebo-controlled study involved exclusively breastfed infants who were randomly assigned at 1 mo of age to iron (n = 37) or placebo (n = 38). Iron (7 mg/d as multivitamin preparation with ferrous sulfate) or placebo (multivitamin preparation without iron) was given from 1 to 5.5 mo of age. Complementary foods were allowed at >4 mo. Infants were followed to 18 mo. Blood concentrations of ferritin, transferrin receptor, hemoglobin, and red cell indexes were determined at bimonthly intervals. Stool consistency and color and feeding behavior were recorded. RESULTS: Iron supplementation caused modest augmentation of iron status during the intervention at 4 and 5.5 mo but not thereafter. Iron supplements were well tolerated and had no measurable effect on growth. One infant developed iron deficiency anemia by 5.5 mo of age. Plasma ferritin and hemoglobin tracked over time. CONCLUSION: Early iron supplementation of breastfed infants is feasible and transiently increases iron status but not hematologic status. Iron is tolerated by most infants. The prevalence of iron deficiency anemia is low (3%) among unsupplemented breastfed infants in the first 6 mo of life.

Iron status of breastfed infants is improved equally by medicinal iron and iron-fortified cereal.

BACKGROUND: Although uncommon, iron deficiency (ID) occurs in breastfed infants. The regular provision of iron may prevent ID. OBJECTIVE: The objective was to test the feasibility and effectiveness of 2 modalities of providing iron (medicinal iron or iron-fortified cereal) to breastfed infants. The study tested the hypothesis that regular provision of iron improves iron status of breastfed infants without adverse effects. DESIGN: In this prospective, randomized, open-label trial, breastfed infants received on a regular basis either medicinal iron (n = 48) or an iron-fortified fruit-cereal combination (n = 45) from 4 to 9 mo or no intervention (control group; n = 59). The interventions provided 7.0-7.5 mg ferrous sulfate/d. Infants were enrolled at 1 mo and were followed to 2 y. Iron-status indicators were determined periodically, stool characteristics were recorded, and growth was monitored. RESULTS: The regular provision of iron led to improved iron status during and for some months after the intervention. Both sources of iron were about equally effective. Iron affected stool color but had no effect on feeding-related behavior. However, medicinal iron was associated with a small but significant reduction in length gain and a trend toward reduced weight gain. ID anemia was observed in 4 infants (2.3%), most of whom had a low birth iron endowment. Mild ID was common in the second year of life. CONCLUSIONS: Regular provision of medicinal iron or iron-fortified cereal improves the iron status of breastfed infants and may prevent ID. Both modalities are equally effective, but medicinal iron leads to somewhat reduced growth. This trial was registered at ClinicalTrials.gov as NCT00760890.