• No results found

Vitamin and Mineral Supplement Needs in Normal Children in the United States

N/A
N/A
Protected

Academic year: 2020

Share "Vitamin and Mineral Supplement Needs in Normal Children in the United States"

Copied!
9
0
0

Loading.... (view fulltext now)

Full text

(1)

PEDIATRICS (ISSN 0031 4005). Copyright © 1980 by the American Academy of Pediatrics.

AMERICAN

ACADEMY

OF

PEDIATRICS

Committee

on Nutrition

Vitamin

and

Mineral

Supplement

Needs

in Normal

Children

in the

United

States

The last 50 yeas have witnessed a steadily

in-creasing understanding of the biochemistry of

vi-tamins and trace minerals and their role in human

nutrition and intermediary metabolism.’7 There

also has been a growing public awareness of the

sometimes dramatic clinical impact of vitamin and

mineral administration in deficiency states.

As nutritional needs became more clearly

de-fined, essential vitamins and minerals were

incor-porated into processed formulas with the aim of

providing an essentially complete food for infants;

specific nutrients likely to be lacking in the diet of

older infants and children were also used to fortify

certain food products, such as infant cereal.

Supple-mental vitamin and mineral drops or tablets

contin-ued to be used, probably to a greater extent than

necessary considering the more extensive

fortifica-tion of food.

Vitamin and/or mineral supplements are

rela-tively inexpensive and available without

prescrip-tion; therefore, it is understandable that they are

used by a substantial portion of the population. The

widespread consumption of these products is also

fostered by a combination of advertising pressure

and concern about dietary adequacy. Many

individ-uals regard vitamin and/or mineral supplements as

a reliable method of ensuring that real or imagined

dietary shortcomings are corrected. Others, on far

less rational grounds, have come to regard

supple-ments in a wide range of doses as the philosopher’s

stone for good health or as treatment for a wide

array of ailments from mental retardation to the

common cold. As a result, vitamin and mineral

supplements are widely abused by the general

pub-lic, occasionally to the point of toxicity.

This statement will review the usual need for

supplements in normal infants and children in the

United States. In addition, the special needs of

preterm and low-birth-weight infants and those of

infants whose mothers are inadequately nourished

will be reviewed. This statement will not consider

the special requirements of infants and children

with overt nutritional deficiencies, malabsorptive

and other chronic diseases, rae vitamin

depend-ency conditions, inborn errors of vitamin or mineral

metabolism, or deficiencies related to the intake of

drugs. Many children with these disorders may

require pharmacologic doses of vitamins, which

should be individually prescribed by the physician.

GOVERNMENT

REGULATIONS

AND

COMMERCIAL

PRACTICE

RELATING

TO

VITAMIN

AND MINERAL

SUPPLEMENTS

Currently available vitamin and mineral

prepa-rations for infants and children in the United States

are in accord with Food and Drug Administration

regulations89 in effect until early 1979. These

regu-lations, designed to minimize misuse, covered the

specific vitamins and minerals and the minimum

and maximum levels allowed and/or required in

multivitamin and/or multimineral supplements for

infants, children, adults, and pregnant or lactating women.

New regulations are in preparation. The new

regulations may be somewhat different and will

probably use updated US Recommended Daily

Al-lowances (US RDAs), based on the revised 1980

RDAs developed by the Food and Nutrition Board,

National Academy of The distinctions

between the RDA and the US RDA are as follows:

recommended dietary allowances (RDAs) are

es-tablished for numerous age groups and according to

(2)

and Nutrition Board of the National Academy of

Sciences, National Research Council. Using the

RDAs as a basis, the FDA established US RDAs as

reference figures for the nutrition labeling of foods

and supplements. US RDAs are established for only

three groups: infants, children from 1 to 4 years old, and

adults

and children 4 or more years old. The scientific basis for the types of supplements consid-ered proper for infants and children has not changed substantially.

