Vanessa Velazquez-Ruiz, MD
Emergency Medicine
Global Health Fellow
St. Luke’s-Roosevelt Hospital

 Affect a variety of health and disease outcomes:
 Child growth and development
 Maternal health
 Malnutrition and vulnerability to infectious diseases
 Estimates of micronutrient malnutrition vary from 20% of the world population (or more than one billion persons)
 Dietary deficiencies represents an enormous problem of
“hidden hunger”

 Series of lectures
 Week #1: Vitamin A and D
 Week #2: Iron, Iodine and Zinc deficiencies
 Week #3: Obesity and the other spectrum of malnutrition

Fasten your seatbelts and enjoy the ride…

 Third most common deficiency in the world
 Affects an estimated
 125-130 million preschool age children
 And 7 million pregnant women in low-income countries
 Prevalent cases of pre school xerophthalmia are believed to number about 5 million
 10% can be considered potentially blinding

 Leading cause of preventable pediatric blindness in developing world
 Underlying cause of at least 650,000 early childhood deaths due to diarrhea, measles, malaria and other infectious disease
 Maternal deficiency may increase risk of maternal morbidity and mortality



Public Health problem in approx 78 countries
 Most widespread across South and Southeast Asia and
Sahelian and Sub-Saharan Africa (where food supplies lack preformed vitamin A)
 Clusters within counties due to common exposures to poor diet and inadequate care, malnutrition

 Age
 Corneal xerophthalmia- 2-3y/o
 Acute onset of corneal disease may follow recent weaning from breast milk, or s/p illnesses
 Gender
 Male > Girls
 Socioeconomics
 Inversely correlates with Vit A deficiency

 Retinol (preformed Vit A): animal products, liver
 Beta-carotenes : Provitamin A (converted to Vit A in intestines)
 Plant source of retinol from which mammals make 2/3 of their Vit A
 Carotenoids: yellow, red fruits/vegetables

 Essential in regulating numerous key biologic processes in the body
 Morphogenesis
 Growth
 Nutrition
 Vision
 Reproduction
 Immunity
 Cellular differentiation and proliferation

 Insufficient intake
 Increase requirements during growth, pregnancy and lactation, infection
 Change from breast feeding to inadequate complimentary feeding
 Socio-cultural and economics factors (intra household distribution and gender preferences)

 Three clinical stages:
 Retinal dysfunction causing night blindness
 Conjunctiva and corneal xerosis
 Corneal ulceration and necrosis

 Earliest manifestation
 Most prevalent stage of xerophthalmia
 Failure in rod photoreceptors cells in the retina
 Responsive to Vitamin A supplementation

 A positive history of night blindness is associated with low-to-deficient serum retinol concentrations in preschool aged children and pregnant women
 Can serve as an indicator of individual and community risk of Vitamin A deficiency

 Xerosis of the conjunctiva
 Appears as dry, non-wettable, rough or granular surface
(best seen on oblique illumination with hand light)
 Histological: transformation of normal columnar epithelium with abundant goblet cells to stratified, squamous epithelium that lacks goblet cells.

Bitot’s spots: gray-yellow patches of keratinized cells and saprophytic bacilli that aggregate on temporal limbus (lesions are bubbly, foamy or cheesy like)

 Corneal xerosis (“drying”) presents as superficial punctuate erosions that lend a hazy, non-wettable, irregular appearance to the cornea
 Usually both eyes
 Severe xerosis, cornea becomes edematous with dry granular appearance (“peel of an orange”)
 Vitamin A successfully treats corneal xerosis

 Appearance: Round or oval, shallow or deep, sharply demarcated and often peripheral to the visual axis
 Only one eye
 Vit A will heal lesion leaving a stromal scar or leukoma

 Keratomalacia (“corneal melting or softening”)
 Initially opaque localized lesions that can cover and blind the cornea
 Treatment with Vit A leaves a densely scarred cornea

Same eye 2 months after Vitamin A therapy
Conjunctival xerosis and localized corneal necrosis in a severely malnourished 2-year-old Indonesian boy.

 Experimental Vitamin A depletion in animals causes a deceleration in weight gain to a “plateau” as hepatic retinol reserves becomes exhausted
 Corneal xerophthalmia is associated with severe linear growth stunting and acute wasting malnutrition
 Recovery from xerophthalmia has been associated with gain in weight

 Predisposes individuals to severe infection
 Higher mortality rates in children and pregnant women
 Vit A maintains epithelial barrier function and regulates cellular and antibody-mediated immunity

 Children with any stages of xerophthalmia
 High potency Vit A at presentation, the next day and 1-4 weeks later (WHO recommendations)
 Children at high risk Vit A deficiency: measles, diarrhea, respiratory diseases, severe malnutrition
 High dose supplementation: single dose if no supplement in
1-4 mo

 q4-6 months
 Infants 50K IU PO
 Infants 6-12mo: 100K IU PO
 Mothers: 200K IU PO w/in 8 wks delivery (WHO recommendation)
 Pregnant or women of reproductive age: small doses 10K IU/d or 25K IU wkly

