micronutrients Vitamin deficiency

1. Overview of micronutrient
deficiency disorders and
clinical signs
By: Darayus P.Gazder

2.  All micronutrients are important for:
1) Growth,
2) Health,
3) Development.

3. BACKGROUND
Vitamins are organic substances that
are essential for several enzymatic
functions in human metabolism
A compound is called vitamin when it
cannot be synthesized in sufficient
quantities by an organism, and must be
obtained from the diet.

4. Functions
 Acts as hormones (vitamin D)
Acts as antioxidant (vitamin E)
 Acts as mediators of cell signalling
and regulators of cell and tissue
growth and differentiation(vitamin
A)
Acts as precusors for enzyme
cofactor biomolecules(coenzymes)
that help act as catalysts and
substrates in metabolism

5. VITAMINS
 Vitamins are classified according
to solubility into fat soluble & water
soluble.
 13 vitamins are known, 4 fat
soluble (KEDA) & 9 water soluble
(C, Folate & the B group).

6. VITAMINS
 Water soluble-dissolve easily in
water readily excreted from the body.
 Fat soluble-absorbed through the
intestinal tract with the help of
lipids(fats).

8. VITAMIN A-Vitamin A is a
generic term for many related
compounds.
Retinol (alcohol), Retinal (aldehyde)
are often called preformed vitamin A.
Retinal can be converted
by the body to retinoic
acid which is known to
affect gene transcription.
Body can convert b-carotene
to retinol, thus called provitamin A.

9. FUNCTIONS
•Immunity: important for activation of T
lymphocyte, maturation of WBC & integrity
of physiological barrier.
•Vision: integrity of eye & formation of
rodopsin necessary for dark adaptation.
•Red blood cell production
•Regulation of gene expression: vital to
cell differentiation & physiologic processes
• Growth & development

10. Animal Foods Plant Foods
Cod liver oil Sweet potato
Liver & kidney Carrots
Egg Spinach
Butter
Milk & cheese
RICH DIETARY SOURCES

11. Vitamin A deficiency
•Deficiency of vitamin A leads to:
1. Ocular change- Night blindness &
xerophthalmia
2. Extra ocular changes
Growth retardation
Acquired immune deficiency
Anemia

12. WHO CLASSIFICATION OF
XEROPTHALMIA
PRIMARY SIGNS SECONDARY SIGNS
 X1A: Conjunctival
xerosis
 X1B: Bitot’s spot
 X2: Corneal xerosis
 X3A: Corneal ulceration
 X3 B: Keratomalacia
 XN: Night blindness
 XF: Fundal changes
 XS: Corneal scarring

13. Xeropthalmia
Bitots spots (X1B) are foamy white areas on the white of the eye.
Corneal Xerosis(X2) Keratomalacia (X3)

15. INVESTIGATIONS:
Clinical evaluation(Skin, Eyes, Growth)
Serum retinol <20 mcg/dL;
Molar ratio of retinol:RBP(Retinol
binding protein) <0.7 is also diagnostic

16. Treatment
• Overall mortality is reduced by 23%
• Death from measles is reduced by 50%
• Death from diarrhea is reduced by 40%

17. TOXICITY- Children and adults ingesting
>50,000 IU/day for several month.
•Vitamin A in excess leads to:
•Dermatitis with xanthosis cutis
•Hepatosplenomegaly
•Fatigue, malaise, anorexia, vomiting
•Bone pain & increased risk of fracture
•Pseudotumor Cerebri
•Xray-hyperostosis of the shafts of long
bones

18. VITAMIN D
 Vitamin D comprises a group of sterols; the
most important of which are cholecalciferol
(vitamin D3) & ergosterol (vitamin D2).
 Humans & animal utilize only vitamin D3 &
they can produce it inside their bodies from
cholesterol.
 Cholesterol is converted to 7-dehydro-
cholesterol (7DC), which is a precursor of
vitamin D3.

20. FUNCTIONS
•Calcium metabolism: vitamin D enhances
Calcium absorption in the gut & renal
tubules.
•Cell differentiation: particularly of
collagen & skin epithelium
•Immunity: important for Cell Mediated
Immunity & coordination of the immune
response.

