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Micronutrient Deficiencies Cases

Micronutrient Deficiencies Cases. Global Health Fellowship St Luke’s/Roosevelt Hospital. Case 1. 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 PE

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Micronutrient Deficiencies Cases

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  1. Micronutrient DeficienciesCases Global Health Fellowship St Luke’s/Roosevelt Hospital

  2. Case 1 • 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 • PE • Ht & Wt are below 5th % • Rest of examination normal • Except for eye exam

  3. Diagnosis? Vitamin A deficiency • Stunted • Retinal is essential for growth & functional integrity of epithelial cells (eye, respiratory, urinary & intestinal tract) • Nyctalopia or night blindness • Due to delay in resynthesis of rhodopsin • Retinal (component of retinal pigments) is important for normal vision • Bitot Spots • Small triangular/oval, silvery, foamlike patches that appear on the conjunctiva due to keratinization

  4. Vitamin A Deficiency • 1st clinical signs • Drying of the conjunctiva • Bitot spots • Xerophtalmia (drying of the cornea) • Nyctalopia or Night blindness • Keratomalacia • Breakdown of cornea • Permanent blindness

  5. Vitamin A Deficiency • PEM • Blindness • Other complicating Nutritional deficiencies • Subclinical Vit A deficiency • 70-80 M children worldwide (including USA) • ↓physical growth • ↑susceptibility to infection • ↓ survival from serious illness • ↑ rates M&M common infectious diseases (resp, GI) • Measles

  6. Vit A Deficiency Prevention • WHO, UNICEF, AAP • Community wide administration of Vit A • WHO recommended: beneficial effects on immunity • ↓ U5MR by 25% • Replacement : q4-6 mos • Infants 50K IU PO • Infants 6-12mo: 100K IU PO • Mothers: 200K IU PO w/in 8 wks delivery • Pregnant /women of reproductive age: 10K IU/d or 25K IU wk

  7. Vit A Deficiency Prevention • Food fortification • Oily/dry forms • Margarine, oil • Sugar • Cereal flours, milk (powder & liquid) • Dietary diversification • Vit A rich foods • Plant & animal • Global Initiative • GAVA • Helen Keller International • CIDA & Micronutrient Initiative • WHO, UNICEF, USAID, World Bank • Vitamin Angels, Operation 20/20

  8. Vit A Deficiency Treatment • Hi dose supplementation • Children 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 Xerophthalmia • 3 doses at age specific doses • 1st immediately on diagnosis, 2nd the next day, 3rd dose 2 weeks later

  9. Case 2 • 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 • PE • Ht & Wt < 5th % • Bowing of legs • Not yet walking, no teeth yet • Rachitic rosary

  10. X rays *Wrists: osteopenia, cupping & fraying of metaphysis *LE: bowing *Rib flaring: enlargement costo chondral junctions

  11. Labs • ↓phosphosrus, calcium • ↑ alkaline phosphatase

  12. Case 3 • 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

  13. More History

  14. X ray & labs • Osteomalacia • Pseudo or real fractures • ↓Phosphorus, calcium • ↑Alkaline phosphatase • ↓Ca urinary excretion

  15. Rickets: Vit D, Calcium Deficiency #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

  16. Vit D / Calcium Deficiency Clinical Presentation • Early • Craniotabes, head asymmetry, frontal bossing, delayed closing ant fontanelle • Delayed tooth eruption, abnormal formation enamel, cavities • Rachitic rosary

  17. Vit D/ Calcium Deficiency • Late • Pigeon chest irregularity, Harrison groove • Motor delays, hypotonia (muscle weakness) • Classic limb abnormalities • Genu varum, genu valgum, windswept deformities • Fraying, widening, cupping metaphysis long bones, fractures • Lordosis, kyphosis, scoliosis • Narrow pelvis: obstructed labor

  18. Vit D, Calcium Deficiencies Clinical Presentations • In Adults • Cardiovascular disease • Insulin resistance • HTA • Muscles • Delayed motor development • Tetany, carpopedal & laryngeal spasm • Convulsions • Pneumonia • 2ary defective immune function • Thorax deformity (restrictive airway) • Cor pulmonale

  19. Diagnosis Rickets • 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

  20. Prevention • Community Health Education • Need for sunlight & animal foods (eggs) • Fish oil for children at risk: premies/infants/patients

  21. Rickets Prevention 1ary, 2ary, 3ary • Vit D intake Recommendations • Infants: 400-1K IU/d, 1-18 ys: 600- 1K IU/d, > 18y: 1.5-2K IU/d • Pregnant/lactating: 1/5-2K IU/d • Obesity : ↑by 2-3x age recommendations • Food fortification with Vit D • Infant formula, (400 IU/L) cow’s milk, • Cereals

  22. Prevention Rickets • Vit D supplementation • Breast fed infants, Toddlers (picky eaters) • High risk groups: northern climates, AA, full dress, indoor life • Pts with ↓absorption w/ gastrectomy, celiac disease, malabsorption, extensive bowel surgery, IBD, CF • Vegan/vegetarian, macrobiotic diets • Dietary Calcium intake • Sufficient intake , even in sunny environments (1,000mg/d)

  23. Rickets: Treatment • Sunlight or ultraviolet light • Vit 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 supplements • Ca intake maintained at 1 K mg/d (avoid hungry bone syndrome) • 30-75mg/kg elemental Ca/d (milk or Ca lactate TID)

  24. Rickets Treatment • Tetany • IV Ca Gluconate 10% solution ( 5-10ml) • PO Ca Chloride 1g q 6 h ( in milk) • Ca supplements • Ca intake maintained at 1,000 mg/d (avoid hungry bone syndrome) • 30-75mg/kg elemental Ca/d (milk or Ca lactate TID)

  25. Prognosis • Healing • 6 -12wks Vit D treatment biochemical changes reverses • ↑urinary Ca excretion • Bones heal more slowly ( treatment x 3 mos) • Treat till Xray evidence of healing observed • May require longer treatments • May never become normal

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