The intention of the FDA regulations was to

require multivitamin and multimineral

supple-ments to contain appropriate combinations of

vi-tamins and/or minerals at levels which ranged from

lower limits (considered sufficient to minimize risk

of deficiency) to upper limits (estimated to fully

meet nutritional needs without undue excess). In

almost all instances, the lower limits for individual

nutrients were about 25% to 50% of the US RDA,

and the upper limits were 100% to 150% of the US

RDA. This type of regulation is useful because some

previously available products called multivitamin

or multimineral supplements omitted important

nu-trients considered conducive to good health. In

addition, many preparations contained insignificant

amounts of certain nutrients, and some contained

levels of nutrients deemed excessive and possibly

harmful if taken over a long period of time.

The products on the market for infants and

chil-dren consist primarily of:

1. Liquid drop preparations for infants (a)

vita-mins A, D, and C, with or without iron; (b) vitamins A, D, C, and E, thiamin, riboflavin, niacin, vitamin

B, and vitamin B12, with or without iron.

2. Chewable tablets for young children (a)

vita-mins A, D, and C, with or without iron; (b) vitamins A, D, and E, and C, thiamin, folic acid, riboflavin,

niacin, vitamin B, and vitamin B12, with or without

iron.

Folic acid is omitted from liquid dietary

supple-ments because it is relatively unstable in liquid

preparations. No liquid multivitamin supplements

containing folate are commercially available for this

reason. To call attention to this omission, the

fol-lowing statement is required on the label

immedi-ately following the list of vitamins (and minerals)

in the product: “This product does not contain the

essential vitamin folic acid.”

The foregoing combinations are also available

with fluoride for infants and children residing in

areas where water is not fluoridated. However,

be-cause of their fluoride content, these products are

only available on prescription. Supplements

con-taming 0.25, 0.5, or 1.0 mg fluoride per dose enable

physicians to prescribe the appropriate amount of

fluoride supplements, when necessary,” along with

the vitamins or vitamins and iron recommended for

a particular child and age group.

Supplements of individual vitamins rarely are

used for infants, except for specific indications.

Ex-amples are the administration of vitamin K at birth

to prevent hemorrhagic disease of the newborn and

vitamin E to prevent hemolytic anemia in small,

premature infants.’2 Iron is the only mineral

sup-plement commonly used in infants, either alone or

in combination with vitamins.

GUIDELINES

FOR SUPPLEMENTATION

The Table summarizes the following guidelines

for the use of supplements in healthy infants and

children. The indications for vitamin K and fluoride are discussed in the text only.

Newborn Infants

Vitamin

K

administration to all newborn infants is effective as a prophylaxis against hemorrhagic

disease of the newborn. This 1961

recommenda-tionh3 was strongly reaffirmed in 1971’ to prevent

or minimize the postnatal decline of the vitamin

K-dependent coagulation factors (II, VII, IX, and X).

Vitamin K, is considered the vitamin derivative of

choice in a single, intramuscular dose of 0.5 to 1 mg

or an oral dose of 1.0 to 2.0 mg. In rare instances,

the dose may have to be repeated after about four

to seven days.

Breast-fed Infants

The renewed emphasis on human milk as an ideal

food has raised the question whether breast-fed

infants require any vitamin or mineral supplements prior to the introduction of solid foods. This subject

bears further discussion, particularly with respect

to the most widely used supplements: vitamins A,

C, D, and E, iron and fluoride.

Rickets is uncommon in the breast-fed term

in-fant, despite the fact that human breast milk

ap-peas to contain small amounts of vitamin D (ie,

about 22 lU/liter). One possible explanation is that

the vitamin D in breast milk is in the form of an

easily absorbed sulfate analogue,’5 but this

needs

to

be confirmed. The antirachitic properties of breast

milk seem to be adequate for the normal term infant

of a well nourished mother. However, if the

mother’s vitamin D nutrition has been inadequate

and if the infant does not benefit from adequate

ultraviolet light (due to dark skin color and/or little

exposure to light)’6 supplements of 400 IU of

vi-tamin D daily may be indicated.

