Community and International Nutrition

Iron Nutritional Status Is Improved in Brazilian Preterm Infants Fed Food

Cooked in Iron Pots1,2
Eliana V. M. Borigato*3 and Francisco E. Martinez†
*Hospital for Medicine of the Locomotor System—SARAH, BrasıB lia, 70330–150, DF, Brazil and †Department
of Pediatrics, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, São Paulo, 14049–900, Brazil

ABSTRACT To determine the efficacy of cooking food in iron pots to prevent anemia in premature infants, a
longitudinal study on iron nutritional status was conducted in preterm, healthy infants from families of low socioeco-
nomic level between mo 4 and 12 of life. The infants were divided randomly into two groups. The study group
consisted of 22 infants whose food was cooked in iron pots; the control group consisted of 23 infants whose
food was cooked in aluminum pots. Supplemental iron [2 mg/(kgrd)] was recommended from 15 d to 12 mo of
age for both groups. At 12 mo of age, the group fed food cooked in iron pots had significantly better hematologic
values than the group fed food cooked in aluminum pots. Differences included hemoglobin (116 { 16 vs. 103 {

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20 g/L, P Å 0.02), hematocrit (0.35 { 0.04 vs. 0.31 { 0.05, P Å 0.005), mean corpuscular volume (72.1 { 10.4
vs. 62.7 { 11.1 fL, P Å 0.005), free erythrocyte protoporphyrin (0.78 { 0.60 vs. 1.46 { 0.94 mol/L, P Å 0.006)
and serum ferritin (median 5 vs. 0 g/L, P Å 0.001). No significant differences between groups were observed in
serum iron concentration, total iron-binding capacity or transferrin saturation. Iron deficiency anemia (hemoglobin
° 110 g/L) was observed in 36.4% (8 of 22) of infants in the group fed food cooked in iron pots and in 73.9%
(17 of 23) of the infants fed food cooked in aluminum pots (P Å 0.03). These results indicate that the iron added
to food cooked in iron pots is bioavailable. However, this increased iron availability was insufficient to satisfy the
high iron requirements of this group of preterm infants. J. Nutr. 128: 855–859, 1998.

KEY WORDS: • iron nutritional status • iron deficiency anemia • iron pots • preterm infants

Iron deficiency is a nutritional problem all over the world.
Iron deficiency anemia is the most frequent form of nutritional
anemia, with the highest prevalence occurring in developing
countries (DeMayer and Adiels-Tegman 1985). Infants õ2 y of
age and preterm newborns, in particular, represent major risk
groups because of their low iron stores at birth, high iron require-
ments for growth, and diets consisting of foods with low iron
content and low iron bioavailability (Dallman et al. 1980).
The high prevalence and consequences of iron deficiency
justify the search for alternative prophylactic measures. Among
the measures to be taken are the prevention of low birth weight
and prematurity, the advocation of exclusive breast-feeding up
to 6 mo of age, discouraging the use of fresh cow’s milk at
least up to mo 9 of life, the use of iron-fortified infant formulas
when formulas are used, the inclusion of foods that facilitate
iron absorption in the diet, the distribution of iron-fortified
foods and iron supplementation (AAP 1992). However, some
of these recommendations are impeded by political and socio-
economic problems, especially in developing countries, so that
iron deficiency remains an unresolved public health problem.
An alternative approach to food enrichment with iron that
has possible applications in developing countries is cooking
1
Supported by CAPES, Brazil, and Nestec SA, Vevey, Switzerland.
2
The costs of publication of this article were defrayed in part by the payment
of page charges. This article must therefore be hereby marked ‘‘advertisement’’
in accordance with 18 USC section 1734 solely to indicate this fact.
3
To whom correspondence should be addressed.
infant diets in iron pots. The iron content of most diets in-
creases significantly when the diet is cooked in an iron utensil
(Borigato and Martinez 1992, Brittin and Nossaman 1986).
Furthermore, in an experiment conducted in rats, the iron
present in food cooked in an iron pot had good bioavailability
(Martinez and Vannucchi 1986).
The objective of this study was to evaluate iron nutritional
status in preterm infants fed food cooked in iron pots between
mo 4 and 12 of life.
SUBJECTS AND METHODS
Research design. The infants that would participate in the study
were selected at 2 mo postnatal age. The controlled clinical trial was
initiated during the beginning of mo 4 postnatal age, with follow-up
to 12 mo of age. Pairs of infants were randomly selected and placed
into two groups. The study group consisted of 22 infants whose food
was cooked in iron pots (IP)4; the control group consisted of 23
infants whose food was cooked in aluminum pots (AP). The AP
(Almar) was purchased on the Ribeirão Preto market. The IP, a 2-L
pot, was manufactured especially for the study by the Fabbris foundry,
Ribeirão Preto, Brazil, using pig iron. A single IP was used by each
infant.
One of the authors (E.V.M.B.) evaluated the infants at the outpa-
tient clinic on a monthly basis during the first half of the study and
4
Abbreviations used: AP, aluminum pot; FEP, free erythrocyte protoporphyrin;
IP, iron pot; MCV, mean corpuscular volume; TIBC, total iron-binding capacity;
TS, transferrin saturation.

