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