micronutrient deficiencies cases
Post on 18-Jan-2016
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Global Health Fellowship
St Luke’s/Roosevelt Hospital
5 yr old M recently adopted from India bib parents for first examination. They report he is doing well except that he seems to bump into objects frequently, particularly in the evening
PEHt & Wt are below 5th %Rest of examination normal Except for eye exam
Vitamin A deficiency
Stunted Retinal is essential for growth & functional integrity
of epithelial cells (eye, respiratory, urinary & intestinal tract)
Nyctalopia or night blindnessDue to delay in resynthesis of rhodopsinRetinal (component of retinal pigments) is important
for normal visionBitot Spots
Small triangular/oval, silvery, foamlike patches that appear on the conjunctiva due to keratinization
1st clinical signsDrying of the conjunctivaBitot spotsXerophtalmia (drying of the cornea)
Nyctalopia or Night blindnessKeratomalacia
Breakdown of corneaPermanent blindness
PEM
Blindness
Other complicating Nutritional deficiencies
Subclinical Vit A deficiency70-80 M children worldwide (including USA)↓physical growth↑susceptibility to infection↓ survival from serious illness
↑ rates M&M common infectious diseases (resp, GI)Measles
WHO, UNICEF, AAP
Community wide administration of Vit AWHO recommended: beneficial effects on immunity↓ U5MR by 25%
Replacement : q4-6 mos Infants 50K IU POInfants 6-12mo: 100K IU POMothers: 200K IU PO w/in 8 wks deliveryPregnant /women of reproductive age: 10K IU/d or
25K IU wk
Food fortificationOily/dry formsMargarine, oilSugarCereal flours, milk
(powder & liquid)
Dietary diversification Vit A rich foods
Plant & animal
Global InitiativeGAVAHelen Keller
InternationalCIDA &
Micronutrient Initiative
WHO, UNICEF, USAID, World Bank
Vitamin Angels, Operation 20/20
Hi dose supplementationChildren at hi risk Vit A deficiency: *measles, diarrhea, respiratory diseases, severe
malnutrition (single dose if no supplement in 1-4 mo)Reduces complications & mortality
Treatment Xerophthalmia3 doses at age specific doses1st immediately on diagnosis, 2nd the next day, 3rd dose 2 weeks later
2 yr old M African American brought in for routine visit
Born at 30 wks gestation, exclusively breastfed until 1 yr age & picky eater since
PEHt & Wt < 5th %Bowing of legsNot yet walking, no teeth yetRachitic rosary
*Wrists: osteopenia, cupping & fraying of metaphysis
*LE: bowing
*Rib flaring: enlargement costo chondral junctions
↓phosphosrus, calcium
↑ alkaline phosphatase
29 y F Muslim mother of 4 children c/o fatigue, headache, weakness & body aches for months
PE Normal VS Diffuse muscle tenderness & proximal weakness Bony ttp tibia, humerus, ulna, sternum
OsteomalaciaPseudo or real fractures
↓Phosphorus, calcium
↑Alkaline phosphatase
↓Ca urinary excretion
#Limited exposure to sun
poor air quality cultural, social habits, dress codes
live > 37TH parallel darkly pigmented skin
#Nutritional deficiencies *breast milk low in Vit D, weaning diets (low in fats / oils)
* ↓intake Ca (↑consumption polished rice), Phosphate
* diets w/ ↑ content phytate (wheat-binds Ca in gut), vegan/vegetarian diets
* ↓ energy supplies, growth outstrips Ca availability
#Malabsorption (repeated GI infections)#Chronic renal, liver disease
Early
Craniotabes, head asymmetry, frontal bossing, delayed closing ant fontanelle
Delayed tooth eruption, abnormal formation enamel, cavities
Rachitic rosary
Late Pigeon chest irregularity, Harrison grooveMotor delays, hypotonia (muscle weakness)
Classic limb abnormalitiesGenu varum, genu valgum, windswept
deformitiesFraying, widening, cupping metaphysis
long bones, fractures Lordosis, kyphosis, scoliosisNarrow pelvis: obstructed labor
In AdultsCardiovascular diseaseInsulin resistanceHTA
MusclesDelayed motor developmentTetany, carpopedal & laryngeal spasmConvulsions
Pneumonia2ary defective immune functionThorax deformity (restrictive airway)Cor pulmonale
Biochemistry Serum Ca: Nl or ↓ Serum Ph: ↓ ↓Urinary Ca excretion Alkaline Phosphatase: ↑ Hydryxyproline excretion: ↑
Radiology Radius/ulna: widened, cupped, frayed ends Costochondral junctions: widened Osteopenia
Bone biopsy Inadequate mineralization Excessive volume of osteoid tissue
Community Health Education
Need for sunlight & animal foods (eggs)
Fish oil for children at risk: premies/infants/patients
Vit D intake Recommendations Infants: 400-1K IU/d, 1-18 ys: 600- 1K IU/d, > 18y:
1.5-2K IU/dPregnant/lactating: 1/5-2K IU/dObesity : ↑by 2-3x age recommendations
Food fortification with Vit DInfant formula, (400 IU/L) cow’s milk, Cereals
Vit D supplementationBreast fed infants, Toddlers (picky eaters)High risk groups: northern climates, AA, full dress,
indoor lifePts with ↓absorption w/ gastrectomy, celiac disease,
malabsorption, extensive bowel surgery, IBD, CFVegan/vegetarian, macrobiotic diets
Dietary Calcium intakeSufficient intake , even in sunny environments
(1,000mg/d)
Sunlight or ultraviolet lightVit D2 (ergocalciferol)
Infants < 1mo: 1K IU/d; 1-12mo: 1-5K IU/d; >1yr: 5K IU/d
PO or IM Vit D2: 150-300K IU once 600K IU PO once (stosstherapy: risk of hyperCa) if poor
compliance or F/U PO calciferol: 3K IU (75mg) QD x 1 mo Cod liver oil (75 IU/ml or 1.8mg/ml) QD x 1mo
Tetany IV Ca Gluconate 10%solution ( 5-10ml) PO Ca Chloride 1g q 6 h ( in milk)
Ca supplementsCa intake maintained at 1 K mg/d (avoid hungry bone
syndrome)30-75mg/kg elemental Ca/d (milk or Ca lactate TID)
Tetany IV Ca Gluconate 10% solution ( 5-10ml) PO Ca Chloride 1g q 6 h ( in milk)
Ca supplementsCa intake maintained at 1,000 mg/d (avoid
hungry bone syndrome)30-75mg/kg elemental Ca/d (milk or Ca
lactate TID)
Healing6 -12wks Vit D treatment biochemical
changes reverses↑urinary Ca excretionBones heal more slowly ( treatment x 3 mos)Treat till Xray evidence of healing observedMay require longer treatmentsMay never become normal
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