Low hemoglobin in a newborn: symptoms, what to do, treatment

Low hemoglobin in a newborn is always a cause for concern, as hemoglobin performs an important function in the baby's body. The lack of oxygen may not be very good for the development of brain cells and internal organs. Therefore, it is important not only to know about the clinical manifestations of this syndrome, but also to find the cause.

[1], [2], [3]

Epidemiology

Statistics of the distribution of low hemoglobin in newborns emphasize that this problem is prevalent at almost all times and does not depend so much on the standard of living of the family. In terms of frequency and significance among all the causes that cause anemia in newborns, hemolysis should be the first place, which depletes hemoglobin. In second place, we can note an insufficient supply of iron for the baby from the mother, and on the third blood loss.

Causes of the low hemoglobin in a newborn

To understand what indicators for a newborn are considered to be lower, one should know about the norms of hemoglobin in a newborn. Features of the circulatory system of the child at a time when it develops in the mother in the abdomen is that only a large circle of blood circulation works. This necessitates that the blood cells work more efficiently. Therefore, hemoglobin in a child who is in utero is not the same as in adults. Hemoglobin is called "fetal", and its functionality is slightly higher. It is able to attach more oxygen than regular hemoglobin, which allows the entire body of the baby to provide enough oxygen. Therefore, the content of hemoglobin in the body of a newborn child is 180-220 grams per liter. These are the normative values for the child during the first month of life. Therefore, a hemoglobin level of less than 180 is considered to be low.

The level of hemoglobin can decrease during the so-called deficient states, when the formation of hemoglobin is violated or there is its excessive destruction. There are different types of deficient conditions, which include iron deficiency, deficiency of folic acid and B12 acid, as well as hemolytic conditions. From this, the main causes of the development of low hemoglobin come out.

The body contains 2000-3000 mg of iron. The main mass - about 2/3 of its total amount - is part of hemoglobin, 200-300 mg - in the composition of cytochromes and cytochrome oxidase, myoglobin; from 100 to 1000 mg of iron is deposited in the liver, bone marrow, spleen in the form of ferritin and hemosiderin. Stocks of iron are created during fetal development of the fetus mainly at the expense of the maternal fund, and later accumulate by absorption of iron from food. The exchange of iron is closely related to the processes of its intake and excretion from the body.

Iron from the child's body is constantly excreted with sweat, urine, depleted cells of integumentary tissues - skin and mucous membrane of the digestive tract. The daily loss of iron is 1-2 mg. To maintain iron stores at the physiological level, it is necessary to ensure the intake of at least 1-2 mg of iron every day. Assimilation is provided by enzymes and biologically active substances that are in the duodenum and in the initial section of the small intestine. In foods, iron is predominantly in the trivalent form. The condition for its assimilation is the transition of trivalent iron into a bivalent one, that is, into a soluble reduced form. This process is carried out in the stomach in the presence of hydrochloric acid.

In cells of the intestinal mucosa, iron forms a complex with the protein - apoferritin, and then passes into ferritin, from which iron is separated in the form of a divalent, enters the blood, binds to transferrin, which carries iron to places of use or deposition.

There is a specific mechanism for regulating iron absorption. Absorption increases when there is even a latent, latent iron deficiency and decreases when iron stores reach the norm. So, the absorption of iron increases after blood loss due to operations in newborns. The absorption of iron affects the composition of the food of the pregnant woman and in the future of the nursing mother. Improves absorption of iron at a sufficient content in the diet of mother protein, ascorbic acid. Reduces the absorption of iron when eating milk food and strong tea - with iron, iron forms insoluble albumins, with tannin also forms insoluble complexes.

The main causes of low hemoglobin development in newborns are as follows:

1. blood loss;
2. violation of iron absorption in a newborn with ulcerative colitis or other pathologies;
3. increased costs of iron can be in a newborn with chronic diseases or congenital heart disease;
4. fixation of iron by macrophages in certain pathological processes.

Repeated hemorrhage increases iron deficiency, first manifested latent, and then obvious anemia. The source of blood loss is most often the digestive canal - in newborns the cause is diaphragmatic hernia, ulcerative colitis, hemorrhagic disease of the newborn, cerebral hemorrhage or ventricles.

Pathologies of iron assimilation are observed after resection of significant areas of the small intestine, which may be due to the inefficiency of conservative treatment.