(3)

TABLE. Guidelines for Use of Supplements in Healthy Infants and Children*

Child

Multivitamin-Multimineral

Vitamins Minerals

Iron

D E Folate

Term infants

Breast-fed 0 ± 0 0

±t

Formula-fed 0 0 0 0 0

Preterm infants

Breast-fed + + ± ± +

Formula-fed + + ± ± +

Older infants (after 6 mo)

Normal 0 0 0 0 ±t

High-risk + 0 0 0 ±

Children

Normal 0 0 0 0 0

High-risk + 0 0 0 0

Pregnant teenager

Normal ± 0 0 ± +

High-riskj + 0 0 + +

* Symbols indicate: +, that a supplement is usually indicated; ±, that it is possibly or

sometimes indicated; 0, that it is not usually indicated. Vitamin K for newborn infants and fluoride in areas where there is insufficient fluoride in the water supply are not shown.

t

Iron-fortified formula and/or infant cereal is a more convenient and reliable source of iron than a supplement.

:j:Multivitamin supplement (plus added folate) is needed primarily when calorie intake is below approximately 300 kcal/day or when the infant weighs 2.5 kg; vitamin D should be supplied at least until 6 months of age in breast-fed infants. Iron should be started by 2 months of age (see text).

§

Vitamin E should be in a form that is well absorbed by small, premature infants. If this form of vitamin E is approved for use in formulas, it need not be given separately to formula-fed infants. Infants fed breast milk are less susceptible to vitamin E deficiency.

II

Multivitamin-multimineral preparation (including iron) is preferred to use of iron alone. #{182}Multivitamin-multimineral preparation (including iron and folate) is preferred to use of

iron alone or iron and folate alone.

was coupled with vitamin D supplementation

be-cause both were provided by cod liver oil. Currently

there is little reason to provide vitamin A

supple-ments; thus, there would be no ham in omitting

vitamin A from supplements designed to provide

vitamin D for infants who are breast-fed. Similarly

there is no evidence that supplementation with

vitamin E is needed for the normal, breast-fed term

infant.

Vitamin B12 deficiency has been reported in

breast-fed infants of strict vegetarian mothers, but

this is relatively rare in North America. The recent

report of a 6-month-old infant of a vegan mother

with severe megaloblastic anemia and coma’7 is a

reminder that the maternal diet strongly influences the concentration of certain water-soluble vitamins

in breast :u18 Thiamin deficiency can also occur

in breast-fed infants of thiamin-deficient mothers, but this situation is virtually restricted to infants in

developing countries. In the United States, the rae

breast-fed infants of mothers who are themselves

malnourished

should receive multivitamin supple-ments.

Iron deficiency rarely develops before 4 to 6

months of age in breast-fed infants because

neo-natal

iron stores can supply the major portion of

iron needs during this period. Although breast milk

may contain little more than 0.3 mg iron per liter,’9 about half of this iron is absorbed in contrast to the

much smaller proportion that is assimilated from

other foods.#{176}This iron helps to delay the depletion of neonatal iron stores, but other sources of iron are

required in midinfancy. In normal, breast-fed term

infants, the addition to the diet of iron-fortified

cereal after 6 months of age probably is desirable to

supply adequate amounts of iron.2’

The benefit of fluoride supplementation in the

breast-fed infant is controversial.22 This is

under-standable because of the dearth of evidence that

fluoride supplementation in the first six months of

life alters the prevalence of dental caries in the

secondary dentition. In addition, the low level of

fluoride in breast milk, even in areas where water

is fluoridated, may provide a teleologic argument

for not supplying extra fluoride in early infancy.

However, the view that fluoride supplementation is

unnecessary during the first six months of life is

tempered by the knowledge that unerupted teeth

are being mineralized in early infancy;

(4)

to have a beneficial effect during this period. In

weighing these opposing views, the Committee

re-cently favored initiating fluoride supplements

shortly

after birth in breast-fed infants, but also

recognized that fluoride supplementation could be

initiated at 6 months of age.22

Fluoride supplements are available alone and in

combination with vitamins, with or without iron.

