Part IV Section 6-A
Micronutrient deficiency at early school age
Robert Karp, MD
SUNY-Downstate Medical Center
Brooklyn, NY
Pre-test:
Q1. Iron deficiency is an unexpected finding at early school age even in poorer communities because (pick best answer)
a. families compensate for decreased income by purchasing foods that are high in iron
b. Iron needs are relatively low compared energy needs at these ages.
c. Iron absorption from low cost vegetables B rice and beans, for example, will increase as iron stores decrease
d. Lack of hygiene increases iron absorption from dirt
Q2. True or false: Your treatment plan: Send affected children home with prescriptions of iron B 4 to 6 mg/kg per day to be taken with food for 3 months with F/U visits to check markers for improved iron status.
Q3. Rising food costs affect nutritional status by (pick best answer)
a. decreasing the likelihood that families will receive nutrition support from WIC, Food Stamp programs and school feeding
b. increasing the availability of food from charitable organizations
c. Increasing selection of high energy, low nutrient content foods.
d. Decreasing the availability of food from charitable organizations.
Q4. True or false: Families of school age children with malnutrition are often likely to be less effective in providing adequate support for their children.
Learning Objectives:
At the conclusion of this module, physicians and residents will able to:
1. Provide a differential diagnosis and evaluation for children found to be anemic at early school age.
2. Appreciate the complex of nutritional, social, and economic problems affecting families of malnourished school-age children.
3. Recognize the impact of poverty itself B rising food costs, falling income, or increasing costs for other necessities on nutritional status.
4. Learn the impact on learning of malnutrition at early school age
5. Provide therapy within a Medical-Home@ in addressing the problems of high-risk children
Facilitator Preparation:
This module is derived from several chapters in Karp, RJ. (Ed) Malnourished Children in the United States: Caught in the Cycle of Poverty. Springer Publishing Co., New York. 1993. as well as a series of works from 1972 to 1992 derived from my work in inner-city Philadelphia. See also
Karp, RJ (1999 and 2005) Malnutrition among children in the United States. The impact of poverty. (in) Shils, ME, Olson JA, Shike M, Ross AC. (eds) Modern nutrition in Health and Disease, 9th edition. Williams and Wilkins, Baltimore, MD.
Karp RJ. The dimensions of poverty among children in the United States: an exposition of causes and consequences. Epilogue to the Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2003. Www.servingtheunderserved.org. This provides a comprehensive view of poverty.
Sia CC. Abraham Jacobi Award Address, April 14, 1992, The Medical Home: pediatric practice and child advocacy in the 1990s. Pediatrics. 1992; 90:419-423
Introduction:
You are a pediatrician working in an inner-city teaching hospital. Your institution prides itself on being able to provide comprehensive care with in a single center "Medical Home" - for the community it serves. You have received grant funding to conduct a mass screening of early school-age children for sickle cell trait. You also check for iron deficiency (ID). The children are attending nearby schools here over 70% of families have incomes below the poverty level. They are from kindergarten to 3rd grade --5 to 9 years of age.
The screening shows that almost 7% of the children have iron deficiency using the standard described by Dr. Bogen in earlier module on ID. [Hyperlink] You are surprised. Iron deficiency is an unexpected occurrence at early school age. Children's rapid growth is over, the iron to energy ratio (nutrient density for iron) of most family's diet should be sufficient to prevent ID. [Hyperlink to Nutrition Notes] You find that many of the iron deficient children have lead poisoning.
A Mock Pre-test
Pick the best answer. Follow up should consist of:
a. Calling parents to come to school to receive iron supplements for affected children. Your treatment plan: Send affected children home with prescriptions of iron B 4 to 6 mg/kg per day to be taken with food for 3 months with F/U visits to check markers for improved iron status.
b. Working with community health workers, each affected child's family is contacted to bring them into your "Medical Home" [see below and Hyperlink to section 3] for comprehensive care. In the health center, there is a careful assessment of every child individually to consider medical causes for ID. . There is also an assessment of the social and economic needs of the family and the behavior and development of the child. The lead poisoning is considered as either a cause or a concomitant finding of the anemia. Housing issues are addressed along with a broad range of social, psychological, and economic needs. There is an assessment of nutritional status of other family members. At this point, appropriate dietary and medical treatment for iron deficiency (see "a" above) is provided along with necessary social, economic, psychological and behavioral services.
The answer is b, of course. But, is that what actually happens?