0022-3166/98 $3.00 q 1998 American Society for Nutritional Sciences.

Manuscript received 12 June 1995. Initial review completed 3 August 1995. Revision accepted 13 January 1998.

855

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856 BORIGATO AND MARTINEZ

on a bimonthly basis during the second, in addition to also seeing TABLE 1

them during unscheduled visits (such as in the case of an illness).
At each return visit, a careful history was taken and each infant General characteristics at birth of the infants studied,
was given a clinical examination to determine general health and
nutritional status. Anthropometric measurements were also made and sociodemographic characteristics of the study
blood was collected for hematologic evaluation. The dates scheduled population and type of cooking utensil used
for each return were monitored carefully, with a tolerance of 3 d.
Growth (weight, length and head circumference) was evaluated every Aluminum
2 mo. The infants were weighed on a Filizola (São Paulo, Brazil) Iron pot pot
pediatric scale with a 10-g sensitivity. Length was measured using an Characteristic n Å 22 n Å 23
anthropometric ruler with a metric scale and 0.5-cm sensitivity. Head
circumference was measured by using a Stanley (São Paulo, Brazil) Sex
2-m flexible, nonexpandable steel tape with millimeter divisions. On Male, % 45.5 (10/22) 47.8 (11/23)
the occasion of the return visits scheduled during mo 4, 8 and 12, Female, % 54.5 (12/22) 52.2 (12/23)
venous blood was collected between 0700 and 1100 h for the determi- Gestational age,1 wk 35 { 1 34 {2
Appropriate-for-gestational-age, % 63.6 (14/22) 60.9 (14/23)
nation of hemoglobin, hematocrit, mean corpuscular volume (MCV), Small-for-gestational-age, % 36.4 (8/22) 39.1 (9/23)
free erythrocyte protoporphyrin (FEP), serum iron, total iron-binding Weight,1 g 1967 { 343 1905 { 397
capacity (TIBC), transferrin saturation (TS) and serum ferritin. Length,1 cm 43.5 { 2.5 43.0 { 2.8
Illnesses noted during the study were classified according to degree Head circumference,1 cm 31.1 { 1.7 31.5 { 1.9
of severity as follows: 1) mild when the mother did not seek medical Maternal age, %
care, when the infant presented with slight irritability, a cold, or õ20 y 13.6 (3/22) 30.4 (7/23)
changes in intestinal habits; 2) moderate when the mother sought 20–39 y 86.4 (19/22) 69.6 (16/23)
medical care, with the infant presenting fever, irritation, coughing, Parity, %
acute otitis media, acute diarrhea or refusal of food for more than 24