Thus, if iron or vitamin D supplements are

indi-cated, it is acceptable to include 0.25 mg fluoride if

the water supply contains less than 0.3 ppm of

fluoride.22

Formula-Fed Term Infants

Infants consuming adequate amounts of

commer-cial cow’s milk formulas which are in keeping with

the recommendations of the Committee23 do not

need vitamin and mineral supplementation in the

first six months of life. They do not require

supple-ments during the latter pat of the first year if

formula continues to be used in appropriate

corn-bination with solid foods. After 4 months of age,

iron-fortified formula and/or iron-fortified cereal

are convenient sources of iron and are preferable to

the use of iron supplements.2’ If powdered or

con-centrated formula is used, fluoride supplements

should be administered only if the community water contains less than 0.3 ppm of fluoride. Ready-to-use

formulas are now manufactured with water low in

fluoride, and recommendations for fluoride

supple-mentation should be similar to those for breast-fed infants.

Vitamin K deficiency is seen occasionally in

in-fants. It is usually associated with diarrhea and

especially with the administration of antibiotics,

through a decrease in the synthesis of vitamin K by

the intestinal microflora. In the past, the feeding of

soy or other non-milk based formulas24’25 was

asso-ciated with vitamin K deficiency, which was related

in part to the type of oil used in the formula.26 In

1976, the Committee recommended that all infant

formulas, particularly non-milk-based formulas, be

required to contain an appropriate level of vitamin

K.23

Preterm Infants

The needs of preterm infants for certain nutrients

are proportionately greater than those of term

in-fants

because of the increased demands of a more

rapid rate of growth and less complete intestinal

absorption. 2

During the first weeks of life (prior to

consump-tion of about 300 kcal per day or reaching a body

weight of 2.5 kg), a multivitamin supplement that

provides the equivalent of the RDAs for term

in-fants should be supplied. The components of this

supplement should ideally include vitamin E in a

form well absorbed by preterm infants, such as

d-a-tocopheryl polyethylene glycol 1000 succinate.27

Folic acid deficiency has been reported in preterm

infants,m’ and folic acid should be included in the

regimen. Folic acid is not in liquid multivitamin-multimineral mixes because of its lack of stability.

However, because the period of administration will

generally

be in a hospital, folate can be added to a

multivitamin preparation in the hospital pharmacy

in a concentration to provide 0.1 mg (the US RDA)

per daily dose. The shelf life should be limited to

one month, and the label should read “shake well”

because folate will gradually precipitate. Iron

sup-plementation is best delayed until after the first few

weeks

of life because extra iron may predispose to

anemia when there is insufficient absorption of

vitamin E.3#{176}Neonatal iron stores are stifi abundant,

and iron needs for erythropoiesis are relatively

small

during

the physiologic postnatal decline in

hemoglobin concentration.

After several weeks of age, when the infant is

consuming more than 300 kcal/day or when the

body weight exceeds 2.5 kg, a multivitamin

supple-ment is no longer needed, but it is a convenient

method for providing the few specific nutrients that

stifi may be required. These include vitamin D,

iron, and possibly folic acid.28

There have been sporadic reports of rickets,

par-ticulaly in breast-fed premature infants.31’32 This

probably results from the low phosphorus content

of breast milk, which has only 150 mg/liter in

contrast to about 450 mg/liter in formulas. The

condition is also correctable with phosphate

supple-mentation. However, there is also evidence that

vitamin D supplementation is helpful.33 Iron is

re-quired at a level of 2 mg/kg/day starting by 2

months of age because neonatal iron stores may

become depleted earlier than in term

infants-be-fore it is appropriate to supply iron in the form of

fortified solid foods. Iron-fortified formula aLso sup-plies sufficient iron for the prevention of iron

defi-ciency in preterm infants.

Home-Prepared Evaporated Milk or Cow’s Milk

Formulas

Home-prepared formulas are seldom used in

North America, but they are in extensive use in

other countries. The need for supplements with

evaporated milk wifi depend on whether the

prep-aration is fortified. Term and premature infants

may need additional vitamins C and D (at US RDA

levels). Supplemental iron should be started no

later than 4 months of age (at a dose of 1 mg/kg/

day) for term infants and no later than 2 months of

(5)

Preterm infants will also need a daily multivitamin

preparation that includes a well absorbed form of

vitamin E and will require folate.29

Older Infants

During the second six months of life, the normal

infant may be on a diet of milk or formula, mixed

feedings, and increased amounts of table food.