Redistribution of iron occurs with certain chronic infections (sepsis), connective tissue diseases, when iron is used not for the needs of erythropoiesis, but for fighting infection, being fixed in the cells of the phagocytic mononuclear system.

Alimentary iron-deficiency anemia develops mainly in newborns who are on artificial or unreasonable feeding. There may also be problems in children whose mothers did not have a rational diet during pregnancy, and thus did not form a stock of iron in the baby.  

[4], [5], [6], [7]

Risk factors

The risk factors for the development of low hemoglobin are as follows:

1. premature babies or toddlers from twins initially have a low supply of iron and hemoglobin;
2. malnutrition of mother during pregnancy;
3. feeding the baby with cow or goat milk;
4. associated diseases in the baby;
5. congenital malformations;
6. hemolytic disease in relatives.

[8], [9], [10]

Pathogenesis

The pathogenesis of the development of low hemoglobin is precisely the lack of iron, which reduces the formation of red blood cells. If we are talking about the loss of blood due to the destruction of erythrocytes, for example, in hemolytic disease of newborns, the pathogenesis in this case is to reduce the number of active erythrocytes during their decay and decrease respectively hemoglobin.

[11], [12], [13], [14],

Symptoms of the low hemoglobin in a newborn

The clinical picture of low hemoglobin in a newborn depends on the level of iron deficiency. The deeper the deficit of iron, the more expressive the clinical symptomatology and the heavier the patient's condition.

The first signs of the pathology of the mother may notice immediately after discharge. A newborn child should be rosy, plump, he should eat well, cry and sleep. If the baby has a bad appetite, he sleeps a lot at night and almost does not wake up to eat, then this can be one of the signs that something is wrong with the baby. With low hemoglobin, the child does not have enough strength to be active and therefore the appetite decreases, because energy needs a lot for feeding, and the cells "starve" from lack of oxygen. But this is a nonspecific symptom.

Pale skin, while the baby should be rosy, is considered a more specific symptom.

Symptoms of low hemoglobin in a newborn with a pronounced deficiency are manifested by symptoms from the internal organs. Cardiac syndrome is manifested by pain in the heart, palpitations, a decrease in cardiac strength, systolic murmur over the apex or above the base of the heart, the noise of the "top" over the cervical veins, the expansion of the border of the heart, the relative insufficiency of the valves resulting from worsening oxygen supply to the myocardium and dilution blood. With severe anemia, signs of heart failure may occur, which can be manifested by the child's pasteurism, swelling of the legs against the background of its small weight. With prolonged "anemic history" may occur manifestations of hypoxia of the brain. The child may be a little delayed in the reaction, be drowsy or inhibited.

Endocrine syndrome develops on the background of insufficient supply of oxygen to the thyroid gland and a violation of the synthesis of thyroid hormones. Therefore, secondary hypothyroidism may develop. Clinically revealed signs of hypothyroidism: a symptom of dirty elbows, dry skin, hair loss, chilliness, puffiness, poor overgrowing of the fontanel, a large tongue.

Dyspeptic syndrome is manifested by a decrease in the secretory function of the stomach, liver, pancreas. This can be detected by constipation or diarrhea. Respiratory failure occurs on the part of the respiratory organs, which is symptomatically manifested by the acceleration of the respiratory rate, the decrease in ZHEL and other reserve standards. This disorder is associated with a decrease in the tone of the respiratory muscles due to inadequate oxygen supply.

If we are talking about a decrease in hemoglobin in a newborn due to hemolytic anemia of a congenital nature, then jaundice of the skin and mucous membranes will also be one of the most important symptoms. Together with a decrease in the level of hemoglobin against the background of anemia, hyperbilirubinemia will be determined. The child will be pale yellow, and against the background of this may be a violation of the general condition.

Speaking about the symptoms of anemia, you need to know that there are successive stages of development of hemoglobin deficiency. If it is a question of a lack of iron, then the manifestation of symptoms depends on the level of this deficiency. Distinguish latent iron deficiency and obvious. With hidden deficiency, there can be no visual signs of low hemoglobin, although there are already changes in the analysis. The apparent deficiency of iron is characterized by its deep deficit, while there are already clearly visible symptoms and changes from the internal organs.