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h; and 3) severe when the mother sought medical care and the infant
required hospitalization. When severe illness occurred, the infant was
excluded from the study. Morbidity was assessed by voluntary mater-
nal recall, depending on the child’s clinical state and individual needs.
Maternal compliance with the continuous use of the cooking
utensil and with the daily administration of medications in the two
groups was evaluated by surprise monthly home visits by E.V.M.B.
When cooked diets were found, samples were collected. The results
of analysis have been reported elsewhere (Borigato and Martinez
1992).
Population sample. From a total of 63 infants selected at 2 mo
postnatal age, 45 fulfilled the requirements (absence of severe illness
or blood transfusions, for example) to enter and complete the study,
which began at 4 mo postnatal age, with follow-up to 12 mo postnatal
age. These infants came from low socioeconomic backgrounds.
Gestational age was 30–36 wk, as determined by the date of last
menstruation and confirmed by the method of Dubowitz et al. (1970).
Birth weight was õ2500 g, and appropriate weight for gestational
age was determined according to the curves proposed by Battaglia
and Lubchenco (1967). There were no congenital malformations,
malnutrition or perinatal complications, and no blood transfusions.
The infants were born and followed up at the University Hospital,
Faculty of Medicine of Ribeirão Preto, State of São Paulo, Brazil.
Written consent to participate in the study was obtained from
each mother after both the objective of the study and the type of
observations in which they would be involved with their infants
were explained to them. The research protocol was approved by the
Department of Pediatrics and the Ethics Committee of the University
Hospital.
Dietary advice was offered, in accordance with the routine of the
service. Breast-feeding was encouraged whenever possible. Breast-fed
infants started to receive fruit juices at the end of mo 3, fruit at the
end of mo 4, cereals by the second half of mo 5, vegetables by the
end of mo 5, meat and liver by the end of mo 6 and legumes by the
second half of mo 7. Artificially fed infants started to receive fruit
juices by the second half of mo 2, fruit by the second half of mo 4,
cereals by mo 4, vegetables by the beginning of mo 5, meat and liver
by the end of mo 6 and legumes by the beginning of mo 7 (Woiski
1988). The cereals (oatmeal or corn meal), vegetables, meat or vis-
cera, and legumes, as well as milk when the infants were artificially
fed, were always prepared in the pot indicated in the study. No iron-
fortified cereals or formulas were used. The infants received the diet
in the form of a pap, i.e., the solid part mixed with broth. This
schedule has now been modified and we are currently following the
recommendations of the American Academy of Pediatrics (AAP
1992).
The mothers of all infants were instructed to start giving their
children a daily vitamin supplement consisting of 50 mg vitamin C
and 3 mg vitamin E starting on d 7 of life and continuing up to
/ 4w38$$2887 04-08-98 13:15:50
1 36.4 (8/22) 30.4 (7/23)
2–3 40.9 (9/22) 43.5 (10/23)
¢4 22.7 (5/22) 26.1 (6/23)
Maternal occupation, %
Housewife 72.7 (16/22) 60.9 (14/23)
Maternal education, %
Incomplete primary schooling 90.9 (20/22) 82.6 (19/23)
Lived within periphery of the city, % 95.5 (21/22) 100 (23/23)
1 Values are means { SD. Groups did not differ significantly, P ú
0.05.
7.5 mo. Ferrous sulfate, providing 2 mg elemental iron/(kgrd), was
recommended from d 15 to 12 mo of age.
Blood analyses. Hemoglobin, hematocrit and MCV levels were
determined by using a model CC-510 (Celm, Barveri, São Paulo,
Brazil) automatic cell counter, a model DA-500 automatic diluter
and a model HB-520 CELM hemoglobinometer. FEP was measured
by the method of Piomelli (1973). Serum iron concentration and
TIBC were determined by the method of Ramsay adapted to a micro-
method (Ramsay 1957a and 1957b). Transferrin saturation was calcu-
lated by the serum iron/TIBC ratio. Serum ferritin was determined
quantitatively by an immunoenzymatic method (Ferrizyme, Abbott
Laboratories, Chicago, IL).
The reference values employed for the classification of the hema-
tologic parameters of preterm infants at 4 mo were as follows: hemo-
globin ú100 g/L, MCV ú 74 fL, serum iron ú 7 mmol/L, TIBC õ
97 mmol/L, TS ú 7% and serum ferritin ú 11 mg/L (Halliday et al.
1984, Heese et al. 1990). The following cut-off levels were considered
at 12 mo: hemoglobin ú 110 g/L, hematocrit ú 0.32, MCV ú 70
fL, FEP õ 0.53 mmol/L whole blood, serum iron ú 5 mmol/L, TIBC
õ 72 mmol/L, TS ú 10%, and serum ferritin ú 10 mg/L (Dallman
and Reeves 1984).
The iron nutritional status of the infants was evaluated on the
basis of combined laboratory data and classified as follows: 1) normal
when hemoglobin, serum ferritin, and 2 or 3 criteria for MCV, FEP,
TS levels were within normal limits; 2) iron deficient when hemoglo-
bin was normal, serum ferritin low, and 0 or 1 of the criteria for
MCV, FEP, TS was abnormal; 3) iron deficiency anemia when hemo-
globin was low, serum ferritin low, and 0 or 1 of the criteria for MCV,
FEP, TS was abnormal; and 4) other type of anemia when hemoglobin
was low and serum ferritin was normal.
Statistical analysis. Student’s t test for data with normal distribu-
tion, the Mann-Whitney U test for data not normally distributed and
the chi-square test for two independent samples were used to compare
the data between the two groups and to analyze the change in blood
concentrations between 4 and 12 mo. Fisher’s exact test was used
when the chi-square test was not feasible. The level of significance
was set at P õ 0.05 (Siegel 1975).
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 IRON STATUS AND FOOD COOKED IN IRON POTS 857