Cow’s milk, if used at this time, should be fortified with vitamin D and cereal fortified with iron. Other

vitamin and mineral supplements are usually not

required, although it is important that the diet

include an adequate source of vitamin C. Infants at

special nutritional risk as a result of lifestyle,

econ-onomic disadvantage, or intercurrent illness may

require multivitamin and mineral supplements.

After Infancy

Recent national dietary and health surveys’m

have shown little evidence of vitamin or mineral

inadequacies, with the exception of iron. In

pre-school children of lower socioeconomic status, the

most prevalent nutritional lack was simply an

in-sufficiency of food.” Thus, there is little basis for

routine vitamin and mineral supplementation in

normal children, especially as the growth rate

de-creases after infancy. An exception is the need for

fluoride where there is insufficient fluoride in the

drinking water. The Committee recently revised

its dosage recommendations for fluoride

supple-ments.22

When evidence of significant nutritional

made-quacy arises, as with iron, the fortification of foods

seems to be the most effective means of dealing

with the problem. Among the disadvantages of

re-lying

on vitamin and/or mineral supplements to

supply essential nutrients is the fact that some of

those most at risk do not have access to the

supple-ments or may not comply with long-term

medica-tion. Poor long-term compliance is a difficult

prob-lem with respect to supplying fluoride supplements

in children residing inareas where drinking water

contains inadequate fluoride. There are,

nonethe-less, some situations in which supplements may be

indicated, and these will be listed. When used for

these groups of children, the supplements should be

composed of the multivitamins and minerals that

provide these nutrients at approximately RDA

levels.

Groups at particular nutritional risk include:

1. Children and adolescents from deprived

fami-lies. Although evidence from the national

surveys36 indicates that economically

underpri-vileged

families, in general, eat wisely and do not

require vitamin supplements, there is a special

sub-set within this group that may be malnourished.

Children who suffer from parental neglect or abuse

are an example.

2. Children and adolescents with anorexia, poor

and capricious appetites, or poor eating habits; also

children on dietary regimens to manage obesity.

3. Pregnant teenagers. Iron and probably folic

acid are needed by these young women, but

uncer-tainty about overall nutritional status in those

con-sidered at special nutritional risk warrants use of a

multi-vitamin-multimineral supplement. The

nutri-tional needs of the pregnant woman are discussed

more fully in the recommendations of an ad hoc

committee on nutrition of the American College of

Obstetricians and Gynecologists.37

4. Children and adolescents consuming

vegetar-ian diets without adequate dairy products may need

supplementation, particularly with vitamin B,2

which is absent from vegetable foods. This vitamin

deficiency has been described in recent reports in

the literature.

PROVIDING VITAMIN AND MINERAL NEEDS

WITH AVAILABLE PREPARATIONS

In most respects, these guidelines for the use of

supplements can be conveniently met with

cur-rently available preparations. However, at present,

it is difficult to supply trace minerals other than

iron to infants and children who are considered to

be in high nutritional risk categories. This is

be-cause multimineral preparations have required the

inclusion of calcium, phosphorus, and magnesium

in relatively large quantities that would be difficult to supply in a liquid or small tablet form. However, there may prove to be a clinical role for a

multivi-tamin-trace mineral supplement that would include

iron, zinc, and copper, and possibly other trace

minerals, which could probably be more readily

prepared in liquid or small tablet form.

There is sufficient evidence to support the

inclu-sion of zinc4’ and copper in

multivitamin-multimi-neral preparations in tablet form.42 The

require-ments for other trace minerals,43 (such as

sele-nium,44 chromium, manganese, and molybdenum)

are under investigation; figures for these nutrients

are included in the 1980 RDAS. These trace

mm-erals might eventually be considered for inclusion

in supplements for infants and children because

evidence to warrant their use may be forthcoming. However, at present, there is insufficient

informa-tion on which to base detailed recommendations for

dosage and appropriate ages for administration.