Complications and consequences

The consequences of low hemoglobin are more frequent with prolonged untreated anemia. Disruption of oxygen delivery to cells can lead to their starvation, which for some organs can be critical. If we talk about the brain, then in a newborn child, its cells actively begin to function under the influence of environmental factors. And with a lack of oxygen, they first begin to suffer, which can cause violations in the future and delay development. Against the background of low hemoglobin, the organism is considered vulnerable to the action of pathogenic factors, so these babies can often get sick. Complications of low hemoglobin can be if its cause is hemolytic disease of a congenital or acquired character. In this case, significantly increases the level of bilirubin in the blood, which is very toxic to the brain. This can lead to the accumulation of bilirubin in cells and the development of nuclear encephalopathy. This is a serious disease with delayed development and cognitive functions.

[15], [16], [17], [18]

Diagnostics of the low hemoglobin in a newborn

Diagnosis of low hemoglobin in a newborn should begin with a visual assessment of his condition. Pale skin and mucous membranes may be one of the signs for further examination of the baby. A specific symptom of this pathology can be seen when you look at the palm of the child in a half-bent state and compare the color of the palm skin with the color of the palm of the mother. With a hemoglobin deficiency in the baby, the palm will be pale.

Further, with an objective examination, there will be a systolic murmur in the heart at the apex, which must immediately be differentiated with functional noise.

Diagnosis of low hemoglobin in a newborn is based on the study of peripheral blood and on the determination of different levels of iron. Take into account the clinical data, the presence of signs of sideropenia. To study the bone marrow resort very rarely.

Analyzes are very important for confirming the diagnosis and determining the degree of severity. Informative is a simple blood test, and in the presence of changes already conduct further tests of serum blood. Changes in blood: the level of hemoglobin is reduced, the number of red blood cells in the early stages of the development of iron deficiency can be normal, then decreases. The color index is lowered (0.8 and lower), which indicates a decrease in the hemoglobin content in each individual erythrocyte. Mark the hypochromia of erythrocytes and decrease their volume. The number of reticulocytes is normal, but after blood loss may increase. The number of leukocytes and the leukocyte formula have not been changed, but in the case of prolonged uncompensated iron deficiency, leukopenia is possible. The number of platelets is normal and may increase due to bleeding.

The serum iron level is lower than normal (<11 μmol / l), free transferrin of blood is elevated (> 35 μmol / l). The saturation level of transferrin is reduced (<25%). The desferal assay is positive. With prolonged chronic course of iron deficiency anemia, there are symptoms of bone marrow hyporegeneration.

Criteria for diagnosis:

1. The hemoglobin level is less than 180 in the newborn period.
2. decrease in the color index is less than 0.85;
3. microcytosis (more than 20% of erythrocytes <6 in diameter) MCV is less than 80.0 of the fetometer, the MCH is reduced to less than 30.4 picograms, the MCS less than 34.4%.

[19], [20], [21], [22],

Differential diagnosis

Low hemoglobin should be differentiated from anemia, due to the pathology of synthesis and utilization of porphyrins - sideroblastic states. These conditions develop with hereditary defects of enzymes involved in the formation of porphyrins and heme, or in the case of the appearance of such a defect, for example, as a result of lead poisoning. These conditions are also characterized by red blood cell hypochromia, however, the normative index of iron is preserved, and the content of sideroblasts rich in ferritin granules is increased in the bone marrow. In persons with lead intoxication, basophilic puncture of erythrocytes is detected, in the bone marrow - an increased amount of sideroblasts with an annular arrangement of ferritin, in urine - lead and an increase in the level of 5-amino-levulenic acid. Hypochromia of erythrocytes is also found in patients with thalassemia. For thalassemia, the characteristic clinical symptoms of hemolysis: anemia, jaundice, splenomegaly, the content of target-like red blood cells in the blood, bilirubinemia, and hemoglobin electrophoresis - increased hemoglobin content F.

If the low hemoglobin is caused by a hemolytic pathology, the jaundice that appears at this juncture must be differentiated from physiological jaundice. And the main distinctive feature is that hemoglobin with physiological jaundice is within the normal range.

Treatment of the low hemoglobin in a newborn

Treatment of iron deficiency anemia has two goals: elimination of the cause, which caused the development of iron deficiency (cessation of bleeding, treatment of the underlying disease), and pathogenetic therapy with iron preparations aimed at eliminating iron deficiency. Treatment of low hemoglobin in a newborn is necessarily performed in several ways: correction of the lactating mother's diet or changes in the infant's mixture if it is fed artificially, as well as drug treatment with iron preparations.

