There are two factors of special importance in the development of anemia in children. These are (1) defective feeding, and (2) a chronic intestinal catarrh, which may be latent and only revealed by observations of the stools. Many cases of severe anemia in children are due to the long-continued use of a diet which is deficient in blood-forming elements, e.g., a diet consisting largely of bread and butter, and pastry, with tea several times daily. This system of defective feeding predisposes to chronic gastrointestinal derangement, which, in turn, reacts unfavourably on the digestive powers of the child. The existence of chronic gastro-intestinal derangement in these cases is shown by the presence in varying degree of the following conditions - constipation, occasional diarrhoea, and, notably, unformed foetid stools, which may contain excess of mucus and undigested food. A contributing factor may be a septic condition of the mouth, due to diseased teeth. Before considering in detail the dietetic treatment, reference may be made to some preliminary essentials in the management of these cases. These include: -

1. Thorough clearing out of the bowels by a judiciously selected course of aperients, e.g., a course of calomel, 1/8 gr. to 1 gr., for several nights according to age of child, followed on alternate mornings by a saline aperient.

2. Careful attention should be directed to the state of the mouth and teeth. All septic stumps should be removed, and an antiseptic mouth-wash used daily.

3. Complete rest in bed is, in some cases, essential to effect a speedy and complete recovery.

4. Sunlight, fresh air, and thorough mastication of the food are important factors for successful treatment.

The Milder Degrees Of Amentia

The first point to determine in these cases is whether the condition is a secondary anemia or a primary one. The common causes of secondary anemia in children are tuberculosis, rheumatism, the infective fevers, eg. scarlet, diphtheria, and worms; if we find the anemia to be of secondary origin, the indication is to treat the cause. When, after careful examination of the child, none of the recognised causes of secondary anemia are discovered, the conclusion is arrived at that the case is one of primary anemia.

The term "primary" anemia merely means an anemia of which the causation is at present unknown. While there is no precise knowledge of the cause of primary anemia in children, there is abundant clinical evidence to suggest that it is very frequently associated with, and dependent on, a chronic gastro-intestinal disturbance of a nature which may have been sufficiently slight to have escaped the observation of the parents. Inquiry into the history of these patients will often indicate that, in addition to living under unfavourable conditions as to fresh air and sunlight, they have for long been injudiciously fed, the diet consisting too largely of tea, bread, and jam pastry, and the like, and containing too little milk, animal food, and fresh vegetables. In the milder degrees of anemia recovery is speedily attained if we stop the unwholesome dietary that has been in use, and restore the proper balance of protein, fat, and carbohydrates in the food. To this end judicious use is made of milk, cream, meat juice, meat foods in moderation, fresh vegetables, and fruit. Complete rest in bed for a short time, careful attention to the bowels, and a diet planned along the following lines, will speedily effect a cure of the condition: -

Amentia - Child After Eight Years

Breakfast

Bowl of porridge, gruel, or other cereal; milk, 10 ounces; slice of bread and butter, or toast and butter, or oatcake.

11 a.m. - Cup of clear soup (8 ounces), to which has been added 1/4 lb. of scraped raw meat; or Cup of soup (8 ounces), thickened with yolk of egg and a little milk; a biscuit.

I P.M. - A good two-course dinner, the meat being plainly cooked. Fish, or chicken, or meat, potatoes, and a vegetable. Light milk pudding, or a custard and stewed fruit.

4.30 P.M. - A good, wholesome tea, plenty of milk to drink, toast, occasionally a bit of plain cake or a biscuit, butter, and a little jam or jelly. Bread foods should not be new.

Bedtime

A cup of soup; or A cup of peptonised cocoa or milk.

In Severe Anemias

In more severe cases of anemia in children the treatment may be much more difficult. These may be similar in character to the pernicious anemias described on p. 388; they are- usually associated with the passage of ill-formed, foetid stools. It may or it may not be possible to get the child to take a diet framed along the lines laid down above, but even if this is possible, no improvement results. The condition remains unchanged, or may get worse. A radical change of diet is then necessary. After a preliminary clearing-out of the bowel by one or two doses of grey powder and saline, a diet is selected which will throw the least strain on the digestive tract, and at the same time diminish the fermentative and putrefactive changes taking place in the bowel. For this purpose it is advisable to materially diminish the total amount of food given in the first few days. The carbohydrates are largely reduced, fats are excluded, plain milk is withheld as being for the time unsuitable, and the food is selected from skimmed milk, buttermilk, white of egg, meat juice, and a small quantity of bread or toast - not new.

Plasmon, Sanatogen, and various malted foods, such as Mellin's, Benger's, Allenbury's, or Savory & Moore's food, may be used to strengthen the fluid nourishment. These greatly strengthen the nutritive value of the diet without adding much to its bulk or to its difficulty of digestion. The beef juice can be given in the form of the juice of 1/4 to 1/2 lb. good steak stirred into good soup, or as raw-beef mince browned by cooking for three minutes, or as scraped beef sandwiches. The white of egg may be given beaten up in the skimmed milk or beef-tea. The breadstuffs that may be allowed must be stale, and include the following: - Malted bread (not new); Bermaline, Hovis, or Veda; biscuits made of the same materials; a dry sponge cake or sweet rusk and plain toast. A little fruit juice may be given daily.

The following dietary may be recommended as most suitable for a severe case of this kind in a child of six to seven years: -

6 A.M. - Skimmed milk, 8 ounces.

8 A.M. - Skimmed milk, 8 ounces, with white of egg beaten up. Half-slice of baked bread.1

11 a.m. - Raw-beef juice from 1/4 lb. of steak given in beef-tea (6 ounces).

1.30 p.m. - Skimmed milk, 8 ounces, with white of egg beaten up. Half-slice stale bread or crisp toast.

4 P.M. - Buttermilk, 8 ounces, with toast.

6 P.M. - Beef-tea or chicken tea.

Slice of toast.

If awake later, drink of skimmed milk, or buttermilk if readily taken.

Under this regime there may be an initial slight increase in the anemia, but this will soon give place to an improvement which will steadily and in favourable cases will rapidly progress. There is at the same time an improvement in the condition of the stools, which soon lose the unformed foetid character formerly present. As a rule, in about eight or ten days the diet may be gradually increased by the addition of meat in the form offish, chicken, or minced rump-steak, more bread, and a milk pudding with a little cream. Later, well-boiled green vegetables may be added. The return to an ordinary diet should be accomplished very slowly, the stools being carefully examined from time to time. The examination of the stools is the most important guide to the successful dietetic treatment of these cases.