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IRON DEFICIENCY

PART 2

Written by Dr Nické Theron, Pediatrician.

Iron deficiency anaemia occurs when the iron stores are so empty that there is not enough iron to make proper new red blood cells. The new red blood cells are thus fewer, smaller and paler and cannot carry oxygen effectively. Your body will always prioritize the available iron to first be used in the red blood cells, but iron has many other functions in the body (see previous post). So by the time that there is iron deficiency anaemia, the brain especially has already suffered from the lack of iron.

This is a sneaky disease because there are almost no symptoms initially. It is thus important that your doctor asks about the risk factors for developing iron deficiency during well-child-visits.

Babies and toddlers between the age of 6months to 3years have an especially high risk to develop iron deficiency anemia. The American Association of Pediatrics recommend that all children should be screened between 9-12 months of age because of the serious effects it has on long term neurodevelopment. Several studies show that the delays in development improves with treatment, but does not normalise completely.

The most common cause of iron deficiency is insufficient intake (see previous post for tips on prevention). Other causes could be blood loss from the gut, specific syndromes where iron is not absorbed from the gut or chronic inflammatory diseases.

Symptoms of Iron deficiency anaemia:

Mild:

  • No specific symptoms
  • Iron deficiency could lead to behavioural changes in your child that is sometimes difficult to pin-point eg. children become more wary, hesitant, solemn, unhappy, keep closer to their mothers.
  • Restless leg syndrome, breath holding spells, sleep disturbances, short attention span, learning difficulties have also been seen to improve when iron deficiency was treated.
  • Pica : an intense craving for weird non-food items such as clay, dirt, chalk, soap, paper, raw rice or ice (pagophagia). No one knows how this works, but it responds very well to iron supplementation.
  • Poor growth

Severe:

  • Pallor (seen especially around the eyes, in the mouth, the nails and on the palms/soles)
  • Severe tiredness and loss of interest in otherwise fun activities
  • Irritability
  • Poor appetite, sores in the corners of the mouth, painful tongue
  • Fast heartbeat, heart failure, fast breathing.
  • Other complications associated with iron deficiency anaemia: Febrile seizures (although no relational cause could be found, several studies have found that children with febrile seizures are more prone to be iron deficient). Iron deficiency also causes paralysis of some parts of the immune system.

If your doctor suspects iron deficiency anaemia blood tests will be the next step to confirm. A hemoglobin or full-blood count and ferritin count will be enough. Treatment with Iron supplements will be started and the effect on the red blood cells will be evaluated after one month of treatment. If there are no response further investigations should be done for other causes of the anemia.

Treatment of iron deficiency anaemia

Ferrous sulphate 3-6mg dly (can be given once a day or in divided dosages.
The best absorption of iron happens when you give it with orange juice (or other juice high in Vitamin C as this improves absorption) in between meals. Foods that can block absorption of iron are dairy, eggs, tea or coffee, whole-grain breads and cereals / bran.

Iron supplements are notorious for having many side effects. However if you start at a low dose and slowly increase it, and give the iron with meals most children tolerate it quite well. Remember to give the drops at the back of your child’s mouth or give it mixed in juice with a straw. Some iron supplements may stain the teeth, but this can be removed by brushing with baking soda (talk to your dentist first). There are many different iron formulations of which some are better absorbed/better tolerated, but this also comes with a significant price increase. In the end the most important thing is that your child drinks the supplement. (Studies show no difference in the end-result for different formulations).

VERY IMPORTANT: Treatment for iron deficiency anaemia should be given for at least 3months, even if the blood count normalises before that. Remember that the body will use any available iron for the red blood cells first, and then the stores still need to be filled to prevent future problems.

Dietary advice

It is important that your child’s diet is also adapted to include more iron rich foods. It is adviced that they should eat at least 2-3 iron rich meals per day. Remember that the iron in animal products is absorbed better and thus you need to eat bigger quantities of plant-based iron to absorb the same amount.

