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Diagnosis and Management of Folate Deficiency in Low Birthweight Infants

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Diagnosis and Management of Folate Deficiency in Low Birthweight Infants Arch Dis Child: first published as 10.1136/adc.54.4.271 on 1 April 1979. Downloaded from Archives ofDisease in Childhood, 1979, 54, 271-277 Diagnosis and management of folate deficiency in low birthweight infants M. K. STRELLING, D. G. BLACKLEDGE, AND H. B. GOODALL Department of Paediatrics, Plymouth General Hospital, and Department of Pathology, Ninewells Hospital SUMMARY Significant folate deficiency in 14 out of 37 preterm infants of birthweights 2 0 kg or less was found to be reliably and most conveniently diagnosed by abnormal morphological changes in peripheral blood and confirmed by the response to folic acid. Deficiency appeared to be more common in light-for-dates infants including the smaller of twins. Neither the clinical status nor the levels of haemoglobin or erythrocyte folate was a reliable guide to the presence of megaloblastic erythropoiesis in the very young preterm infant. 100-200 tg folic acid a day, orally or IM, may be required to ensure an optimal haematological response, and this would be appropriate for therapeutic trial if the diagnosis is in doubt. This amount would also replenish tissue folate stores; larger doses are likely to exceed the requirements of small infants. In an earlier paper (Strelling et al., 1966) we drew completed weeks*, (b) birthweight 2-0 kg or less*, attention to the vulnerability of premature infants (c) unaffected by a major congenital abnormality or to folate-responsive megaloblastic anaemia. The haemolytic disease. They were as far as possible most appropriate dose of folic acid for the treatment consecutive admissions to a special care baby unit. http://adc.bmj.com/ of affected infants is however unknown. The effect 24 were term (38-42 completed weeks), normal, of varying amounts of folic acid on 19 infants is singleton infants from uncomplicated 1st or 2nd reported, in whom the morphology of the peri- pregnancies weighing at least 3*O kg at birth pheral blood was either frankly megaloblastic or selected as controls with informed parental co- highly suggestive of such change. The diagnosis of operation. All these infants thrived. folate deficiency in the very young low birthweight None of the mothers in either group of infants infant and the value of a therapeutic trial with small had been folate-deficient or had received folic acid 'physiological' amounts of folic acid are also con- supplements during pregnancy. on September 26, 2021 by guest. Protected copyright. sidered. Feeding. The preterm infants were fed evaporated milk (Carnation) changing to full-cream dried milks Materials and methods when their weights had reached 2 5 kg. From the 3rd week they were given 22 mg elemental iron in The infants with observed or suspected megalo- 4 ml sodium iron edetate (Sytron, Parke-Davis) and blastosis were discovered during the course of an 7 drops of a multivitamin preparation not con- investigation into the folate status of approximately taining folic acid (Protovite, Roche) each day. All 100 infants between birth and 12 months. 37 of these except 2 control infants who were breast fed fulfilled the following criteria: (a) gestation <37 received dried milk feeds. The milks were sterilised by autoclaving after reconstitution. Plymouth General Hospital, Devon M. K. STRELLING, consultant paediatrician Investigations. Blood was taken by heel prick just Dubbo Base Hospital, Dubbo, New South Wales, Australia after birth, repeated at 2 to 4 weeks, and at least D. G. BLACKLEDGE, consultant obstetrician twice during weeks 5 to 10. Further samples were Ninewells Hospital, Dundee, Angus *One infant of 37 weeks and one of birthweight 2 -06 kg with H. B. GOODALL, senior lecturer in pathology suspected megaloblastosis were included. 271 Arch Dis Child: first published as 10.1136/adc.54.4.271 on 1 April 1979. Downloaded from 272 Strelling, Blackledge, and Goodall taken during weeks 11 to 20 and between months Nine (64%) of the confirmed megaloblastic group 6 and 12. The following examinations were made: had birthweights below the 10th centile compared Hb, MCHC, reticulocytes, PCV, and films. Buffy with 5 (28 Y.) of the normoblastic group. In all the coat smears were taken from microhaematocrit 45 infants who were below 37 weeks' gestation preparations spun relatively slowly (750 rev/min) irrespective of birthweight, there were significantly for 5 minutes. more who were light-for-dates in the megaloblastic Assays of whole-blood folate (L. casei) were group (P<0*05). made