 Dietary diversification
 Fortification
 Supplementation

 Increase intake from available and accessible foods
 Nutrition education
 Social marketing
 Community garden programs
 Measures to improve food security

 Taking advantages of existing consumption patterns of fortifiable foods to carry Vitamin A into the diets
 Examples:
 Vitamin A fortification of sugar in Guatemala
 Vitamin A fortified monosodium glutamate in Southeast
Asia

 Encompassing community based efforts to provide Vit A supplements to high-risk groups
 Preschool-aged children
 Mothers within 6-8weeks after childbirth
 UNICEF procures and distributes over 400 million Vit A supplements to nearly 80 countries
 Integrating vitamin A delivery with immunization services during each of three routine contacts in the first 6 months of life

 Resurgence in the prevalence of Rickets
 In developing countries, not only associated with effects on bone growth and mineral homeostasis but also with infant and child mortality when accompanying lowerrespiratory tract infections

 Disease of the growing bones from a failure or delay in the calcification of newly formed cartilage at the growth plates of long bones and failure of mineralization of newly formed osteoid (osteomalacia)
 Bones no longer able to maintain normal shapes

 Calciopenic rickets
 Phosphopenic rickets
 Primary defect of mineralization
*
Nutritional Rickets is a form of calciopenic rickets and is classically associated with Vitamin D deficiency

 Active Rickets
 Impaired Calcium homeostasis
 Consequent to impaired dietary calcium absorption or inadequate intake
 Vit D (or more specifically 1,25-(OH)2D) controls the absorption of Calcium
 ↓ serum Ca → induce ↑ PTH secretion → osteoclasts ↑ resorb bone → demineralization of bone & cartilage at sites of rapid growth & remodeling

 Predisposition to lower respiratory tract infections by
 Effects on immune system
 Muscle weakness and hypotonia
 Effects of rickets and osteomalacia on rigidity and support provided by the ribs during respiration

 During pregnancy and early infancy
 Poor maternal weight gain
 Higher incidence of maternal hypocalcaemia, poor neonatal bone mineralization and fractures, and reduced longitudinal growth
 Increase risk of DM type 1, multiple sclerosis and bipolar disorder

 Diet
 Fortified food products
 Fish oils, egg yolks, mushrooms
 Animal products (fatty parts, liver)
 Vit D in diet: cholecalciferol or ergocalficerol

 Via skin synthesis under the influence of UV-B radiation

 Decrease amount of UV-B reaching the earth
 Season of the year
 time of the day
 pollution, clouds
 distance form equator

 Human factors
 Amount of skin exposure (cloth coverage, social and religious customs)
 Duration of exposure
 Sunscreens
 Degree of melanin concentration

 In young children
 Before children start to walk- decrease sun exposure
 Breast-fed – very little Vit D in breast milk
 Low dietary Calcium intake (ex. Consumption of polish rice)
 Genetic causes
 Malabsorption (repeated GI infections)
 Chronic renal, liver disease

 Results of the widening and splaying of the growth plates and resultant deformities of the metaphyses of the long bones
 Widening of wrist, knees and ankles
 Palpable and enlarged costochondral junctions (rickety rosary)
 Deformities of the long bones


 Craniotabes, head asymmetry, frontal bossing, delayed closing anterior fontanelle
 Delayed tooth eruption, abnormal formation enamel, cavities
 Rachitic rosary

 Late
 Pigeon chest irregularity, Harrison groove
 Classic limb abnormalities
 Genu varum, genu valgum
 Fraying, widening, cupping metaphysis long bones, fxs
 Lordosis, kyphosis, scoliosis
 Narrow pelvis: obstructed labor

 Hypotonia and myopathies resulting in delayed motor milestones (muscle weakness)
 Hypocalcemia manifestations like apneic attacks and convulsions in infants

 Clinically: presence of bony deformities
 Radiological examination of growth plates
 Biochemically
 hypocalcemia
 hypophosphatemia
 elevated alkaline phosphatase
 elevated PTH
 Confirmation of low 25(OH)D concentrations

 Vitamin D supplements (Oral Vitamin D2 or D3)
 5,000 to 15,000 IU/day for 4-8 weeks
 Single large dose when compliance problematic??
 Adequate UV radiation
 Vitamin D + Calcium supplementation (50mg/kg for several months)
 Calcium supplementation alone

 In US and Canada- fortification of all dairy milk formulas with Vit D (400
IU/quart)
 American Academy of Pediatrics recommends supplementation with
200 IU/day to all breast-fed and children not drinking at least 500ml of cow’s milk

 Large doses of Vitamin D supplementation every 3 months???
 Add ground fish bones to pourish????
 Education about sunlight and animal food ingestion

Stay tuned for more on micronutrient deficiencies next week… same channel, same time