The case history that follows recounts the author's 10 year experience in north central Philadelphia working with disadvantaged children and their families in a "Follow-Through" program designed to help children maintain the gains achieved in pre-school "Head Start". Follow along to see how ID at early school age represents an expression of a complex inter-relationship among social deprivation, poverty and malnutrition affecting individual children, their families and communities.
A (real) Case History:
Andre R., a 9 year old 2nd grade child, was identified as anemic, as part of a school screening. The screening was conducted by a health team from a pediatric department capable of providing comprehensive care in a "Medical Home". On evaluation of the child and family, you note that he is older than expected. When you ask `why,= you find that entry was delayed by the mother because it was easier to keep him at home then have him enter school. Also, Andre had to repeat 2nd grade. The family history suggests disarray in that the three children were closely spaced, and the mother has not sustained relationships with the several fathers. Immunizations were not up to date when Andre entered school. The mother works occasionally as a baby sitter, and she is receiving public assistance for dependant mothers. She has little family support as her own mother and siblings live in another city. There is a history of low level lead poisoning (Pb = 21ugm/dL at 2 years of age) on Andre's record. The siblings have not come in for care.
Q1. What medical factors might contribute to Andre=s being iron deficient?
A1. Andre needs a comprehensive medical evaluation. Though this case history is heavily weighted to describe social precursors to malnutrition, it is possible that he has a medical diagnosis that causes anemia. Poor health is engendered by chronic poverty and disengagement from the health care system.
The most common medical cause for the anemia would be iron deficiency as a result of GI bleeding, and a stool guaiac should be obtained. In younger children, ID causes bleeding. By early school age, this is unlikely. Peptic and inflammatory bowel diseases should be considered especially if there is concomitant blood in the stool, loss of appetite, growth retardation, or symptoms of GI distress. Growth retardation alone, however, could be caused by the social and economic circumstances in the family. Other hematologic conditions are possible though less likely. One must look at the other cell lines to be sure that the deficiency is not a part of an oncologic process.
Q2. Why is iron deficiency an unlikely diagnosis in early school age?
A2. As shown in Pediatric Nutrition Notes, [Hyperlink] energy needs are relatively low when compared to those of infancy or adolescence. The nutrient density of a reasonable diet should be sufficiently high as to prevent micronutrient deficiency from occurring. If, however, the nutrient density of the family diet is too low, micronutrient deficiencies will occur in other children and the mother. GI cancer would be the most likely diagnosis for anemia in an adult male in any social circumstance.
The following graph from Nutrition Notes [Hyperlink] demonstrates the likelihood of deficiency occurring at various ages
Table 1. Iron needs at different ages with ratio of required iron adjusted for energy.
* increased need because of menses
** "at-risk" for iron deficiency
*** RDA for energy is based on a balance between intake and
expenditure, not an absolute for intake.
TEACHING CAPTION: Micronutrient needs should always be considered in relation to energy intake. As shown above, iron to energy needs is lowest at early school age.
Unless a medical cause for the iron deficiency can be found, iron deficiency at early school age suggests that the diet contain inadequate iron for the energy consumed. The diet itself is deficient. Causes include: poverty, lack of food support from WIC, Food Stamps, or School Feeding, and less effective use of foods available.
Learner's Exercise: Construct a nutritious diet on the allotment of the USDA for the Low Cost Food Plan -- $2.40 a day for an adult woman or $3.60 a day for an adult man. Then try and live on it for I day, 2 days, a week. Then report
A compensation mechanism that could be expected is that iron absorption generally increase with iron deficiency. Iron deficient endothelial cells absorb iron more easily. As shown in the figure below, however, this phenomenon does not occur with purely vegetable sources for iron in the diet.
Figure 1. Selective absorption of iron from mineral salts, blood, meat, and vegetables with meat B not from vegetables alone.
TEACHING CAPTION: Iron, as FeSO4, is remarkably well absorbed by the iron deficient child. Thus, it is not necessary to give high doses of iron. Rather, lower doses for longer time are preferred. Iron is best absorbed from meat or meat containing meals, but not from vegetables, alone, even with ID.
It is not, however, an adequate explanation of malnutrition among the poor to assume that parents with malnourished are uncaring. The constellation of problems affecting poor families leave poorest and least educated part of the population B those least able to counter the impact of chronic poverty B with the greatest burden for doing so. Because families are affected, undernutrition at early school age increases likelihood that other family members are affected. They have the same diets and live in the same social circumstances.
As shown in Table 2, below, almost all of the infant siblings of these ID school age children were themselves iron deficient from the actual study -- conducted before iron fortification of infant formulae-- and 40% of untested school age siblings and 50% of mothers were iron deficient. The control group B siblings and mothers of non- ID school age children were significantly less likely to be iron deficient.