TABLE 2 significantly between groups, whereas at 12 mo of age they

were significantly improved in IP infants, except for serum
Percentage of infants breast-fed at selected ages, by type of iron, TIBC and TS (Table 4).
cooking utensil used Between 4 and 12 mo, the change in several hematologic
indices differed significantly between groups (Table 5). In the
Iron pot Aluminum pot IP group, mean hemoglobin (P Å 0.01) and transferrin satura-
Age tion (P Å 0.05) increased, whereas they decreased in the AP
(mo) n % n % P1 group. The IP group experienced a smaller decrease in mean
corpuscular volume (P Å 0.05) and serum iron (P Å 0.04)
1 18 81.8 17 73.9 0.84
2 16 72.7 13 56.5 0.41
than the AP group.
3 12 54.5 8 34.8 0.30 No significant differences in blood concentrations of hemo-
4 10 45.5 6 26.1 0.29 globin, MCV, FEP, serum iron, TIBC, TS and serum ferritin
5 9 41.0 6 26.1 0.46 were observed at any of the ages tested between infants with
¢6 8 36.4 5 21.7 0.45 appropriate for gestational age weight and infants with small
for gestational age weight, within or between groups (data not
1 Chi-square test.
shown).
Iron nutritional status at 12 mo of age, evaluated on the
RESULTS basis of combined hemoglobin, serum ferritin, MCV, FEP and
TS data, was significantly better in the IP group than in the
The general characteristics of the children in the two groups AP group (P Å 0.03) (Table 6).
were similar and are presented in Table 1. There were no
significant differences in sex, gestational age, percentage of