Some foods that are high in iron include:

  • Meat – red and white. Liver is especially high in iron.
  • Other animal sources: Eggs (especially the yolk), fish
  • Dried fruits: raisins, apricots
  • Green leafy vegetables
  • Dried beans and lentils
  • Oats, other grains
  • Soybeans

I hope you now feel more confident in the whys and hows of iron deficiency. There are still so many ongoing studies and new developments with regards to the influence and treatment of different neurodevelopmental diseases such as autism and ADHD that I am sure this is a topic that we will still hear a lot about!

Resources

  1. Ozdemir N; “Iron deficiency anemia from diagnosis to treatment in children”; Turk Pediatri Ars; 2015 Mar; 50(1): 11-19
  2. http://www.uptodate.com
  3. https://www.mayoclinic.org/drugs-supplements/iron-supplement-oral-route-parenteral-route/description/drg-20070148
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IRON DEFICIENCY

PART 1

Written by Dr Nické Theron, Pediatrician.

This is a topic that I have been avoiding for a while because there is so much conflicting advice and evidence available. I started giving our son iron supplementation from 6months but because it tasted horrible and stained all his clothes and he struggled with constipation, I stopped at around 10months. After attending the European Academy of Pediatrics congress in September I was reminded about how important iron is for brain development, and I felt very guilty that I did not give Eran enough iron-supplements. But was it really necessary? When should babies and toddlers use iron-supplements and what sort of iron should they use? Read on to learn with me:

Iron is a vital mineral in our bodies. It is used in red-blood cells to carry oxygen and to help manage the storage and usage of oxygen in the muscles. Iron also plays a very important role in brain development in babies and toddlers, regulating the structure as well as the hormonal messengers of the brain. The immune system also needs iron to function well. Luckily the body regulates iron very closely, and as red blood cells break down it is recycled and used again. We do however loose a small amount of iron daily from our skins and gut, and during menstruation. If we do not take in enough iron to counter-act these losses, it leads to iron deficiency.

Adults need to absorb about 5% of their daily iron needs from food. Children need to absorb up to 30% due to their rapid growth and development. This already places them at a high risk for iron deficiency.

“Iron deficiency” occurs when there is not enough iron in the “stores” of the liver. (Mostly measured by doing a “Ferritin level” on a blood test). If there is no treatment it will progress to “Iron deficiency anaemia” where the iron-levels in the red blood cells are also dropping, leading to fewer and smaller red blood cells. (Measured by testing the “Hemoglobin level” or a “Full Blood Count”). It is mostly only when a child becomes pale and tired that the problem is picked up. However there is already a big effect on brain-development, behaviour and growth long before the “Iron deficiency anaemia” causes symptoms. Sadly iron deficiency is the most common nutrient deficiency in the world, and the effect it has on children’s behaviour and development is scary.

“As iron sharpens iron, so one person sharpens another”

Proverbs 27:17

Children who have a high risk of iron deficiency are:

  • Mother has an iron deficiency during pregnancy (the baby will still take the iron it needs, but there is not enough iron to totally fill all the stores)
  • Mother has hypertension or diabetes mellitus during pregnancy (the iron in the mother’s body is not as easily available for baby / the baby has a higher need for iron)
  • Premature babies (iron stores are filled during the last few months of pregnancy, so premature babies miss out on this. They also have a smaller blood volume and undergo many blood-tests while in NICU).
  • Low-birth-weight babies (multiple reasons for high risk)
  • Early cord clamping (allowing more blood to flow to the baby from the placenta increases the amount of iron they start out with)
  • Insufficient dietary intake during early infancy
  • Early introduction (<1 year) of unmodified cow’s milk or consuming large amounts of cow’s milk (>500ml) after 1year of age. (Early introduction may cause an increase of blood loss from the bowels as the bowels are not ready for the large proteins / via allergic reactions. Cow’s milk contains very little iron, thus the risk is high if your baby does not eat enough other iron-containing foods)
  • Exclusive breastfeeding for longer than 6months (breastmilk has a very low iron content. See below. It is important to start iron-rich supplemental food from 6months).
  • Picky-eaters, children with multiple food allergies, children following specific diets.
  • Obese children
  • Children with malnutrition, chronic diseases or bowel-diseases.

