VITAMIN AVITAMIN A

DR KAUSIK SURDR KAUSIK SUR D.C.H,DNBD.C.H,DNB

ASSISTANT PROFESSORASSISTANT PROFESSOR

DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS

VIVEKANANDA INSTITUTE OF MEDICAL VIVEKANANDA INSTITUTE OF MEDICAL SCIENCESSCIENCES

RAMAKRISHNA MISSION SEVA PRATISTHANRAMAKRISHNA MISSION SEVA PRATISTHAN

KOLKATA,INDIAKOLKATA,INDIA

SOURCESSOURCES

ANIMAL FOODSANIMAL FOODS LiverLiver EggEgg ButterButter CheeseCheese Whole milkWhole milk FishFish MeatMeat

PLANT FOODSPLANT FOODS SpinachSpinach CabbageCabbage LettuceLettuce CurryCurry Reddish leavesReddish leaves Yellow pumpkinYellow pumpkin MangosMangos PapayaPapaya TomatosTomatos

Most of the retinol is esterified with Most of the retinol is esterified with saturated fatty acids saturated fatty acids incorporated into lymph chylomicron incorporated into lymph chylomicron enter bloodsteram converted enter bloodsteram converted to chylomicron remnants taken to chylomicron remnants taken up by liver together with their up by liver together with their content of retionolcontent of retionol

THIS REACTION IS ACCOMPANIED BY A CONFORMATIONAL CHANGE THAT INDUCES CHANGE IN PERMEABILITY OF CATIONS, INCRSED POLARIZATION OF MEMBRANES AND TRIGGERING OF A NERVE IMPULSE

RETINOIC ACID RETINOIC ACID PARTICIPATES IN PARTICIPATES IN

GLYCOPROTEIN SYNTHESISGLYCOPROTEIN SYNTHESIS Retinoic acid participates in Retinoic acid participates in

promotion of growth and promotion of growth and differentiation of tissuesdifferentiation of tissues

Retinoyl phosphate functions as Retinoyl phosphate functions as a carrier of oligosaccharides a carrier of oligosaccharides across the lipid bilayer of cellacross the lipid bilayer of cell

VITAMIN A IS ESSENTIAL VITAMIN A IS ESSENTIAL FORFOR

Normal maintenance and function of Normal maintenance and function of body tissuesbody tissues

VisionVision Cellular integrityCellular integrity Immune competenceImmune competence GrowthGrowth

BETA CAROTENE – BETA CAROTENE – 1.1. Antioxidant propertyAntioxidant property2.2. Scavenger of free radiclesScavenger of free radicles

Vitamin a and beta carotene may Vitamin a and beta carotene may reduce the incidence of lung, breast, reduce the incidence of lung, breast, oral, esophageal, bladder canceroral, esophageal, bladder cancer

RECOMMENDED DAILY INTAKERECOMMENDED DAILY INTAKE

INFANTS 350 INFANTS 350 µgµg

1-6 YEARS 400 µg1-6 YEARS 400 µg

7-12 YEARS 600 µg7-12 YEARS 600 µg

DIAGNOSIS OF VIT A DIAGNOSIS OF VIT A DEFICIENCYDEFICIENCY

Assessment of dietary vit.AAssessment of dietary vit.A Eye examinationEye examination SERUM RETINOLSERUM RETINOL level(normal level is 28 level(normal level is 28

to 86 μg/dl (1 to 3 µmol/L) to 86 μg/dl (1 to 3 µmol/L) not an acurrate indicator not an acurrate indicator unless the deficiency is severe and liver stores depletedunless the deficiency is severe and liver stores depleted

ROSE BENGAL STAIN ROSE BENGAL STAIN TEST(RBST)TEST(RBST) for for early conjunctival xerosisearly conjunctival xerosis

CONJUNCTIVAL IMPRESSION CONJUNCTIVAL IMPRESSION CYTOLOGY(CIC)CYTOLOGY(CIC) for preclinical VAD for preclinical VAD

Night vision threshold testNight vision threshold test

WHO CLASSIFICATION OF WHO CLASSIFICATION OF XEROPTHALMIAXEROPTHALMIA

CIassification of xerophthalmia World Health Organization, 1976)

XS Night blindness XI A Conjunctival xerosis XIB Bitot’s spot X2 Corneal xerosis X3A Corneal ulceration-keratomalacia > 1/3

corneal surface X3B Corneal ulceration- keratomalacia < 1/3

corneal surface XS Corneal scar XF Xerophthalmic fundus

Conjuctiva becomes dry- Conjuctiva becomes dry- CONJUNCTIVAL XEROSISCONJUNCTIVAL XEROSIS

Conjunctive keratinizes and develops Conjunctive keratinizes and develops plaques- BITITS SPOTplaques- BITITS SPOT

Cornea keratinizes, becomes opaque, Cornea keratinizes, becomes opaque, is susceptible to infection and forms is susceptible to infection and forms dry, scaly layer of cellsdry, scaly layer of cells

Infection occurs, lymphocytes infiltrates Infection occurs, lymphocytes infiltrates and the cornea becomes wrinkledand the cornea becomes wrinkled

Degenerates irreversibly Degenerates irreversibly (KERATOMALACIA)(KERATOMALACIA)