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appropriate for gestational age, weight, length, head circumfer-
ence at birth or sociodemographic characteristics.
During the longitudinal follow-up, 18 losses occurred in the
initial group of infants selected at 2 mo (28.6%; 18 of 63) for
the following reasons: 7 were due to severe disease, 2 from
the IP group (1 with prolonged diarrhea and the other with
bronchopneumonia) and 5 from the AP group (3 with pro-
longed diarrhea, 1 with infectious hepatitis, and 1 with gastro-
esophageal reflux); 2 losses were due to the fact that the family
moved to another town (both in AP group); 7 did not return
to the clinic (2 in IP group and 5 in AP group); and 2 were
due to the fact that the mothers stopped using the iron pot
after 4 and 5 mo of use.
Of the 45 infants who completed the longitudinal follow-
up, 10 from the IP group (10 of 22, 45.4%) and 9 from the AP
group (9 of 23, 39.1%) presented mild-to-moderate illnesses
consisting of infection of the upper airways, acute otitis media
or acute infectious diarrhea.
The groups did not differ significantly in duration of breast-
feeding (P ú 0.05), which was 6 mo or more for 36.4% of the
infants (8 of 22) in the IP group and 21.7% (5 of 23) in the
AP group (Table 2).
On the occasion of the home visits, it was observed that
the iron pot was used in the daily routine, whereas the adminis-
tration of medication (ferrous sulfate and multivitamins) was
not regular, reflecting the low maternal compliance.
The two groups did not differ significantly in weight, length
or head circumference at 4 or 12 mo (Table 3).
Blood concentrations of hemoglobin, MCV, FEP, serum
iron, TIBC, TS and serum ferritin at 4 mo of age did not differ
DISCUSSION
The diets offered to infants are frequently inadequate in
terms of satisfying the iron requirements for growth (Pizarro
et al. 1991). Despite the rapid accumulation of new informa-
tion about iron deficiency, the diversity of feeding regimens
and the economic situations prevailing in many parts of the
world represent special problems that require a variety of solu-
tions. Fortification of milk and cereals and oral iron administra-
tion have prevented iron deficiency in term and preterm new-
born infants in developed countries (Miller et al. 1985). In
developing countries, the establishment of programs of food
fortification for the target population is often impeded by polit-
ical and socioeconomic problems. Appropriate strategies di-
rected at the prevention of iron deficiency anemia are neces-
sary in these countries, where the incidence of the disorder
is so high as to reach epidemic proportions among infants
(Florentino and Guirriec 1984, Macphail and Bothwell 1992).
The low maternal compliance with oral iron administration
and the precarious living conditions of the population may
lead to failure of standard programs for the prevention and
treatment of iron deficiency.
The supply of some trace elements can be increased by the
use of different forms of food processing and by the type of
cooking utensils employed. These provide an approach to diet
fortification and possibly effective prevention of certain defi-
ciencies. Analysis of the iron content of an infant diet cooked
in an iron pot demonstrated a significant increase in dietary
iron concentration (Borigato and Martinez 1992). However,
the nutritional and toxicologic importance of these casual
metal sources in the diet should be carefully analyzed (Reilly

TABLE 3
Anthropometric variables measured at 4 and 12 mo of age in preterm infants fed food cooked in iron or aluminum pots1

4 mo2 12 mo2

Iron pot Aluminum pot Iron pot Aluminum pot

Weight, g 5303 { 664 5007 { 889 8708 { 987 8747 { 1159

Length, cm 57.6 { 2.7 56.6 { 3.1 71.7 { 2.2 70.8 { 2.8
Head circumference, cm 39.5 { 1.2 39.3 { 0.6 45.3 { 1.5 45.0 { 1.6

1 Values are means { SD.

2 Values did not differ significantly between groups at the same age (P ú 0.05).

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858 BORIGATO AND MARTINEZ

TABLE 4
Blood variables at 4 and 12 mo of age in preterm infants fed food cooked in iron or aluminum pots1

4 mo2 12 mo

Blood concentrations Iron pot Aluminum pot P3

Hemoglobin, g/L 111 { 15 110 { 14 116 { 16 103 { 20 0.02

Hematocrit 0.35 { 0.07 0.33 { 0.03 0.35 { 0.04 0.31 { 0.05 0.005
MCV, fL 86.3 { 11.3 84.9 { 10.8 72.1 { 10.4 62.7 { 11.1 0.005
FEP, mmol/L 0.91 { 0.51 1.38 { 0.94 0.78 { 0.60 1.46 { 0.94 0.006
Serum iron, mmol/L 10 { 5 11 { 5 9{4 8{ 5 0.28
TIBC, mmol/L 66 { 12 70 { 15 67 { 14 74 { 16 0.14
Transferrin saturation 0.16 { 0.10 0.17 { 0.09 0.19 { 0.17 0.13 { 0.11 0.19
Serum ferritin,4 mg/L 10 (1, 30) 5 (0, 18) 5 (2, 14) 0 (0, 4) 0.001

1 Values are means { SD.

2 Values did not differ significantly between IP and AP, P ú 0.05.
3 P-values at 12 mo differ between IP and AP at 4 and 12 mo of age.
4 Value is a median (25th, 75th percentiles).

