Anaemia in Kwashiorkor-Adams et al.
BRrrrsAugust~~~~~~~~~~~~~~~~~~~~~~~~~~~M EDICALJUSLIn the 60 infants reported here the mean serum bilirubin on admission was within the normal range (0.82 mg./100 ml.) and the initial reticulocyte count was usually only slightly raised (mean 3%), both values being little higher than corresponding control means of 0.54 mg./100 ml. and 1.6%. For this reason it seemed unlikely that the anaemia was predominantly haemolytic. When temporary marrow hypoplasia occurs, however, it does not affect the haemoglobin appreciably unless the red cell survival time is considerably reduced, which has been shown by Hoffenberg (1967, personal communication) to be the case in kwashiorkor. A haemolytic element should therefore be added to the factors which may contribute to the anaemia in this disease, though its importance remains to be clarified.
Iron and Folic Acid as Supplements During TreatmentWe previously demonstrated (Adams and Scragg, 1965) that iron deficiency may occur in the recovery phase of kwashiorkor and we have now shown that it can be prevented by administration of iron. Since the detection of iron deficiency with any degree of certainty may require sophisticated tests which are not practicable except as research procedures, we recommend the administration of intramuscular iron to all infants with this disease, a total of 9 ml. of iron dextran being given over the first two weeks. In view of the high proportion of controls who appeared to be iron-deficient, judged on plasma iron patterns, it may well be that the occurrence of iron deficiency in kwashiorkor is not related to the disease itself but to the general iron status of infants in the age group at risk.The case for supplements of folic acid is less easy to substantiate. It has been seen that partial megaloblastic erythropoiesis and subnormal serum folate levels are not uncommon findings on admission. Though they do not appear to limit haematological progress over the first four weeks, their existence can hardly be regarded with complacency. We have incomplete information about their long-term effects, but occasionally have observed the full picture of megaloblastic anaemia emerging later on. We therefore believe that the addition of folic acid to protein feeding is sound therapy in kwashiorkor, and recommend a routine supplement of 5 mg. thrice daily in all cases.
SummaryFrom a controlled clinical trial evidence is submitted in favour of the addition of iron to treatment with high-protein diet in kwashiorkor. Though iron-deficiency anaemia is seldom present on the patient's admission, routine treatment with iron prevents its development during the recovery phase.No evidence was found that vitamin-B12 deficiency plays a part in the production of anaemia in kwashiorkor, and there was little support for the view that its severity may be related to the presence of infection, though this complication undoubtedly affects prognosis adversely.Partial megaloblastic erythropoiesis and folate deficiency are shown to be common finding...