I would like to explain a little more about the iron-needs in babies. Term, healthy infants usually has enough iron in their bodies for the first 5-6months of life (they have a relatively high “hemoglobin” at birth and their stores are filled during the 3rd trimester). Their iron-needs are thus quite low during the first few months. Breastmilk contains very little iron (+- 0.3mg/L) but it is very easily absorbed (up to 50%). Formula milk is usually supplemented with up to 12mg/L iron, but it is not as available to be absorbed (4-6%).

After 6months of age the iron requirements increase rapidly, and thus breastmilk alone is not enough to sustain the iron-needs in babies. They need to take in extra iron in some form. Iron-rich foods and iron-fortified foods such as cereals has been shown to be more effective than medical supplements in the long term to sustain normal iron stores. (If your baby already has a deficiency it is easier to fill up the stores with medical supplements, see next article).

So how do you prevent iron-deficiency?

  • The American Association of Pediatrics recommends that all healthy term babies who are exclusively breastfed should receive supplemental iron (1mg/kg/day) routinely from the age of 4months until they eat sufficient quantities of iron-rich food. (At least 2 meals per day containing iron rich food or iron-fortified food). The European society feels that there is no need for general iron supplementation in healthy babies and children as long as there are no other risk factors.
  • Formula-fed babies should receive enough iron in the formula for the first 6months and thus do not need further supplementation.
  • All premature babies should receive iron supplementation from the age of 2weeks until 1year (2-4mg/kg/day).

You can give the supplements as part of a multivitamin (eg Vidaylin with iron) or separately (eg Ferro-drops or Ferrimed). Seeing that there are some risks involved in using iron supplements in otherwise healthy children (some studies show that babies with normal iron stores that were supplemented with iron did not grow as well in length as those that were not supplemented) I think it is very important to discuss this topic with your pediatrician at the 6week check-up to make an informed decision with them after looking at all the risk factors for YOUR baby.

Iron deficiency has serious implications in your child’s development and should be carefully managed and monitored. In the next article I will discuss the effects of iron deficiency anemia and the treatment thereof.

Resources:

  1. Lonnerdal B, Georgieff MK, Hernell O; “Developmental physiology of iron absorption, homeostasis and metabolism in the healthy term infant”; J Pediatr 2015 Oct; 167(4 0): S8-S14
  2. Baker RD, Greer FR, The Committee on Nutrition; “Diagnosis and Prevention of Iron Deficiency Anemia in Infants and Young Children (0-3years of age)”; American Academy of PediatricsClinical Report
  3. Friel J, Qasem W, Cai C; “Iron and the Breastfed infant”; Antioxidants (Basel). 2018 Apr; 7(4): 54
  4. ESPGHAN guidelines for Iron Requirements of Infants and Toddlers
  5. http://www.uptodate.com
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OUMAS (& OUPAS)

Dit is ‘n ongelooflike voorreg as oupa en ouma naby genoeg bly om gereeld oor en weer te kan kuier. Kleinkinders hou die grootouers jonk😉 en oupas en oumas kan soveel wyshede vir ons kinders leer en onvoorwaardelike bederf-liefde in hul hartjies deponeer.

‘n Mamma met ‘n pasgebore baba het iemand nodig wat vir babalyfie kan vashou, dat sy net vinnig iets kan eet of stort of aantrek of badkamer toe gaan – dat sy net weer mens kan voel. Dis wonderlik as Ouma of selfs Oupa naby is om hand by te sit.

‘n Moëe mamma is ook bitter baie dankbaar as Ouma die kinders bietjie kan besig hou – veral die besige kleuters met hulle oulike sê-goedjies en houdingtjies. Díé mini-mensies kan wel soms baie veeleisend raak as daar ‘n klein babalyfie ook in die huis is… (sien gerus “Die Baba-siklus” storie)

In ons geval, bederf Ouma en Oupa ons dikwels met saam-eet middagetes of ons ry uit na ‘n lekker restaurant met ‘n mooi uitsig. Dis presies wat hierdie ‘cabin-fever’-mamma nodig het om nie heeltyd net soos ‘n ‘jersey’ koei te voel nie!