Iron preparations have a different content of ionic iron and are selected individually, so tolerated is not always good. This is due to the irritating effect of iron salts on the mucous membrane of the digestive canal, manifested as a belching, taste in the mouth, bloating, diarrhea. Iron preparations are usually administered orally. It should be borne in mind that the possibility of its absorption is limited and amounts to 7-10% of the iron that is injected into the stomach, and only after a blood loss, in the case of a deep deficit, it can increase to 20-25%. In connection with this, the doses of iron that are injected into the body must correspond to therapeutic, but not less than 100-300 mg per day. At the same time with iron preparations it is desirable to prescribe ascorbic acid, which improves the assimilation of iron. Dosage of any drug for a newborn is 3-5 milligrams per kilogram of body weight with calculation for the elementary gland. The following sequence of iron preparations is proposed: first protective iron sulphate, and in case of pathology on the part of the stomach or intestine other forms are used in the form of gluconate, succinate or fumarate. The additional administration of ascorbic acid will increase the absorption of iron and will allow the use of smaller doses, and also reduce the number of side effects.

The activity of assimilation and the further action of iron directly depends on the form of the medicine. Better absorbed and manifest a pronounced therapeutic effect of medicines in liquid form (drops, syrups).

Deteriorates the absorption and action of drugs in dysbacteriosis and therefore contributes to its absorption of probiotics.

A dose-dependent paradox has been revealed: as the single dose increases from 40 to 400 mg, the amount of iron absorbed decreases from 30-35% to 5-7%. For children recommended the most convenient form in the form - Potassium hydroxide sulfate medicine for children containing 12 mg elemental iron in 5 ml or a polysaccharide-ion complex (nipherex) containing 100 mg elementarily iron in 5 ml. Before use, it is bred. Iron in dosage forms with slow release and chelating compounds less often causes pronounced intoxication.

Typically, conventional iron-containing tablets are coated with a bright coating and contain ascorbic acid (Tardiferone, where iron 80 mg ascorbic acid 30 mg), Sorbifer durules (lentil tablets with 100 mg of iron and 60 mg of vitamin C, haemophore - red double-bulb with 325 mg of iron) .

In addition, iron preparations are prescribed in gelatin capsules (Aktiferin in the form of an oily paste where there is 34.5 mg of iron sulfate), Ferutat (ferric fumarate) with folic acid 0.5 mg, orofer (fermented complex of ferric acid with folic acid - 0 , 55 mg) and in a dragee - Fereplex (with 30 mg of ascorbic acid). An interesting dosage form for the treatment of anemia is the chewable tablets Multifer-foul.

Preparations of divalent iron convenient for dosing in drops for intake: (Hemofer), fermented complex of ferric iron (Multiferous hydroxide), in syrups (Ferrum lek and Orofer in a polymaltose complex with a dosage spoon where in 5 ml 50 mg iron hydroxide), Multofer with 10 mg of iron in 1 ml, Totema (iron, manganese and copper gluconate complex in oral ampoules), suspension - Ferronate (iron fumarate, in which 1 ml is 10 mg elemental iron).

Treat low hemoglobin with iron preparations that are administered intravenously and intramuscularly, only if intestinal absorption is impaired (nonspecific ulcerative colitis in a newborn). Blood transfusion for iron deficiency is prescribed only for vital indications - in case of severe hemodynamic disorder, preparation for urgent surgery.

Control over the effectiveness of iron therapy is carried out through the study of blood. After 10-12 days from the beginning of therapy, an increase in the number of reticulocytes is detected, followed by an increase in the hemoglobin content. Treatment should be carried out until the hemoglobin level and the color index are normalized. After that, supportive treatment with half doses of the same drug used for treatment should be performed for several months. Also recommend a diet rich in iron for mom. It should include a mandatory daily intake of meat, green vegetables. If the child is on artificial feeding, then you need to transfer it to a mixture rich in iron.

