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PAPERS: J Williams, A Wolff, A Daly, A MacDonald, A Aukett, I W Booth, and Stuart Logan Iron supplemented formula milk related to reduction in psychomotor decline in infants from inner city areas: randomised study • Commentary: Iron deficiency and developmental deficitthe jury is still out BMJ 1999; 318: 693-698 [Abstract] [Full text]

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Iron supplemented formula milk

Wendy Hodge   (7 April 1999)

Anaemia and iron deficiency - the normal and the pathological

David Stevens   (9 April 1999)

Iron supplemented milk - the Birmingham study

J K Anand   (22 July 1999)

Re: Iron supplemented milk - the Birmingham study

Ian Booth   (28 March 2000)

Iron supplemented formula milk 7 April 1999
Wendy Hodge Send response to journal: Re: Iron supplemented formula milk	Dear Editor This paper does not clearly prove that iron is the cause of the slowing of the psychomotor decline of infants in inner city areas; rather, it shows us what we already know, that inner city children may well be iron deficient and that giving adequate iron, in formula milk which is (presumably) well tolerated by infants and toddlers, can improve these chidren's iron status and reduce anaemia. It also provides supportive evidence for the clinically accepted comment that most anaemia in young infants and children in inner city areas is due to dietary lack. However, when considering the possibility that it is the iron in the formula milk which causes the shown slowing of psychomotor decline, the authors are ignoring data which is clearly laid out in Table 1, which shows that not only is iron supplemented in formula milk when compared to unmodified cows' milk, but several other nutrients (vitamin A- 60% more in formula milk than cows' milk; vitamin E- 5 times as much is present in formula milk compared with cows' milk), which have postulated effects on the developing brain, as well as some which (as far as I am aware) have not been suggested as crucial for brain development (vitamin C- 10 times more in formula milk as compared to cows' milk; vitamin D- more than 30 times more in formula as compared with cows' milk; nicotinamide- 6.5 times more in formula milk) are also present in different quantities. The fact that anaemia improves with iron supplemented milk does not prove that the observed effect on psychomotor performance (or rather its decline) is also due to the iron alone- for this to be shown as due to iron alone, the trial should be conducted using a milk formula which is the same as cows' milk in everything except iron content (which, to my knowledge, does not exist.) In summary, the authors seem to have simply shown that inner city children are likely to be nutritionally deprived and that use of a formula milk can be asociated with improvements in nutrition which may also be associated with a slowing of the psychomotor decline which seems to affect such children (and which is a recognised feature of malnutrition.) Yours sincerely Wendy Hodge MBChB(Hons); MRCP (Paeds)(UK); MRCPCH
Anaemia and iron deficiency - the normal and the pathological 9 April 1999
David Stevens, Consultant Paediatrician and Senior Lecturer Gloucestershire Royal Hospital Send response to journal: Re: Anaemia and iron deficiency - the normal and the pathological	A double blind randomised controlled trial(1) showed that iron in a formula milk, with the same iron concentration as that used in the trial by Williams et al, had no effect on haemoglobin concentrations and serum ferritin levels in infants between 6 and 12 months of age There was no evidence in this trial that formula milk was an important source of iron. While recognising that there is little benefit in feeding infants with door step cow's milk it may be wise for the jury to remain out a bit longer before we rely on formula milk as a source of iron in infancy after the first 6 months of life. Stuart Logan is correct to point out that we need more evidence before coming to conclusions about iron deficiency anaemia and developmental deficit. He might have added that the jury may be hampered by the unsatisfactory nature of the tests that we use to assess anaemia and iron deficiency. We do not know how many children with 'low' haemoglobin levels in the world are iron deficient(2), or the cut off levels of haemoglobin and ferritin that signify a disadvantage, or clinical disease, for children. It is possible that the search for these cut off points will prove illusory and we that we will have to wait for laboratory tests that tell us more about the needs of the patients. Vierordt's measurement of haemoglobin in the blood in 1873(3 )was an important advance but surely the warning signs were there in 1894 when Stone(4) found that clinical prediction of low haemoglobin levels in young women was no more accurate than the tossing of a coin. David Stevens, Gloucestershire Royal Hospital References 1. Stevens D, Nelson A. The effect of formula milk after 6 months of age. Arch Dis. Child 1995;73:216-20 2. Stevens D. The epidemiology of hypochromic anaemia in young children. Arch Dis Child. 1991; 66:886-9 3. Verso ML. The Evolution of Haemoglobinometry. Treffusis Publications. Melbourne 1981. 4. Stone AK, Richardson AG, Joslin EP, Denny FP. A study of anemia cases with the aid of the hemometer and blood-counter. Boston Medical and Surgical Journal.1894; cxxxi:183-85.
Iron supplemented milk - the Birmingham study 22 July 1999
J K Anand Send response to journal: Re: Iron supplemented milk - the Birmingham study	Editor- The paper by Williams et al (13 March,pp693-697) calls forth a few comments. Their study population was 75% Caucasian, 24% Afro- Caribbean and 2% Asian (Indians). This adds up to 101%. Secondly, it is a little odd that in that in this racial cauldron in the heart of England, only "pure" specimens of the three subgroups of the human race found their way in to the study. Finally, the authors do not tell us whether the three subgroups exhibited identical findings in the developmental studies. J K Anand Retired public health physician
Re: Iron supplemented milk - the Birmingham study 28 March 2000
Ian Booth, Professor of Paediatrics and Child Health University of Birmingham Send response to journal: Re: Re: Iron supplemented milk - the Birmingham study	In reply to Dr Anand There were 74% Caucasian, 24% Afro-Caribbean, 2% Asian. We are unsure how 74% suddenly became 75%. They were correctly published in the Archives of Disease in Childhood. Dr Anand's comments that it is a little odd that only 3 sub groups of the human race found their way into the study. However, part of the study protocol was to target a Caucasian population. Much of the work that had been done prior to this had targeted the Asian population and this is why we deliberately targeted a white Caucasian population to see if the same level of iron deficiency anaemia was observed.