Table 2. Iron deficiency in Families of Iron Deficient Inner-City School Children
TEACHING CAPTION: Iron deficiency is not an isolated occurrence in the lives of affected children. Other family members are likely to be affected by iron deficiency or other forms of malnutrition.
From: Karp RJ, Haaz WS, Starko K, Gorman J. Iron Deficiency in Families of Iron Deficient Inner-city School Children. Am J Dis Child. 1974;128:18-20.
Q3. What is the problem with the answer -- "Just give iron and then follow-up" in the Mock Pre-test? "The diet has too little iron, so give iron"
A3. As described in the case study, malnutrition is invariably a part of a complex of nutritional, social, and economic problems. Iron deficiency and other forms of micronutrient deficiencies at early school age often are an expression of significant psychological, social, and economic problems in the family. In these Philadelphia studies, families of ID school age children were more likely to be economically dependant. They also exhibited a characteristic of living in chronic poverty called "disengagement". That is, they were unwilling or unable to use the services of the institutions of the larger society. In the study, it was found that fathers were reported less often as living in the home, but this finding was not presented for publication. Reporting that "the father is in the home" would cause the family to lose public assistance.
This policy, denying support to intact nuclear families, is an example of how "disengagement" is a reflection of public policy as well as family behavior, an unwillingness or inability to provide services of the institutions of the larger society. An inability of affected to use and society to provide are complementary phenomena.
Table 3. Social Characteristics of Families of Iron Deficient Inner-City School Children
Caption: It was an odd finding reported by the statistician. "Mothers of ID children were less likely to be tested for ID than mothers of non-ID children." Parents were not informed of ID status of their children until after their willingness to be tested was asked. This is "disengagement."
Also From Karp et al, AJDC ., 1974; 128:18-20.
A follow-up study showed less effective parenting in families of undernourished children B as compared to well nourished controls. Affected families were more dependent on convenience foods that were often of low-nutrient value. Though Ajunk-food@ consumption was higher, the critical factor was failure to prepare nutritious food at home.
The Case study continues:
Following intervention, Andre and the other children received some of the support required. They received iron and dietary guidance. The parents showed an improved appreciation for the importance of iron containing food in the diet. Hemoglobin levels rose for most children after iron therapy and diet counseling. Three years later, in 1976, the affected children were re-surveyed. Hemoglobin levels were not maintained. In fact, they fell to levels below those originally obtained.
Q4. What are the economic impacts of rising food costs, falling income, or increasing costs for other necessities on nutritional status?
A4. "Timing", say the comedians, "is everything".
The original survey was conducted in 1972. The follow-up was in 1975. Several months after the original survey, there was a war in the Middle-East -- the Yom-Kippur War of 1973. This was followed by an oil boycott and a substantial rise in the cost for food. There were significant changes in food selection patterns with meat and animal product consumption falling and vegetable origin foods rising. This is shown in the Figure below.
Table 4. Purchasing patterns in a prosperous community.
CAPTION: National data shows that rising food costs were followed by a major shift in food consumption patterns. Lower cost for energy vegetable sources were preferred
This pattern of change was not universal. The poorest part of the population was more substantially affected. The Low cost food plan had a 50% increase in cost while the cost of the High Cost plan was only 20%. One consequence was that foods formerly available cheaply to the poor B ground beef and chicken wings B entered the diet of the affluent. The cost of sardines I fed to my cat has raised from 9 to 35 cents a can in 3 months.
To see the effect on children in north central Philadelphia, sales were compared for two supermarkets from the same chain. One was in the inner-city community where these studies took place and the other was a middle class community.
Table 5. Purchasing patterns in an inner-city community.
CAPTION: Sales for meat, dairy, groceries (dry packaged goods), produce, and "Deli" were compared for 52 matched weeks for 1972 and 1975. For 51 of 52 weeks, sales for meat dropped in the inner city market while sales of grocery items increased.
These data document that as food costs rise, food selection narrows to those items containing most energy at lowest cost. Nutrient density falls, and malnutrition follows. Unfortunately, the compensatory mechanism that increases iron absorption with mild ID failed because iron absorption from a purely vegetable diet does not increase even with ID. As noted above, beans, alone do not compensate for iron deficiency. This is called the Engel's phenomenon from observations of the diet of English workingmen in the 1840s.
The Engels' phenomenon
The particular findings cited above were the first sighting of the "Engels' phenomenon" in the United States after the Great Depression of the early 1930s. The pressure of rising food costs or decreasing income promotes a narrowed food selection to those items containing the most energy at lowest cost (Karp, 1999). Malnutrition ensues. This observation, called the Engels' phenomenon (68) derives from a description of eating patterns of English workers from the mid l9th century by Freidrich Engels'.
