Vitamin a Deficiency... Dr Castro

8/6/2019 Vitamin a Deficiency... Dr Castro

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VITAMIN A DEFICIENCY

&

IRON DEFICIENCY ANEMIA:

A GLOBAL HEALTH CONCERN

Rebecca Abiog Castro, MD

P i tri tr nt r l H t l N triti n

UST Hospital


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Vitamin A Deficiency (VAD):

Definition:

It is the tissue concentration of vitamin A low

is no evidence of clinical xeropthalmia.

WHO 1998


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VITAMIN A DEFICIENCY (VAD):A PUBLIC HEALTH PROBLEM

Major nutritional concern in poor societies,

especially in developing countries

Assessed by measuring the prevalence of deficiencyin a population, represented by:

specific biochemical markers (low serum retinol)

clinical indicators of status (xerophthalmia)


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A GLOBAL HEALTH CONCERN


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VITAMIN A DEFICIENCY (VAD):A PUBLIC HEALTH PROBLEM

Global prevalence of vitamin A deficiency in populations at risk 19952005WHO Global Database on Vitamin A Deficiency


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LOCAL DATA:

VAD IN THE PHILIPPINES

4 in every 10 children or 38%, of 0-5 years of age;

2 out of every 10 or 22% ofpregnant and 16% of lactating mothers,

had deficient to low plasma retinol levels in 1998;

Considering the economic situation from 1998 to the present, the

vitamin A deficiency problem is not expected to decline, and may

be getting worse.

6th National Nutrition Survey FNRI, DOST


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PHILIPPINE DATA: VAD


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Vitamin A (called retinol in mammals) is a fat-soluble vitamin

Beta-carotene is converted to vitamin A in the body: 6 mg of beta-

VITAMIN A


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The daily recommended dietary allowance (RDA) is expressed as retinol

activity equivalents (RAEs; 1 RAE = 1 g all-trans-retinol;)

Retinol Activity Equivalents based on age:

infants 01 yr : 400500 g

3 yr : 300 g

VITAMIN A

48 yr : 400 g

913 yr : 600 g

Boys 1418 yr of age and men: 900 g; Girls 1418 of age and women: 700 g

During pregnancy: 750770 g

during lactation: 12001300

g

A daily tolerable upper level of vitamin A for adults is 3,000 g of preformed

vitamin

Nelson Textbook of Pediatrics, 18th edition


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Vitamin A: Functions

Vision

Epithelial differentiation Growth

Reproduction

Pattern formation during embryogenesis Bone development

Hematopoiesis

Brain development

Immune system function


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VITAMIN A: METABOLISM


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Vitamin A: Absorption and Bioavailability

70 90% of vitamin A from the diet is absorbed in the intestine

Within the intestinal lumen: vitamin is incorporated into a micelle

and absorbed across the brush border into the enterocytes

Greater than 90% of the retinol store within the body enters as

retinyl esters that are subsequently found within the lipid portion of

the chylomicron

Absorption: very rapid (maximum absorption occurring 2-6 hours

after digestion)


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Within the enterocyte:

precursors of vitamin A(carotenoids) are converted to

active forms of the vitamin;

VITAMIN A:Absorption & Bioavailability

Newly formed products &

precursors packaged into

chylomicrons and readied for

transport throughout the body


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Transport

After leaving the enterocytes, chylomicrons( carry retinyl esters,

carotenoids, and unesterfired retinol, triglycerides) are circulatedfirst through the lymphaticgeneral circulation

VITAMIN A:

a ex ra- epa c ce s:

chylomicrons release triglycerides

vitamin A remains within the chylomicron and is incorporated into a

chylomicron remnant

The chylomicron remnant then travels back to the liver where it is

taken up and further metabolized or stored.


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Vitamin A:Storage

Approximately 50 to 85% of the total body retinol are stored in the

liver when vitamin A status is adequate;

90% of the retinol is stored in the form of retinyl esters inside

hepatic stellate (star-shaped) cells along with droplets of lipid (fat-soluble)

Retinol returning to the liver is re-esterfied before storage


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Once hepatic stellate cells are saturated with all the retinol they can

hold, hypervitaminosis can result;

Precursor to vitamin A, beta-carotene, can be stored in adipose cells

VITAMIN A:Storage

o a epo s roug ou e o y;

Excess beta-carotene supplementation carotenemia


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Vitamin A: Excretion

The kidneys are the main paths of RBP and retinol excretion from

the body

Achieved mainly via renal catabolism and glomerular filtration

Those persons suffering from renal disease often experience

elevated serum levels of RBP and retinol and therefore must be

more aware of vitamin A toxicity.