Ek dink dis belangrik om aan die Oupas en Oumas spesifiek te kommunikeer oor wat jy van hulle verwag en hoe hulle jou kan help en bystaan. Elkeen se situasie lyk verskillend…

Mammas, dit is ook belangrik om grense te stel. Jy en jou huweliksmaat besluit saam oor hoe julle jul kinders wil grootmaak, die waardes wat jul hul gaan leer en hoe julle gaan dissiplineer ens. Grootouers moet die grense wat julle stel, respekteer. Al stem hul nie noodwendig daarmee saam of is dit nie dieselfde manier waarop hulle jóú groot gemaak het nie. (Hierdie kan soms ‘n taai toffie wees!)

Oumas (en Oupas), dit sal wonderlik wees as julle betrokke en beskikbaar kan wees…sonder om te veel voor te skryf. Om raad te gee wanneer daar vir jou gevra word… In my geval, het ek begin voel my ma laat my nie toe om die mamma te wees nie. Ek het gevoel my manier van dinge doen is nie goed genoeg nie. Want dis nie háár manier nie. Die oorsaak van hierdie “inadequate” gevoelens is ‘n kombinasie van postpartum hormone, slaap-tekort en leuens van die vyand. Oumas, wees maar bietjie meer sensitief daarvoor en luister na jou dogter/skoondogter se hart. As sy kla of huil, wees net daar. Sy’s op ‘n baie kwesbare en uitdagende plek in haar lewe, en gewoonlik wil sy graag net ‘n klankbord hê…en nie regtig iemand wat kom met lyste van “oplossings” nie.

Oumas, dit beteken nie jy het nóóit ‘n geldige opinie of moet op eiers loop nie! (Ek’s seker jy weet waarvan jy praat! Jy het immers jou kinders mooi groot gekry 😉) Dis maar net ‘n fyn balans van die regte hoeveelheid ondersteuning, sonder om “judgemental” oor te kom (al bedoel jy goed). Laat haar toe om self te probeer, leer en foute te maak – solank dit nie dodelik is of ewigheidskade aanrig nie!

Oumas, val maar eerder in by die ma. Vra byvoorbeeld eers wat die kinders mag eet of nie mag eet nie. Dieselfde reëls wat by die huis geld, moet by Ouma se huis ook toegepas word. Dubbelstandaarde is frustrerend en verwarrend. Konsekwentheid is die sleutel.

(Nuwe) mammas, ek wil afsluit deur te sê dat ons ook ekstra bietjie genade met die oumas moet hê. Ons moet onthou hulle was eens op ‘n tyd ook die mamma – en dít is wat hulle ken en onthou…Nóú moet hul ‘n splinternuwe rol aanleer en dít bring dalk onsekerhede en misverstande…
“Have a little grace. It goes a long way.”

♡

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HUMMUS

* Kekerertjiesmeer *

“Kids LOVE dipping stuff” –
Dis ‘n maklike & potensieel gesonde manier om verskillende groente(stokkies) in jou kleinspan se lyfies te kry!

Die gesondheidsvoordele van Chickpeas sluit in:
Dis hoog in vesel, ‘n bron van proteïene, propvol vitamienes en minerale en het ‘n laer glisemiese indeks (‘low GI’) – wat beteken dat dit help om bloedsuikervlakke te beheer!

Loer hieronder vir 2 maklike Hummus resepte. Die eerste een is vir almal wat hou van ‘n vars ‘plain’ smaak. Die 2de resep het ‘n voller smaak en is vir dié wat bietjie meer met speserye wil eksperimenteer en hou van ‘n “skop”! Albei is baie ‘yummy’ en gesond!

WENK: Gooi ‘n klein bietjie koue water by die mengsel om dit makliker te meng/’blend’ en romerig te maak.

Dankie aan Nadene Esterhuizen en Nancy Cloete vir die 2 resepte!

♡

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SONDAG-INSPIRASIE

GASSKRYWER

‘n Vrou se handsak
Deur Magda Burger

Iets waaroor haar man definitief nie praat nie. En in ons huis lyk my man of die donderweer hom gaan tref as hy iets in myne moet soek.
So elke kort-kort moet ek maar inklim en regpak. My Pandora’s box hou nogal interessante dinge in, veral as die seuns dit ook gebruik.

Ek kry nou die dag ‘n klip in my handsak. Net ‘n gewone klip. Niks spesiaals nie. Inteendeel ek het deksels swaar aan die ding gedra! Vies haal ek dit uit.