OTHER FEATURES OF VITAMIN OTHER FEATURES OF VITAMIN A DEFICIENCYA DEFICIENCY

SKIN CHANGES-SKIN CHANGES- Scaly, toad like Scaly, toad like (phrynoderma)(phrynoderma)

Squamous metaplasia of respiratory mucosa Squamous metaplasia of respiratory mucosa more prone to more prone to RESPIRATORY RESPIRATORY INFECTIONSINFECTIONS

Alteration in mucosa of renal pelvis and UB Alteration in mucosa of renal pelvis and UB formation of formation of RENAL AND VESICAL CALCULIRENAL AND VESICAL CALCULI

Atrophy of germinal epithelium may interfere Atrophy of germinal epithelium may interfere with with REPRIDUCTIVE FNREPRIDUCTIVE FN

DIARRHEADIARRHEA ANEMIAANEMIA APATHYAPATHY MRMR INCREASED INTRACRANIAL INCREASED INTRACRANIAL

PRESSUREPRESSURE

TREATMENT OF VITAMIN A TREATMENT OF VITAMIN A DEFICIENCYDEFICIENCY

SPECIFIC- SPECIFIC- ORAL VIT.A ORAL VIT.A 50,000 IU50,000 IU(<6 months)(<6 months) 1 LAKH IU1 LAKH IU (6-12 months) (6-12 months) 2 LAKH IU2 LAKH IU (> 1 year) (> 1 year)

SAME DOSE SAME DOSE NEXT DAYNEXT DAY SAME DOSE SAME DOSE 4 WEEKS LATER4 WEEKS LATER

PARENTERAL WATER SOLUBLE VIT. PARENTERAL WATER SOLUBLE VIT. A A

DOSE- 3/4DOSE- 3/4thth DOSE <6 months DOSE <6 months

½ DOSE 6-12 months½ DOSE 6-12 months

INDICATION- INDICATION-

1.1. Impaired oral intakeImpaired oral intake

2.2. Persistent vomitingPersistent vomiting

3.3. Severe malabsorptionSevere malabsorption

LOCAL TREATMENTLOCAL TREATMENT

CORNEAL ULCER-CORNEAL ULCER-ANTIBIOTICS DROPS/OINTANTIBIOTICS DROPS/OINT. THRICE . THRICE

DAILYDAILY(to prev. sec. infection)(to prev. sec. infection)PADDING OF EYEPADDING OF EYE (to prevent (to prevent

dehydration and furthur corneal dehydration and furthur corneal exposure)exposure)

MYDRIATIC- ATROPINE DROP 1% ORMYDRIATIC- ATROPINE DROP 1% OR OINT.OINT. ONCE DAILY ONCE DAILY

PREVENTIONPREVENTION NOT BREAST FED INFANTS- NOT BREAST FED INFANTS-

50,000 IU50,000 IU BY BY 2 MONTHS2 MONTHS AGE AGE

( OR 2 DOSES OF 25000 IU AT I MOMTH ( OR 2 DOSES OF 25000 IU AT I MOMTH INTERVAL)INTERVAL)

EVERY INFANT-EVERY INFANT-

ONE DOSE OF ONE DOSE OF 1 LAKH IU1 LAKH IU VIT A ALONG VIT A ALONG WITH MEASLES VACCINE AT WITH MEASLES VACCINE AT 9 MONTHS9 MONTHS

4 MORE DOSES OF 4 MORE DOSES OF 2 LAKH IU2 LAKH IU EACH AT EACH AT

18,24,30,36 MONTHS18,24,30,36 MONTHS

IN VIT.A ENDEMIC AREASIN VIT.A ENDEMIC AREAS CHILD SUFFERING FROM CHILD SUFFERING FROM 1.1. MEASLEAMEASLEA2.2. SEVERE PEMSEVERE PEM 2 DOSES2 DOSES OF ORAL VIT.A ON 2 OF ORAL VIT.A ON 2

CONSECUTIVE DAYSCONSECUTIVE DAYS(1 LAKH FOR <1 YEAR AND 2 LAHS >1 (1 LAKH FOR <1 YEAR AND 2 LAHS >1

YEAR)YEAR)

PERSISTENT DIARRHEA, OTHER PERSISTENT DIARRHEA, OTHER PROLONGED FRBRILE CONDITIONPROLONGED FRBRILE CONDITION

One dose in each episode with 1 One dose in each episode with 1 month interval month interval

CONSUMPTION OF FOODS RICH IN VIT A CONSUMPTION OF FOODS RICH IN VIT A LONG TERM PREVENTION STRATEGIESLONG TERM PREVENTION STRATEGIES

1.1. Nutrition education and dietary Nutrition education and dietary diversificationdiversification

2.2. HORTICULTURAL INTERVENTION incl. Home HORTICULTURAL INTERVENTION incl. Home gardeninggardening

3.3. Nutritional supplementationNutritional supplementation

4.4. Selective fortification for high risk and Selective fortification for high risk and special groupsspecial groups

All Infants with birth weight of ≤1 kg All Infants with birth weight of ≤1 kg should receive 5000IU of Vitamin A should receive 5000IU of Vitamin A i.m 3 times a week for first 4 weeks- i.m 3 times a week for first 4 weeks- slightly reduce the incidence of slightly reduce the incidence of chronic lung diseasechronic lung disease

Manual of neonatal care – john p cloharty, Manual of neonatal care – john p cloharty, 66thth ed ed