21. Sources of Vitamin D
Sunlight is the most important
source
 Fish liver oil
 Fish & sea food (herring & salmon)
 Eggs
 Plants do not contain vitamin D3
Human milk deficient in vit. D,
contains only 30-40 IU per liter mostly
from 25(OH)D3

22. Vitamin D deficiency
•Deficiency of vitamin D leads to:
 Rickets in small children.
 Osteomalacia

23. RICKETS
Lack of adequate mineralisation of growing bone
CLINICAL FEATURES

24. RICKETS
Sign and symptoms-
•Skeletal deformity-bowed legs(genu varum) in toddlers,
knock knees (genu valgum) in older children,
craniotabes (soft skull), spinal and pelvic deformities,
growth disturbances, costochondral swelling(rickety
rosary), harrisons groove, greenstick fractures, bone
pain and tenderness, muscle weakness and dental
problems.

25. INVESTIGATIONS
Radiologic changes-loss of normal zone of provisional
calcification adjacent to metaphysis.
Widening of the growth plate.
Splaying and cupping of metaphysis.
Generalized reduction in bone density.
Low circulating levels of 25(OH)D3.
Elevated serum alkaline phosphate.
Calcium level may be normal or low
Phosphate level usually are unchanged or low.

26. Metaphyseal
cupping and
fraying in the
distal radius
and ulna in
rickets

27. TREATMENT
 AAP: 400IU/day for all breastfed infants, beginning in
1st 2months of life and continue until infant is receiving
>500ml/day of vitamin of formula or vitamin D fortified
milk
 Rickets: 1600-5000IU of VitD3 per day
 Stross therapy:

29. TOXICITY
•Hypervitaminosis D – infants-2,000-3,000 IU/day,
adults-10,000 IU/day for several months.
causes hypercalcemia,hyperphosphatemia,
hypertension which manifest as:
Nausea & vomiting
Excessive thirst & polyuria
Severe itching
Joint & muscle pains
Azotemia, nephrolithiasis, ectopic calcification.
Disorientation & coma.

30. Vitamin K
 It is a cofactor of the enzyme that catalyzes one
step in the formation of prothrombin.
 Needed for the generation of several clotting
factors in the liver.
 Source- green leafy vegetables.
 Deficiency-coagulation defect due to
hypoprothrombinemia and deficiency of factor VII
resulting in hemorrhagic disease of the newborn.
 1mg IM –newborn.
 In severe deficiency-2.5 to 5 mg/day parenterally.

31. Vitamin C - Ascorbic Acid
 Humans are among the few species that
cannot synthesize vitamin C and must obtain
it from food
 Manufacture of collagen
 Helps support and protect blood vessels,
bones, joints, organs and muscles
 Protective barrier against infection and
disease
 Promotes healing of wounds, fractures and
bruises
 Sources
 Citrus fruits, strawberries, kiwifruit,
blackcurrants, papaya, and vegetables

32. Scurvy – Signs & Symptoms
 Small blood vessels fragile
 Gums reddened and bleed easily
 Teeth loose
 Joint pains
 Scorbutic rosary: Costochondral junction is more angular
and has a sharper step-off
 Dry scaly skin
 Lower wound-healing, increased susceptibility to
infections, and defects in bone development in
children
 Legs assume a “frog like position”(Hips and knees
are semiflexed with the feet rotated outwards)

33. Diagnosis
 History+Clinical Features
 Xray appearance of long bones:
1. Ground glass appearance of bones
2. Cortex is reduced to “Pencil Point” thinness
3. There is white line of Fraenkel (An irregular but
thickened white line at metaphysis representing
the zone of well calcified cartilage
 Low levels of Vitamin C

34. Treatment
 Prevented by a diet of Vitamin C
 Daily therapeutic dose of Vitamin C is 100-200mg
or more.
 Daily requirement is 45-60mg/day in children

35. Thiamin – Vitamin B1
 What it does in the body
 energy production and carbohydrate and fatty
acid metabolism
 vital for normal development, growth,
reproduction, healthy skin and hair, blood
production and immune function
 Deficiency due to diets of polished rice

36. Beri Beri- Signs & Symptoms
 Develop within 12 weeks
 Dry Beriberi  peripheral neuropathy
 Difficulty walking and paralysis of the legs
 Reduced knee jerk and other tendon reflexes, foot
and wrist drop
 Progressive, severe weakness and wasting of
muscles
 Wet Beriberi  cardiopathy
 Edema of legs, trunk and face
 Congestive heart failure (cause of death)