The main drugs for treating low hemoglobin are the following:

1. Maltofer  is a preparation of ferric iron, which is contained in the form of polymaltosate. This drug is used to treat anemia in newborns due to the simplicity of dosing, since it is available in the form of drops, syrup and capsules. One milliliter of the drug contains 50 milligrams of elemental iron. Dosage for newborn babies with low hemoglobin is 3-5 milligrams per kilogram or one drop per kilogram of the child's weight. The minimum course of treatment is one month. Side effects can be in the form of bloating, colic, diarrhea. Precautions - do not use to treat hemolytic conditions.
2. Sorbifer  is a preparation of ferrous iron in the form of sulfate with a complex of ascorbic acid, which improves the assimilation of this drug. One tablet contains 100 milligrams of pure iron. Dosage of the drug is calculated on the weight of the child's body (3-5 milligrams per kilogram). The way of application - can be dissolved in the juice and given to the child either in pure water. Side effects can be in the form of a stool delay, staining it in black.
3. Aktiferin  is a preparation of ferrous iron in the form of sulfate. This medicine is available in the form of drops, syrup and capsules, which can be used for small children. One milliliter of syrup or drops contains 34.5 milligrams of iron. The dosage is calculated 3-5 milligrams. The method of administration should be oral, by dividing the daily dose by three times with the intake one hour after water and two hours before meals. Precautions - this form of iron can cause nausea in a child, so you need to drink a little water. Side effects can be in the form of dyspepsia.
4. Tardiferone  is a divalent drug in combination with ascorbic acid. This product is available in the form of tablets with prolonged action. Dosage of the drug for children according to body weight. One tablet contains 80 milligrams of iron. Method of use - tablets are not recommended to break, so it is better to dissolve in water. Precautions - considering the prolonged form and difficult availability of the drug, it is better to use it for maintenance therapy when the hemoglobin level has already normalized.
5. Feroplex  is a preparation of ferrous sulfate with ascorbic acid. It is available in the form of a dragee and contains 11 milligrams of pure iron. This product is dosed on the weight of the child and for ease of use it can be dissolved in water. Side effects can be in the form of nausea, stool disorders, the child's refusal of the drug, which requires dose adjustment. Precautions - do not use in children with congenital intestinal pathologies.

Vitamins for a child with a low hemoglobin is good to use already at the stage of maintenance therapy with iron preparations. This ensures the normalization of the level of iron and other necessary vitamins for red blood cells and other cells of the body. For this purpose, use complex vitamin preparations approved for newborns.

Physiotherapeutic treatment in acute period is not used.

Alternative treatment

Alternative therapies can be used to improve the effect of medication. In most cases, such methods can be used by a mother if she is breastfeeding, since for a newborn baby this can be a risk of developing allergic reactions.

1. Garnet is an incomparable source of vitamins of the group C, B, and also iron. Considering the content of ascorbic and succinic acid in it, it helps to improve the absorption of iron and leads to an increase in the level of hemoglobin. The folk method of treatment implies taking pomegranate juice every day to mom. He with milk after four hours immediately gets to the baby and has its useful effect. To avoid allergic reactions, it is recommended to take two tablespoons five to six times a day.
2. Beetroot is also considered a universal remedy that helps increase hemoglobin. For treatment, you need to cook beets, clean it and grind it in a blender. To this mass, you need to add five drops of lemon juice and drain all the juice that has formed. He can brighten up with the addition of lemon, which should not be alarming. If desired, you can add a little salt or sugar to the juice. Take a fresh one tablespoon three times after eating.
3. Very useful for correction of low hemoglobin in a baby medicine of the following ingredients: you need to take two dessert spoons of cocoa, two teaspoons of butter, and two dessert spoons of honey. All this must be mixed and melt in a water bath so that a uniform mass is obtained. Then in the blender you need to grind one hundred grams of black ashberry and, adding the resulting mass to the mountain ash, bring to a homogeneous consistency. Slightly need to cool, so you get a semi-solid mass. To take such a medicine you need a mom on a teaspoon in the morning on an empty stomach for a month.

Herbal treatment can also be used by the mother to improve the result.