1987). In a study comparing iron and aluminum utensils in the American Academy of Pediatrics Committee on Nutrition

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terms of increased dietary content of Fe, Zn, Cu and Pb, the
detection of toxic levels of any of the metals was not reported.
There was a higher Fe concentration in food cooked in the
iron utensil and no important differences were reported for
Pb, Zn or Cu. In some diets, Pb levels were higher in foods
cooked in aluminum utensils (Reilly 1985).
Aluminum utensils have been widely used since 1960, and
have the following advantages compared with iron utensils:
they are good heat conductors, do not alter food color, do not
rust, they are lightweight and cost less. However, aluminum
utensils not only supply less iron but also release aluminum,
which is suspected of being harmful to health (Karlik et al.
1980). Although this was not evaluated, in theory it would
be safer to use an iron pot to cook food because it releases less
Al and Pb (Reilly 1985).
During mo 4 of life or earlier, the iron reserves derived
from the mother are depleted in infants and, unless available
supplemental iron is supplied, late anemia of prematurity de-
velops (Friel et al. 1990). A study evaluating low birth weight
infants receiving 2 mg Fe/(kgrd) from d 15 of life and compar-
ing them with a group receiving 4 mg Fe/(kgrd) after 4 mo
of age showed that the lower iron dose was insufficient to
prevent iron deficiency (Lundström and Siimes 1980). In that
study, the use of an iron pot was started at 4 mo of age as a
complement to the supplementary iron dose recommended by
TABLE 5
Change in blood variables from 4 to 12 mo of age in preterm
infants fed food cooked in iron or aluminum pots1
Blood Iron pot Aluminum pot
concentrations n Å 22 n Å 23
(AAP 1976). Diversification of the diet offered to the infants
was also started during this period.
In this study, mothers were instructed to administer 2 mg
Fe/(kgrd) as ferrous sulfate starting at 15 d and extending to
the end of the first year of life for both infant groups, in
addition to the use of an iron pot for cooking the diet for the
IP group and of an aluminum pot for the AP group. On the
occasion of the home visits it was observed that the iron pot
was used in the daily routine, whereas the administration of
medication (ferrous sulfate and multivitamins) was not regular,
reflecting the low maternal compliance; however, no quantita-
tive documentation has been obtained at this point. The rea-
son reported by the mothers for not offering the medication
on a daily basis was that their household dutes caused them
to forget. The mothers participating in this study were of a
low socioeconomic level, ranging in age from 20 to 39 y; most
of them were multiparous housewives with minimal schooling,
residing in the periphery of the city. Daily administration of
medication to apparently healthy children for a period of sev-
eral months is difficult to sustain even for mothers of relatively
high socioeconomic status (Palti et al. 1987). The greater
compliance in the use of the iron pot represented a practical
advantage of this method of iron enrichment of the diet.
Growth pattern affects iron needs. Low birth weight infants
TABLE 6
Classification of iron status at the age of 12 months in
preterm infants fed food cooked in iron or aluminum pots
Iron pot Aluminum pot
P n % n %

Hemoglobin, g/L 0.52 { 1.83 00.74 { 1.58 0.01 Normal1 7 31.8 2 8.7
Hematocrit 00.02 { 8.59 02.54 { 5.60 0.25 Iron deficiency without
MCV, fL 014.3 { 14.5 022.2 { 13.5 0.05 anemia2 7 31.8 4 17.4
FEP, mmol/L 07.64 { 37.0 4.72 { 57.2 0.39 Iron-deficiency anemia3 8 36.4 17 73.9
Serum iron, mmol/L 02.71 { 30.2 017.1 { 26.0 0.04 Total 22 100 23 100
TIBC, mmol/L 6.39 { 64.0 23.9 { 113.0 0.52
Transferrin 1 Hemoglobin ú110 g/L, serum ferritin ú10 mg/L, 2 or 3 criteria for
saturation 2.66 { 15.9 04.1 { 7.77 0.05 MCV, FEP and %TS within normal limits.
Serum ferritin,2 2 Hemoglobin ú110 g/L, serum ferritin °10 mg/L, 0 or 1 criterion
mg/L 00.95 (012, 8) 02.6 (013.8, 0) 0.38 for MCV, FEP and %TS within normal limits.
3 Hemoglobin õ110 g/L, serum ferritin °10 mg/L, 0 or 1 criterion
1 Values are means { SD. for MCV, FEP and %TS within normal limits. P õ 0.03 by chi-square
2 Value is a median (25th, 75th percentiles). test.