The combination of vitamin A, C, and D for

infants (with vitamin E and/or iron as optional

ingredients)was originally designed to complement

home-prepared formulas. Now that most infants

(6)

needs have shifted somewhat. In referring to the Table, there would seem to be roles in infant feeding

for combinations of vitamin D with iron, vitamin D

with vitamin E and possibly folate, and vitamins D,

E, folate, and iron.

Although some comments in this statement are

relevant to future developments in

supplementa-tion, currently available supplements and foods can

be used to meet all recognized nutritional needs of

infants and children. It must also be emphasized

that, although deficiencies have been recorded in

the infant of a malnourished mother,45’46 the normal,

breast-fed infant of the well nourished mother has

not been shown conclusively to need any specific

vitamin and mineral supplement. Similarly, there is

no evidence that supplementation is necessary for

the full-term, formula-fed infant and for the

properly nourished normal child.

ACKNOWLEDGMENT

The preparation of this report was supported by FDA contract 223-76-2091.

REFERENCES

COMMITTEE ON NUTRITION

Lewis A. Barness, MD, Chairman

Peter R. Dailman, MD

Homer Anderson, MD

Platon Jack Collipp, MD

Buford L. Nichols, Jr, MD

Claude Roy, MD

W. Allan Walker, MD

Calvin W. Woodruff, MD

1. Wickes IG: A history of infant feeding. I. Primitive peoples: Ancient works: Renaissance writers. Arch Dis Child 28:151,

1953

2. Wickes IG: A history of infant feeding. II. Seventeenth and eighteenth centuries. Arch Dis Child 28:232, 1953

3. Wickes IG: A history of infant feeding. III. Eighteenth and nineteenth century writers. Arch Dis Child 28:332, 1953 4. Wickes IG: A history of infant feeding. IV. Nineteenth

cen-tury continued. Arch Dis Child 28:416, 1953

5. Wickes IG: A history ofinfant feeding. V. Nineteenth century concluded and the twentieth century. Arch Dis Child 28:495,

1953

6. Woodruff CW: The science of infant nutrition and the art of infant feeding. JAMA 240:657, 1978

7. Fomon SJ, Filer U Jr, Anderson TA, et al: Recominenda-tions for feeding normal infants. Pediatrics 63:52, 1979 8. Food and Drug Administration: Label statements relating to

vitamins and label statements relating to minerals. Code of

Federal Regulations 21:125.1, 1973

9. Food and Drug Administration: Dietary supplements of vi-tamins and minerals. Code ofFederal Regulations 21:105.85, 1977

10. Food and Nutrition Board, National Research Council:

Rec-ommended Dietary Allowances, ed 9. Washington, DC,

Na-tional Academy of Sciences, 1980

1 1. Committee on Nutrition: Fluoride as a nutrient. Pediatrics

49:456, 1972

12. Committee on Nutrition: Nutritional needs of

low-birth-weight infants. Pediatrics 60:519, 1977

13. Committee on Nutrition: Vitamin K compounds and the water-soluble analogues: Use in therapy and prophylaxis in pediatrics. Pediatrics 28:500, 1961

14. Committee on Nutrition: Vitamin K supplementation for infants receiving milk substitute infant formulas and for those with fat malabsorption. Pediatrics 48:483, 1971 15. Lakdawala DR, Widdowson EM: Vitamin D in human milk.

Lancet 1:167, 1977

16. Bachrach S, Fisher J, Parks JS: An outbreak of vitamin D deficiency rickets in a susceptible population. Pediatrics 64: 871, 1979

17. Higginbottom MC, Sweetman L, Nyhan WL: A syndrome of methylmalomc aciduria, homocystinuria, megaloblastic ane-mia, and neurologic abnormalities in a vitamin B,2-deficient breast-fed infant of a strict vegetarian. N Engl J Med 299: 317, 1978

18. Gopalan C, Belavady B: Nutrition and lactation. Fed Proc

20(suppl 7, pt 3):177, 1961

19. Siimes MA, Vuori E, Kuitunen P: Breast milk iron-a de-dining concentration during the course of lactation. Acta Pediatr Scand 68:29, 1979

20. Saarinen UM, Siimes MA, Dallman PR: Iron absorption in infants: High bioavailabiity of breast milk iron as indicated by the extrinsic tag method of iron absorption and by the concentration of serum ferritin. J Pediatr 91:36, 1977 21. Committee on Nutrition: Iron supplementation for infants.