1. You need to mix 20 grams of fresh clover leaves and 30 grams of dry dandelion leaves. Adding to the herbs one hundred grams of hot water you need to steam for 30 minutes. After that you can take 50 grams in the morning and in the evening. There may be a slight dizziness that is considered normal, since these herbs slightly lower the pressure. In this case, you must take after eating.
2. Rosehip fruits have many useful properties, including normalize the level of hemoglobin. This is mainly due to the fact that rosehip enhances the formation of the protein globin in the liver, which is a direct part of hemoglobin. This accelerates the formation of new red blood cells. To treat 100 grams of rosehips, add 300 grams of okropa and boil for five minutes. Take such an infusion of nursing mothers need at least one month a glass per day, which can be divided into several receptions.
3. Leaves of strawberries and birch buds should be taken in equal quantities and poured cold water overnight. After this, such a solution must be boiled and insisted for another two hours. You need to take Mom on a teaspoon of this infusion five times a day. Such a solution can increase the amount of urination in the child, which is normal and requires no action.

Homeopathy can be used to correct anemia of different etiology, and hemolytic states are not contraindications for this. This is the advantage of such treatment methods. Also there are homeopathic remedies, which, according to the doctor's recommendation, can be taken by the baby.

1. Calcium phosphor is a homeopathic remedy that is used to treat low hemoglobin in children and adults. The drug enhances the formation of new erythrocytes by activating the sprouts in the bone marrow. For treatment it is necessary to use a preparation in the form of homeopathic granules. For a newborn, the dose is one pellet four times a day. Method of application - you can crumble the granule and put the baby on the tongue and she melt. Side effects are very rare, but there can be an easy twitching of the muscles, which indicates the need to reduce the dose. The minimum course of treatment is one month.
2. Ferrum phosphoricum is an inorganic preparation that contains processed and diluted phosphorus, which is a specific stimulant for the formation of erythrocytes. The drug can be taken to the nursing mother in the form of tablets. Dosage - one tablet five times a day. Side effects can be in the form of diarrhea, which occurs after several days of regular use of the drug. Precautions - do not use for treatment if the child has very pronounced jaundice, since the drug reduces the utilization of bilirubin.
3. Litsetinum in the sixth breeding is an organic homeopathic preparation, the main substance of which is lecithin. Depending on the production, it is obtained from the yolk of eggs or from the tail portions of seafood. To treat low hemoglobin, you need to use the egg extract, since it is less allergenic for newborns. The way to use for mom - you need to start one grain a day and increase the dose for a week to six a day if the child does not have allergies. If there are allergic manifestations, then you need to return to a smaller dose and take it for three weeks. Side effects can be in the form of rashes.
4. Hina is an organic homeopathic medicine that can be used with low hemoglobin when its level is not critical and is caused by a small blood loss, for example, hemorrhagic neonatal disease. Dosage of the drug for the baby - two grains once a day before feeding, they need to be grinded and can be dissolved in water. Side effects can be in the form of bloating, which passes after feeding.

Transfusion of blood to a newborn with low hemoglobin is usually performed with hemolytic disease, when a high level of bilirubin and there is a risk of acute damage to the brain. In this case, there is a low hemoglobin, since anemia develops against the background of hemolysis. In this case, blood transfusion is performed by catheterization of the umbilical vein. One and one-blood blood is transfused, which is also taken from the umbilical artery to determine the group, since after birth there may be errors with the mother's antibodies in the child. Transfused washed red blood cells with further determination of laboratory parameters of hemoglobin and supporting treatment if necessary in the form of detoxification. Iron preparations are not prescribed after a while.

[23], [24], [25], [26], [27]

Prevention

Prevention of low hemoglobin in a newborn is aimed at the timely treatment of diseases that can cause iron deficiency, the prescription of iron preparations for children born to anemic mothers, women during pregnancy, lactation and in the case of polymenorei, a full diverse diet of the mother in the first place. In the future, premature babies are recommended preventive doses of iron to prevent the development of a hidden deficiency in the neonatal period.

[28], [29], [30], [31]

Forecast

The prognosis for low hemoglobin in a newborn is favorable, provided a radical elimination of the cause that caused iron deficiency and complete compensation of iron deficiency. If the cause is congenital hemolytic anemia, then it is important to control the level of not only hemoglobin but also bilirubin, then the prognosis for preventing complications will be favorable.

Low hemoglobin in a newborn is one of the signs of anemia of a congenital or acquired nature. Correction of these conditions should be carried out as early as possible, because the full growth and development of the baby requires a sufficient amount of oxygen. Therefore, mothers should know when they should think about the level of hemoglobin in a child and when it is necessary to prevent these conditions. 

[32],