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Main underlying cause of VAD: diet that is chronicallyinsufficient in vitamin A

VITAMIN A DEFICIENCY (VAD): A PUBLIC HEALTH PROBLEM

CAUSE

Can lead to lower body stores and fail to meet

physiologic needs (e.g. support tissue growth, normal

metabolism, resistance to infection)


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Low vitamin A intake during nutritionallydemanding periods in life greatly raises the risk of

vitamin A deficiency disorders (VADD):

VITAMIN A DEFICIENCY (VAD): A PUBLIC HEALTH PROBLEM

CAUSE

Infancy Childhood

Pregnancy

Lactation


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Vitamin A deficiency: due to chronic failure to eat sufficient

amounts of vitamin A or beta-carotene blood-serum level

of vitamin A defined range

VITAMIN A Deficiency: Clinical Features

e a-caro ene s a orm o pre-v am n rea y conver e o

vitamin A in the body

Night blindness is the first symptom of vitamin A deficiency

Prolonged and severe vitamin A deficiency can produce total

and irreversible blindness


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Vitamin A deficiency: Clinical manifestations

Associated with the requirement of this vitamin for the

maintenance of epithelial functions:

GI tractdiarrhea

Respiratory tractbronchial obstruction

Genito-urinary tract

Squamous metaplasia of the renal pelvis,ureters and vagina may lead to increased infections in,

hematuria and pyuria.


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Vitamin A Deficiency: Clinical manifestations

Skin dry, scaly, hyperkeratotic patches, commonly on the

arms, legs, shoulders, and buttocks.

Eye night blindness, xerophthalmia, bitot spots

, ,

Others:

poor overall growth,

susceptibility to infections Anemia

Apathy

mental retardation


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o spo xerop a m a


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Vitamin A Deficiency: Diagnosis

Clinical manifestations:

Night blindness

Xeropthalmia (Bitots spot, keratomalacia)

Dark adaptation tests assess early-stage vitamin A

deficiency

Vitamin A levels (NV:2060 g/dL)


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Treatment

Sign of vitamin A deficiency Treatment: < 6 months: 150,000 IU X 3 = 450,000 IU

6-12 months: 100,000 IU x 3 = 300,000 IU

> 12 months: 200,000 IU x 3 = 600,000 IU

Given on day 1, day 2 and 2 weeks from first dose


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Preventive Measures

NO sign of vitamin A deficiency: Prophylaxis

50,000 IU single dose (< 6month) 100,000 IU single dose (6-12 month)

200,000 IU single dose (>12 month)

Diet:

Green leafy vegetables

Yellow fruits & vegetables

Milk

Egg

Fortified foods


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IRON DEFICIENCY ANEMIA (IDA)


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For the period 1990 to 2001, the # of underweight pre-school childrendecreased by a mere 3.9 percentage points from 34.50% in 1990 to 30.60% in 2001. In terms of pop., this translates into an estimated 3.67 million

underweight preschool children in 2001.


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In terms of geographical location, the Bicol Region appears to

be the worst-off in underweight prevalence, followed byregions mostly in Mindanao island (Region 10, CARAGA,


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The prevalence of anemia among 6 months to < 1 year has

remained unabated since 1993, and increased from 49.2%to an alarming rate of 66 %.

Anemia among 1-5 y/o remained at 29.1%.


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Stages of IDA1. Iron depletion

Storage iron is absent or decreased

Normal serum iron conc and Hgb levels

2. Iron deficiency without anemia

Decreased or absent iron storage

Low serum iron concentration

Low transferrin

No frank anemia

3. Iron deficiency anemia

Low Hgb/Hct value


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IDAA significant body of causal evidence exists for:

1. Iron-deficiency anemia and workproductivity

. evere anem a an c mor a y

3. Severe anemia and maternal mortality

4. Iron-deficiency anemia and child

development


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IDATissue effects of IDA:

1. GIT: anorexia, pica, atrophic glossitis, leaky-gutsyndrome (exudative enteropathy)

. , ,

function

3. CVS: HR & CO, cardiac hypertrophy, plasma

volume


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What can be done?

Regular response to adequate amounts of iron is an

important diagnostic and therapeutic feature.

. .,

sulfate, gluconate, fumarate) provides inexpensiveand satisfactory therapy.


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What can be done?

Therapeutic dose

46 mg/kg of elemental iron in 3 divided doses

Ferrous sulfate - 20% elemental iron by weight.