Pediatrics 58:765, 1976

22. Committee on Nutrition: Fluoride supplementation: Revised dosage schedule. Pediatrics 63:150, 1979

23. Committee on Nutrition: Commentary on breast feeding and infant formulas, including proposed standards for formulas.

Pediatrics 57:278, 1976

24. Moss MH: Hypoprothrombinemic bleeding in a young in-fant: Association with a soy protein formula. Am JDiS Child 117:540, 1969

25. Goldman HI, Amadio P: Vitamin K deficiency after the newborn period. Pediatrics 44:745, 1969

26. Schneider DL, Fluckiger HB, Manes JD: Vitamin K, content of infant formula products. Pediatrics 53:273, 1974 27. Gross S, Melhorn DK: Vitamin E-dependent anemia in the

premature infant. III. Comparative hemoglobin, vitamin E, and erythrocyte phospholipid responses following absorption of either water-soluble or fat-soluble d-alpha tocopheryL J Pediatr 85:753, 1974

28. Stevens D, Burman D, Strelling MK, et al: Folic acid sup-plementation in low birth weight infants. Pediatrics 64:333,

1979

29. Strelling MK, Blackledge DG, Goodall HB: Diagnosis and management of folate deficiency in low birth weight infants.

Arch Dis Child 54:271, 1979

30. Williams ML, Shott RJ, O’Neal PL, et al: The role of dietary iron and fat on vitamin E deficiency anemia of infancy. N Engl JMed 292:887, 1975

31. Rowe JC, Wood DH, Rowe DW, et al: Nutritional hypo-phosphatemic rickets in a premature infant fed breast milk.

N Engl JMed 300:293, 1979

32. O’Connor P: Vitamin D deficiency rickets in two breast-fed infants who were not receiving vitamin D supplementation. Clin Pediatr 16:361, 1977

33. HoffN, Haddad J, Teitelbaum S, et al: Serum concentrations of 25-hydroxyvitamin D in rickets of extremely premature infants. J Pediatr 94:469, 1979

34. Owen G, Kram KM, Garry PJ, et al: A study of nutritional status of preschool children in the United States, 1968-1970.

Pediatrics 53:597, 1974

35. Dietary Intake Findings, 1971-74. National Health Survey. DHEW Publication No. (HRA) 77-1647. Hyattsville, MD, National Center Health Statistics, Series 11, No. 202, 1977

36. TenState Nutrition Survey, 1968-70: Highlights. DHEW

Publication No. (HSM) 72-8134. Atlanta, Center for Disease Control, 1970

37. Pitkin RM, Kaminetzky HA, Newton M, et al: Maternal nutrition: A selective review of clinical topics. J Obstet Gynecol 40:773, 1972

(7)

vege-tarian rickets. Am J Dis Child 133:129, 1979 Child 49:589, 1974

39. Dwyer JT, Dietz WH, Ham G, et al: Risk of nutritional 43. Underwood EJ: Trace Elements in Human and Animal rickets among vegetarian children. Am J Dis Child 133:134, Nutrition. ed 4. New York, Academic Press, 1977

1979 44. Lombeck I, Kaspereck K, Bonnermann B, et al: Selenium

40. Zmora E, Gorodischer R, Bar-Ziv J: Multiple nutritional content of human milk, cow’s milk and cow’s milk infant deficiencies in infants from a strict vegetarian community. formulas. Eur J Pediatr 129:139, 1978

Am J Dis Child 133:141, 1979 45. Fomon SJ, Strauss RG: Nutrient deficiencies in breast-fed

41. Committee on Nutrition: Zinc. Pediatrics 62:408, 1978 infants. N Engl J Med 299:355, 1978

42. Alexander FW: Copper metabolism in children. Arch Dis 46. Waterlow JC, Thomson AM: Observations on the adequacy of breast-feeding. Lancet 2:238, 1979

HISTORY OF A CASE OF STAMMERING, SUCCESSFULLY TREATED BY

THE LONG CONTINUED USE OF CATHARTICS, AS REPORTED IN 1831

Of all the therapies I have read about for stammering, the following, published

in 1831, is the most unusual.’ One wonders whether “tincture of time” was not

far more important than the use of cathartics.