37. Wrist & foot drop:
Dry Beri Beri
Edema:
Wet Beri Beri

38. Riboflavin Deficiency
 Deficiency is rare and often occurs with other
B vitamin deficiencies
 Several months for symptoms to occur
 Burning, itching of eyes
 Angular stomatitis
 Cheilosis
 Swelling and shallow ulcerations of lips
 Glossitis

39. Riboflavin deficiency
Angular stomatitis Glossitis

40. Niacin – Vitamin B3
 Essential for healthy skin, tongue, digestive
tract tissues, and RBC formation
 Processing of grains removes most of their
niacin content so flour is enriched with the
vitamin

41. Pellagra – Signs & Symptoms
 ‘Three Ds’: diarrhea, dermatitis and dementia
 Reddish skin rash on the face, hands and
feet which becomes rough and dark when
exposed to sunlight (pellagrous dermatosis)
 acute: red, swollen with itching, cracking,
burning, and exudate
 chronic: dry, rough, thickened and scaly with
brown pigmentation
 dementia, tremors, irritability, anxiety,
confusion and depression

42. Pellagra Dermatitis

43. Anemia
 Iron deficiency is the most common cause of anemia and
most common preventable nutritional deficiency.

44. Causes:
Nutritional
 Mother anemic
 Increased Fe
demands:(Preterm,IUGR,
Cyanotic heart disease)
 Prolonged breastfeeding,
cow milk
 Malabsorption
 Poor weaning
Blood Loss
1. Neonates:
 Fetomaternal transfusions
 Twin to twin transfusions
 Bleeding from umblical cord
 Hemorrhagic disease of
Newborn
2. Children:
 Hookworm infestation
 Rectal polys
 IBD

45. Anemia- Signs & Symptoms
 Symptoms
 Tiredness/ Fatigue/ Headache/Breathlessness
 Signs
 Pallor: Pale conjunctivae, palms, tongue, lips, skin,
Spoon shaped nails.
 Tachycardia, Systolic murmur
 If Hb<3, check for
signs of CHF

46. Investigations:
 CBC: 1) Hemoglobin <11.0 g/dL
 MVC/ MCH/ MCHC are all decreased
 Reticulocyte count: Normal or minimally elevated
 Peripheral blood smear:
Microcytic hypochromic anemia
 Serum Fe levels: Decreased
 TIBC: Increased
 Serum ferritin levels: Decreased

47. Normal Blood Film

48. MICROCYTES

49. HYPOCHROMIA

50. Anemia- Treatment
 Dietary counseling: Infants fortified milk formula less than 1yr
of age
 Dietary diversification
 Foods that are rich in iron include:
 Meat/ Fortified cereals/ Spinach/Lentils and beans
 Iron supplements
 Mild to moderate anemia: 3-6mg/kg/day of iron (3-5 months)
 Severe anemia and cardiac decompensation: Start blood
transfusions, packed RBC’s: (2-3ml/kg)

51. Zinc Deficiency
 Zinc essential for the function of many enzymes
and metabolic processes
 Zinc deficiency is common in developing countries
with high mortality
 Zinc commonly the most deficient nutrient in
complementary food mixtures fed to infants during
weaning
 Zinc interventions are among those proposed to
help reduce child deaths globally by 63% (Lancet,
2003)

52. Zinc Deficiency- Signs & Symptoms
 Skin lesions
 Immune impairment
 Diarrhea
 Poor growth
 Acrodermatitis enteropathica:
 AR disorder (defect of Zn absorption)
 Begins within 2-4 weeks of
weaning
 Perioral/ Perianal dermatitis/
Failure to thrive

53. Zinc Deficiency- Assessment
 No simple, quantitative biochemical test of zinc status
 Serum Zinc
• Can fluctuate as much as 20% in 24-hour period
• Levels decreased during acute infections
• Expensive
 Hair zinc analysis

54. Zinc Deficiency- Treatment
 Regular zinc supplements can greatly reduce common
infant morbidities in developing countries
• Adjunct treatment of diarrhea
-10 mg/day for infants below 6 months,
-20mg/day of zinc for 10-14 days(>6months)
Zinc deficiency commonly coexists with other
micronutrient deficiencies including iron, making
single supplements inappropriate
Emperical trial of Zinc supplementation(1ug/kg/day)
is safe and reasonable