Figure 2. The Engels Phenomenon
Under the influence of rising food costs, food selection narrows to those items containing the most energy at lowest cost. If these conditions persist, essential nutrients diminish in the diet and malnutrition endues."
An appropriate response to the Engels' phenomenon is to recognize that market economies often drive the costs of essential goods and services beyond the ability of those who produce those goods and services to afford them. In the United States, provision of food stamps, school lunches, breakfasts and the special program for Women, Infants and Children (WIC) has improved nutritional status both by providing nutritious food and by allowing the purchase of higher quality diet with the same amount of money budgeted for food -- thus effectively reversing the Engels' phenomenon. These supports are often referred to as "welfare" implying that there is an unearned benefit to the recipient. Actually, the benefit for these programs is to children, who in developed societies are not responsible for their own support, and they benefit everyone by creating a healthy population able to learn, work and earn. They do not create "welfare dependence" since supplemental programs provide essential food to working families and their children. Contemporary food programs have never been shown to be a detriment to work. Rather, they are an alternative to the bread lines and soup kitchens of a post-Victorian era.
Q5. How should interventions be undertaken?
A5. Intervention requires attention to both social and nutritional precursors to iron deficiency. Thus, it is essential to use a comprehensive approach in addressing nutritional problems of the sort shown by Andre. These should begin as early in the life cycle as possible and include protection of the in-utero environment, promotion of effective parenting, good nutrition, and support for the mother, and providing a strong social support from society-at-large. As Gopalan writes,
"differences in the nature of intra-familial distribution of food, in particular in infant feeding and child-rearing practices, between the families and between communities can result in important differences with nutritional status (especially of children) between households, and between communities with nearly similar overall levels of dietary inadequacy." (13)
Long-term commitment to ensuring the availability of nutritious food is an important first step in prevention and treatment of malnutrition and its consequences among children and adults living in poverty. Promoting good nutrition plus addressing multiple developmental risks must inform public policy
Treatment for the ID should be undertaken within a "Medical Home" capable of addressing the multiple needs of families simultaneously. Andre and his family require multiple sources of help to address the underlying problems described. It is beyond the scope of the text to address each individually. What is necessary is to address the full complex of problems affecting Andre. The family needs to have increased resources for food, housing, education and training in effective parenting. Without access to care, however, the family will be unable to achieve any of these service objectives.
Figure 3. The Medical Home
TEACHING CAPTION: Establishing a "Medical Home" for every child includes insuring accessibility, cultural sensitivity, and availability of a full complement of services in a single place.
Beyond public policy, personal commitments to poor children, their families and communities are required to make the best public policy work. Often, the first step for a person to leave the world of disadvantage is a personal contact with another human being who offers help when it is needed and wanted. It was that one person "in the right place at the right time," who cared enough to listen and to respond who made the difference. Committed people being at "the right place" to establish and maintain trust is a prerequisite for care of the disadvantaged.
Summary:
Iron deficiency or any other from of undernutrition at early school age is not an isolated occurrence in the life of an affected child. Iron needs relative to energy are small without an underlying medical problem such as GI bleeding; a school age child should not become iron deficient. ID at early school age is most common among the poor who are highly vulnerable to shifts in the economy. Undernutrition is likely when food costs or those of other necessities rise or when income falls. The most vulnerable poor families are those who have difficulties in their own environment. Simply stated, chronic poverty is associated with falling into patterns of behavior that ill-serve children. Our goal has to be the prevention of that fall. The myriad social problems associated with chronic poverty, however, can never be taken as an excuse for inaction. Rather a comprehensive approach is suggested that addresses the problems of the family and societal support simultaneously. With respect to specific nutritional problems, the specific nutrition support programs - WIC, Food Stamps, and School feeding - are remarkably effective.
References:
Karp, R.J. Haaz, W.S. Starko, K., and Gorman, J.: Iron Deficiency in Families of
Iron Deficient Inner-City School Children. Am. J. Dis. Child., 1974;128:18-20 [First study in a series examining school health and nutrition in an inner-city community.]