on duplicate samples of 50 ,ul blood using the Hb was invariably below 10 g/dl in the megalo- method described previously (Strelling et al., 1966), blastic infants at diagnosis but it was also at this red-cell folate being calculated from the haematocrit. level in 13 of the 18 normoblastic infants. The mean Abnormal haemopoiesis was assessed on blood difference in Hb at average age 7 weeks was 1 1 and buffy coat smears as: (1) megaloblastic; the g/dl, values in the megaloblastic group being presence of megaloblasts or transitional megalo- significantly lower (P <0 05, Table 2). blasts with eosinophilic or polychromatophilic Erythrocyte folate levels in 22 of the 37 low cytoplasm, or (2) suspected megaloblastic; ortho- birthweight infants at average age 7 weeks were chromatic oval macrocytes, macronormoblasts, and below those in controls of comparable postnatal age hypersegmented neutrophils. Marrow biopsies were (P<0 05, Table 2). Values in 3 infants with con- not taken. firmed or suspected megaloblastosis and in 5 of the normoblastic low birthweight group were never- Folic acid treatment. Folic acid was given daily as theless within the control range. follows: (1) 5 mg IM (6 infants) and orally (1 infant), None of the control infants at any time and no (2) 1-2 mg orally (4 infants), (3) 60 ,ug IM (2 infants) low birthweight infant over 12 weeks showed any or 50 ,ug orally (2 infants), and (4) 15-120 ,ug IM cytological evidence of folate deficiency on peri- initially, the amount being increased every few days pheral blood examination. Three of the normo- depending on the haematological response (4 blastic low birthweight infants who did not receive infants). folic acid had erythrocyte folate levels <100 ,ug/I As only 5 mg tablets of folic acid were available at 6 months. both 1 mg and 50 tug tablets of folic acid were pre- The condition of no infant caused undue pared commercially. A parenteral folic acid solution concern when morphological evidence of folate containing 15 mg/ml (Folvite, Lederle) was appro- deficiency was found, although in 4 there had been priately diluted immediately before each IM in- previous clinically mild infections of the urinary or http://adc.bmj.com/ jection. respiratory tracts. The haemopoietic response was assessed on the Serum vitamin B12 values (Lactobacillus leich- reticulocyte count, blood films, and buffy coat manni) in 5 low birthweight infants were 150-335 smears. ng/l (normal 160-950 ng/l). Birthweight/gestation centiles. These are from the Treatment with folic acid. data of (1) Thomson et al. (1968) for infants born after 31 completed weeks, allowing for sex and Standard doses (1-5 mg daily) on September 26, 2021 by guest. Protected copyright. parity, (2) Babson et al. (1970) for infants born An unequivocal response occurred in all 6 infants between 28 and 31 completed weeks. given 5 mg folic acid daily TM (Cases 1-6) and in 3 of the 4 given 1 or 2 mg orally (Cases 7-9). Blood Results films and buffy coat smears examined between days 3 and 7 showed normoblastic transformation and a Findings in low birthweight infants. Megaloblastosis pronounced increase in polychromatophilic erythro- was observed in 19 of the preterm infants with cytes. Reticulocytes were often slightly increased birthweights of 2 kg or less. Data on these infants before treatment but a definite subsequent rise was are shown in Table 1. In 14 the diagnosis was con- nevertheless demonstrable. Enlargement of spleen firmed by the haematological response to treatment and/or liver was noted in several infants after with folic acid, but this was suboptimal in 4 (Cases treatment with folic acid; the reason for this was 15-18) and was not assessed in one (Case 19). The not clear. remaining 18 low birthweight infants showed no The haematological response was suboptimal in morphological evidence of folate deficiency, and Case 15 (5 mg/day orally) and was not assessed in none of the 6 who received a trial of folic acid Case 19 (2 mg/day orally). showed any haematological effect. Data on these Whole-blood folate was estimated in 4 megalo- infants and the controls are shown in Table 2. blastic infants receiving 5 mg/day folic acid IM and Arch Dis Child: first published as 10.1136/adc.54.4.271 on 1 April 1979. Downloaded from Diagnosis and management offolate deficiency in low birthweight infants 273 I0) lb co Cd S. w N " "" 0-4 "" 0 0 0 0--4 0* 0. o-, 0 0 00 on *C0:s 00 4- 00 e -a 3%x _ tX0i '0 t- I 0e be o be 'L15 ~ - tho tll000 Ob F00 b0-t t 00000000 0 )in)in .. .) O --- 0 in 0 ~ v e4 v v " E MN" M 0,b I0%00C^ e000-I 00 IC0 Q) (J .2: N 0% e4 e't ') 0% 000% 00C') _0? 0% C C') b000 et00 ? . S. 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