A boy of robust form and florid aspect, of a healthy constitution, of more than ordinary activity both of mind and body, when between two and three years old, and after having acquired considerable readiness in speaking, was suddenly affected with so great a degree

of stammering as to be almost incapable of uttering a single syllable. Two eminent

physicians were consulted: they confessed their inability to propose any specific plan of treatment which might afford a prospect of success, but in consequence of a somewhat plethoric state of the child, they advised that a strong purgative should be given. The effect of the medicine appeared so favourable, that it was repeated three or four times, and each time with such decided benefit, as to leave no doubt on this point in the minds either of the parents or the practitioners. The complaint, however, shortly recurred, was again attacked with the same remedy, and was again subdued. After this plan had been continued for some time, it was conceived that, in addition to the purgative system, the

effect of which, although so salutary, was temporary, further advantage might be

obtained by adopting a system of diet which should permanently reduce the plethoric habit, and obviate the necessity for the continual repetition of the purgatives. This was accordingly done, and was rigidly adhered to for several years. Animal food was totally abstained from, and even vegetables were taken in as sparing a quantity as was consistent with the support of the system ...

By a steady adherence to this discipline for about eight years, the complaint was kept at bay; but whenever any relaxation in the diet took place, or when the purgatives were

omitted or too long delayed, symptoms of the impediment immediately appeared. At

length, when about twelve years of age, the tendency seemed so far subdued, that a relaxation of the restrictions was not followed by the usual unfavourable consequences, and the boy being then at a public school, it was not so easy to maintain the former discipline. For some time no bad effects ensued, but at length the complaint recurred, and was unusually obstinate, so as to require a long and severe course of purgatives, which, however, was finally successful ...

With respect to the purgatives employed in this case, it appeared to be of little

importance which were used, provided the bowels were very completely evacuated. What

was the most frequently employed was a full dose of calomel and jalap, succeeded by

Epsom salts . ...

Noted by T.E.C., Jr, MD

REFERENCE

(8)

1980;66;1015

Pediatrics

Nichols, Jr, Claude Roy, W. Allan Walker and Calvin W. Woodruff

Lewis A. Barness, Peter R. Dallman, Homer Anderson, Platon Jack Collipp, Buford L.

Vitamin and Mineral Supplement Needs in Normal Children in the United States

Services

Updated Information &

http://pediatrics.aappublications.org/content/66/6/1015

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(9)

1980;66;1015

Pediatrics

Nichols, Jr, Claude Roy, W. Allan Walker and Calvin W. Woodruff

Lewis A. Barness, Peter R. Dallman, Homer Anderson, Platon Jack Collipp, Buford L.

Vitamin and Mineral Supplement Needs in Normal Children in the United States

http://pediatrics.aappublications.org/content/66/6/1015

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

Related documents

The purified enzyme was examined for its ability to hydrolyze various carbohydrates such as corn starch, amylose, glycogen, cellulose, hemicelluloses at a final concentration

Therefore, the diagnostic combination of hsTn and MAPSE being assessed by cMRI might detect poten- tially early stages of LV dysfunction as being indicated by impaired MAPSE

Through an episode in seventeen year old Hajra's story, I illustrate a narrative constitu- tion of refugee identity as an alterna- tive expression of the identity of an

The aim of this study is to appraise the use of ICT by the professionals in Nigeria construction industry while the objectives are to appraise the various software being used by

prevalence of risk factors for acute myocardial infraction is high in Bangladesh, especially in urban areas. Further research, in particular longitudinal studies, is needed for

Figure 2: Schematic Diagram of Single Emulsion Based Method of Microspheres Preparations..