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Problems with oral iron tx

1. Unpleasant taste - can be camouflaged by mixingwith flavored syrup

2. Older children and adolescents sometimes have GIcom laints

Constipation can be minimized by water &fiber intake

Abdominal discomfort can be minimized by

administering iron with food, but maydecrease iron absorption to some

extent.


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Case: History

Samantha, an 18 month old female, was brought tothe out patient department due to cough and colds of 3

days duration. She was also noted to have fast breathing.Samantha is the youngest in the brood of 3. She

was exclusively breastfed until 10 months old.omp ementary ee ng o 4-6 ta espoons o porr ge an

noodle soup, given once a day, was started at 12 months

old.

Primary series of immunization except Measles

vaccine was given at the local health center.She was given Vitamin C 0.5 mL daily only since 6

months old.


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Case:Physical Examination

PPE:

irritable, in respiratory distress, not dehydrated, thin, not ill looking

Wt=7.8kg (Z=< -3) Lt= 74.0cm (z=< -2) HC = 43.0cm (z= -1)CR= 135/min RR= 55/min T=380C

sunken eyeballs, whitish plaque on right medial conjunctivae, dry buccalmucosa

no significant adenopathiessymmetrical chest expansion, with intercostal retractions, fine crackles onboth lower lung fields

adynamic precordium, apex beat at 4th LICS MCL, no murmurs

abdomen slightly globular, soft, non-tender, normoactive bowel sounds,liver 2 cm below RCM, spleen not palpable

Full pulses, slightly pale palms and soles


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Salient Features from the History

18 months old female

Lower respiratory tract infection Exclusive breastfeeding until 10 months

Late introduction of Complementary Foods (12months)

Inadequate CF

Poor Quality of food intake (5 basic food groups notpresent)

Delayed Measles vaccination

Lack of iron supplements


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Salient Features: Physical Findings

Thin

In respiratory distress Anthropometric measurements:

-

Length: z= < - 2;

HC= 43 cm: z= -1.

Whitish plaque right eye

Pale soles and palms


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Case: Laboratory Results

Lab results:

CBC: Hgb=9.5g/dL; Hct=30 vol%;

RBC=3.5M/mm3; MCV=68fL; MCH=21pg/cell;WBC=12 x 109/L, neutros=40%, lymphos=60%; Plateletcount=500 x 109/L

Urinalysis: yellow, clear, pH=6.5, SG=1.010, RBC= 0-3/hpf, WBC=2-4/hpf


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Case: Laboratory Interpretation

Mild anemia

microcytic (low MCV), hypochromic (low MCH)with low RBC count

s g y e eva e p a e e coun

normal WBC and differential count


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Hypochromic cells and poikilocytes

Normal red blood cells


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1) What are the nutritional deficiencies present in this patient?

PEM

Underweight Severe ( WFA: z= < -3)

Stunted (LFA= < - 2)

Wasting: WFL=

Vitamin A Deficiency

Bitots spot right eye

IDA:

Pale soles and palms

Mild anemia (hypochromic microcytic rbc)

Guide Questions:


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Guide Questions:

2) Identify the risk factors for these nutritionaldeficiencies?

Delayed introduction of CF

Inadequate food intake:

amount

quality

No iron supplements started at 6 months of age


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3) What diagnostic tests will you request?

PEM severe: Cbc

TPAG

IDA: CBC with blood indices determination

Peripheral smear

VAD:

Clinical manifestations

Serum retinol if available


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4) How do you manage these nutritional

deficiencies?

PEM:

Nutritional rehabilitation ( Ten steps in the Mx of Severely

Malnourished children by WHO)


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VAD:

Vitamin A: 200,000 IU given for 3 doses on day 1, 2and 2 weeks after the first dose

Adequate food intake with five basic groups eaten daily*

IDA:

3-6 mg / kg /day for 3 months

Adequate food intake with five basic food groups eaten daily*

* Use the PSPGN Food Guide Pyramid & Dietary prescription


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5) Outline the preventive measures on these

problems.

Proper introduction of CF at 6 months


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5) Outline the preventive measures on these problems

Iron supplementation: 2 months for preterm infants

6 months for term infants

High risk groups Neonates: Prematurity, LBW, Blood loss

Infants/toddlers and adolescentsid growth, Inadequate

Women from menarche to menopause:

Vegetarians esp vegans (no eggs, meat, butter, cheese)

5. laborers (Hard Labor, Manual Labor)

6. Frequent Blood Donors


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5) Outline the preventive measures on these problems.

Balanced diet: adequate intake of 5 basic food groups

Regular growth monitoring with the use of growth charts Monthly 1st 12 months

Quarterly > 12 months

Annually > 5 years


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Vitamin a Deficiency... Dr Castro