Toe besef ek hoe baie klippe dra ons in ons harte:
Al die onnodige gemors. Is nie lus om daai ou te vergewe nie, en dan bly ek maar vies elke keer wanneer ek aan daai een dink. Die gekrap as iemand die hele tyd vir my vra om iets te doen. Vriendelik te wees en ‘n nors antwoord terug te kry, en dan maar dae lank daaroor ontsteld te wees. Soveel irritasies wat elke dag se mooi uitsuig.

Haal die klippe uit. Maak jou hart ligter. Dan kan jy in elk geval meer liefde inpak wat jy weer in oorvloed kan uitdeel.

♡

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TRIPPE TRAPPE TONE

Ek’s seker ek hét gekyk waar die eerste trappie is. Ek’s amper 100% seker…

Hierdie mamma het heel Vrydag soos ‘n absolute vrot ma gevoel! Ek het met baba en al by ons boonste verdieping se trap afgeval. Darem net tot in die helfte van die trap…maar nogsteeds… 😬 Eina.

Met my baadjie onder die een arm, dummy & Telement in die hand, selfoon in die gatsak en baba op die heup, het ek aan die bopunt van die trap gestaan en vlugtig afgekyk. Ek was haastig. Ek misgis toe die tweede trap vir die eerste een, en daar steier ek vooroor, met enkels wat swik en voete wat skraap, soos ek probeer om vastrapplek te kry! Toe ek die teëls sien nader kom, en ons 2 aanhou gly, besef ek ons ontmoeting met die grond is onvermydelik. Ek probeer vir boetiebaba nader trek, maar met die momentum (en sy 10kg lyfie) “ka-plaks” ons boude-eerste op die harde teëltrap. Ek kreun, en boetie snak na sy asem – toe begin hy hartverskeurend huil. Gelukkig hou ek hom steeds vas (hy het genadiglik nie uit my arms geglip nie!) en alhoewel hy opsigself ‘okay’ lyk, kan ek hoor hy’s in pyn. Ek gil histeries vir my man om te kom help, en soos hy vir baba uit my arms tel, voel ek my eie seer: my elmboog, my linkerboud, my enkel (díé het alreeds ‘n golfbal-swelsel aan die vorm).

Ons uitstappie na Ongevalle en X-strale bevestig: geen gebreekte/gedislokeerde bene. Dankie, Vader. My enkel is net sleg verstuit. Maar boetiebaba het ‘n diep sny onder sy 3de toontjie… Só wag ons toe vir die chirurg wat hom heelmoontlik teater toe sal moet neem vir narkose en steke…

Die chirurg kom sien ons toe ‘n paar uur later in die kindersaal (genade, maar dis sleg om ‘n kind – wat nog te sê van ‘n borsvoedende baba – nil per mond te hou! Ek’t as dokter-mamma beslis nuwe perspektief en empatie bygekry). Steke is toe nie nodig nie! Ons kan sy voetjie konserwatief met verbande behandel – halleluja!

Oudste, met sy klein hartjie en kinderlike geloof, het by die huis al vir mamma en boetie se voete gebid. Pappa noem na die hele gedoente hoe hy tóé al gesien het hoe die voetjie se swelling sak…

Boetiebaba se naam-betekenisse het in hierdie (kort) 7 maande vir my werklik “lewendig” geword: Kampioen en God is genadig. Deur al die “trials & tribulations”…deur septiese skok en breinvliesontsteking en brongiolitis…en sy ma wat heel simpel was om nie aan die trapreëling vas te hou nie… Hy is ‘n dapper klein mensie & God is altyd genadig.

♡

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DIE “REGTE” DING

Hoe weet jy wat is die régte ding om te doen? In ‘n wêreld waar alles RELATIEF geword het: mý waarheid, jóú waarheid?

Hoe kies jy? Waarop maak jy staat? Intuïsie? “Gut” gevoelens? Besluite gebaseer op vorige ervarings? Wat sê die samelewing?