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 IRON STATUS AND FOOD COOKED IN IRON POTS
have lower iron reserves and rapidly growing infants require
more iron. The growth patterns observed in this study were
similar to those reported by Gorten and Cross (1964). The two
groups of children studied here were of similar size at birth and
presented adequate growth during the first year of life, with no
significant difference between them at 4 and 12 mo of age. This
indicates that growth rates did not affect the different iron
nutritional status indices detected in the two groups.
The type of feeding is one of the variables affecting the iron
status of infants. In this study, 64.4% (29 of 45) of the infants
received artificial feeding at 4 mo, a proportion that increased
to 71.1% (32 of 45) at 6 mo. Despite the subtle shift toward
more breast-feeding in the IP group, there was no significant
difference between groups. All infants received boiled cow’s
milk after being weaned from the breast. No iron-fortified food
or formula was used by the infants because of the families’
economic restrictions. In poor Brazilian communities, despite
recommendations to the contrary (AAP 1992), boiled cow’s
milk is the only possible option for artificial feeding of infants
after they are weaned from the breast.
The longitudinal design of the study reduces the ability to
follow up all infants. On the other hand, follow-up provides the
opportunity of evaluating clinical problems that occur during
treatment. Cooking food in iron pots was not associated with
a difference in morbidity between groups. Most of the infants
that became ill during the period of observation (42.2%, 19 of
45) presented signs and symptoms of diseases commonly oc-
curring in infants and classified as mild to moderate, i.e., infec-
tion of the upper airways, acute otitis media or acute infectious
diarrhea. Despite the good doctor-patient relationship created
during the study, there is the possibility that the method used
for morbidity surveillance would not be sensitive to mild ill-
nesses. The two groups also did not differ in terms of the infants
excluded because of diseases that were classified as serious and
that would interfere with nutritional iron status (11.1%, 7 of
63). The losses in longitudinal follow-up observed in this study
(28.6%, 18 of 63) were similar to those reported by Heese et
al. (1990) in a study on the same type of population receiving
iron supplementation by the oral or parenteral route. Friel et
al. (1990) reported a 39.5% drop-out rate at the end of 12 mo
of observation of low birth weight infants receiving milk formula
fortified with iron.
Analysis of the results obtained during mo 4, when the study
was started, did not show a significant difference in blood vari-
ables between the two groups studied in terms of levels observed
or their clinical importance. At that time, the iron stores of
the infants were already depleted. At 12 mo of age, hemoglobin,
hematocrit, MCV and serum ferritin were higher and FEP lower
in the IP group than in the AP group. The change in blood
concentrations from 4 to 12 mo showed a similar trend. Iron
nutritional status, evaluated on the basis of a combination of
examinations, was significantly better in the IP group.
At the end of the study, we noted that supplementation with
medicinal iron in both groups and iron fortification by the use
of iron pots in the IP group did not adequately increase the iron
stores. Also, even though FT levels were significantly higher in
the IP group than in the AP group, the exogenous iron offered
was not sufficient to replenish depleted iron stores during the
first year of life.
A combination of various factors that adversely affect iron
reserves was present in the population studied here: low iron
reserves at birth, very rapid growth rate and a diet consisting
of foods with low intrinsic iron content.
Evaluation of these results demonstrates that the increase in
iron in food cooked in iron pots was insufficient to satisfy the
/ 4w38$$2887 04-08-98 13:15:50
859
high iron requirements of preterm infants during the first year
of life. The better nutritional iron status of the IP infants indi-
cates that further studies should be conducted on foods cooked
in iron pots containing factors that facilitate non-heme iron
absorption or lower levels of inhibitory factors. Although cook-
ing in iron pots alone was not sufficient to satisfy the high
requirements of preterm infants, under the presents conditions,
they exerted a positive effect on iron balance and might be
considered a useful adjunct to programs to prevent iron defi-
ciency in populations with high rates of this condition.
ACKNOWLEDGMENT
We thank Isabel Machado de Souza for technical assistance.
LITERATURE CITED
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