Karp, R.J., Nuchpakdee, M., Fairorth, J., and Gorman, J.: The School Health Service as a Means of Entry into the Inner-City for the Identification of Malnourished Children. Am. . Clin. Nutr., 1976;29:216-218. [This documents the effectiveness of an integrated school health and nutrition program]
Karp, R.J. Fairorth, J., Kanofsky, P., Matthews, W., Nelson, M., Solimano, G.: Effects of Rising Food Costs on Hemoglobin Concentrations of Early School-Age Children, 1972-1975. Public Health Reports, 1978;93:456-459. ["food costs rise, some poor children become malnourished" ….Now the trouble starts. The economics of poverty trouble some people, two of whom were the Dean and President of the University where I was working. AYou=ve hired a Communist.@ shouts the Dean (so I=m told) to my Chair.)
Karp RJ, Snyder E, Fairorth JW, et al. Parental behavior and the availability of foods among undernourished inner-city children. J Family Practice 18,731-35,1984. [… Now I offend the opposite pole of the political spectrum. Those affected by poverty have the least personal and social resources with least effective patents having most affected. AYou are a Fascist pig.@ was the comment scrawled in black marking pen on a submitted copy of this paper. This happened a week or so after my encounter with the Dean.]
Karp RJ, Martin R, Sewell T, Manni J, Heller A. Growth and academic achievement among inner-city kindergarten children. Clinical Pediatrics. 1992;32:336-40,
[This is the only paper in the North American literature showing a linear association between poor growth and non-verbal development.]
Karp R. Wadowski S. Reader's Forum. Response to "A multifaceted intervention for infants with Failure to thrive" Archives of Pediatric and Adolescent Medicine 149-50, 1995. [This is a remnant piece of data from my north Philadelphia experience showing that children with malnutrition do not respond to intervention as well as their well-nourished but equally poor classmates.]
These works are reviewed in:
Karp, RJ. (Ed) Malnourished Children in the United States: Caught in the Cycle of Poverty . Springer Publishing Co., New York. 1993.
Karp RJ. The dimensions of poverty among children in the United States: an exposition of causes and consequences. Epilogue to the Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2003. Www.servingtheunderserved.org. This provides a comprehensive view of poverty.
The Engels phenomenon in the United States
Meyers A, Frank D, Roos N, et al. Housing subsidies and pediatric undernutrition. Archives of Pediatrics and Adolescent Medicine 1995;149:1079-84.
Frank DA, Roos N, Meyers AM. et al. Seasonal variation in weight for age in a pediatric emergency room. Pub Health Rep 1996; 111: 366-71.
Bhattacharya J, DeLeire T, Haider S, Currie J. Heat or Eat? Cold-weather shocks and nutrition in poor American families. American Journal of Public Health. 2003 July; 93: 1149-54.
Engels F. The conditions of the Working Class in England. Penguin Classics. First published in 1844. London. 1987.
Iron Deficiency
Hallberg L, Hoppe M, Andersson M, Hulthien L. The role of meat to improve the critical iron balance during weaning. Pediatrics 2003;111:864-870
Moore CV.(1968) Occurrence, causes and prevention of nutritional anemias (in) Blix G (ed) Symposia of the Swedish Nutrition Foundation: VI Amqvist & Wiksell. Stockholm. P 96.
Trowbridge F, Martorell R. Summary and recommendations: Policy and strategies issues (in) Forging effective strategies to combat iron deficiency. Journal of Nutrition 2002;132:875S- 879S.
See also Bogan [hyperlink]
Medical Home
Sia CC. Abraham Jacobi Award Address, April 14, 1992, The Medical Home: pediatric practice and child advocacy in the 1990s. Pediatrics. 1992; 90:419-423
Annotated Answers
A1. The answer is b. The rise in food costs as nutrient density increases has been recognized for over 150 years. It is the principle reason for micronutrient deficiency among the poor. Iron absorption does increase with deficiency except for foods of vegetable origin. Pardon the prejudicial assumption about hygiene. In fact, iron from soak is Ferric (+3) and is poorly absorbed when consumed.
A2. The answer is False. Please do not expect for patients to adhere to a change in diet or to use of a prescribed medication with such a cavalier and disinterested approach. Take time to find what foods are likely to be consumed, whether the family can afford them. Also, the 6 mg/kg dose of elemental iron is likely to cause gastric distress and will not be taken. Use 2 to 3 mg/ day for 3 months.
A3. The answer is c. This is a corollary of q 1. WIC and other food supplementation programs are helpful for long term help. Hunger, e.g., acute malnutrition, is often addressed by charitable organizations. I
A4. The answer is True. At any given level of income or education, parents who plan meals and attend to children are less likely experience malnutrition. One can not expect, however, that poor parents will be exceptional practitioners of home economics. Moreover, the Thrifty food Plan designed for incomes at the poverty level does not provide RDA levels of many nutrients including folate, and zinc and iron.