Ek besef net weer op hierdie vars nuwe Maandagoggend: my emosies kan my om die bos lei…dan voel ek sus en dan voel ek so. My vorige besluite was nie noodwendig die beste besluite nie…En die samelewing word tans ongelukkig met ‘n “anything goes”-uitkyk aan die slaap gesus…

Mag die Heilige Gees my hierdie week lei (en elke week wat kom!). Mag Hý my ware Noord wees. En mag ek werklik stil word…en na Sy stille fluisterstem lúíster. Sodat ek regtig kan weet wat die regte ding is om te doen.

♡

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TANTRUMS & TAAI TOFFIES

“Nee, Mamma moet. Mamma moet by my lê! Nie Pappa nie. Mamma!!!”

Só kerm-huil-skreeu my groot-oog amper-3-jarige kabouter net voor slaaptyd oor wie hý besluit het vanaand by hom moet lê tot hy na Droomland weggevoer word…

Dis al weer een van dáái dae. Daai hóógs uitdagende dae: van verseg-om-my-middag-slapie-by-die-skool-te-vat-en-nou-is-ek-totaal-verby-moeg-en-aaaaaalles-is-‘n-stryd!

Moet my nie verkeerd verstaan nie. Ek is ontsettend lief vir my 2 seuntjies. Maar party dae voel dit asof my geduld en kreatiewe-redenasie-vermoeëns tot die uiterste beproef word! Veral met Oudste (Boetiebaba praat (gelukkig?) nog nie terug nie, maar gil net in sy skril stemmetjie as hy gehóór wil word).

Terug by vroeër vandag:
Die groen plastiek-eetlepel móés eintlik blou gewees het, Rupert het sy hand gelek😱, en hý wou die asmapompie se oranje doppie “SELF” (julle ken mos daai woord😉🙈) afgehaal het. Emosies het behoorlik gesneeubal in ‘n sneeu(senu-ineen)storting…

Vanaand is almal moeg. Hierdie mamma het nog soveel om te doen voor dit mý beurt is om in te kruip. En hier sit Oudste Kabouter steeds kiertsregop en verseg om te slaap. “Want Mamma moet by my lê!” (Alhoewel Pappa nog altyd die laaste paar maande goed genoeg was!)…

Ek bid vir wysheid. Ek bid vir onderskeiding: Dat ek sal weet wat om te doen, wat om te sê.
Wanneer is dit als net die moegheid wat praat en wanneer is dit pure ongehoorsaamheid (soos wanneer hy aspris kliphard geluide maak as ek met manlief probeer praat)?

Wanneer moet ek grense stel en dissiplineer en wanneer het hy net liefde en aanvaarding nodig – net vir my nodig om by hom te wéés?

Vanaand het ek die “by-hom-te-wees” opsie gekies, my arms om sy snikkende lyfie gevou en hom net vasgehou. ‘n Paar sout-trane-soentjies op die wang en twee snot-tissues later, krul sy mondhoekies weer in ‘n half-glimlag op en soek sy groot oë myne. En ek weet in my hart dit was die regte besluit. Ons siele het ontmoet en ons verhouding het verdiep.

♡

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KREATIWITEIT

Ek het die laaste week of wat gevoel ek ly bietjie aan “writer’s block”…

Daar was ‘n swetterjoel van emosies – opwinding, vreugdes en effense senuagtigheid – maar ek kon nét nie my gedagtes kreatief inryg en sinvol verwoord nie!

So, ‘n mens kan glo nie jou kreatiwiteit OP gebruik nie… En hoe méér kreatief jy is en jou passie uitleef, hoe meer GROEI dit…Maar my woorde hét min geword.

Ek word toe stil in Boetie se kamer (deesdae is dit my plek van stiltetyd hou, met Kleinboet in my arms)! En sjoe, ons Pappa-God is getrou – ek ervaar: my kreatiwiteit is ‘n uitvloeisel van my verhouding met Hom (die beste skrywer, skilder, pottebakker en algehele Skepper)…

Belê in ONS verhouding, en kreatiwiteit sal die vrug daarvan wees.

♡

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INTIMITEIT

Volheid en glorie
My lewe, U storie
My begeertes, U drome
Geplant langs waterstrome

Stukkie vir stukkie
Word stil vir ‘n rukkie
Koester verhouding
Net dán kan dit uitkring

Gefluisterde soene
Trek uit my skoene
Bely met my mond
Dis Heilige grond

♡