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Dr Ranjith Kumar  Dr S.Balasubramanian  KKCTH
Background information : <ul><li>2 ½ month old female , Birth Wt:2.3kg ,Breast fed upto 2mon  </li></ul><ul><li>Refractory...
<ul><li>Developmental delay  in the form  </li></ul><ul><ul><ul><li>Not able to sit with support </li></ul></ul></ul><ul><...
 
25/ 27/05/10
Diagnostic dilemma?: <ul><li>Are  we dealing with </li></ul><ul><ul><ul><li>Vitamin D deficient Rickets </li></ul></ul></u...
Investigations USG abdomen :Mild Hepatosplenomegaly Renal system normal RFT: normal Phenobarbitone level: 23mcg/dl  (15-30...
Management: <ul><li>Vitamin D 6 lacks IM followed by oral  Vitamin D 0.25mcg twice daily for 4wks </li></ul><ul><li>Follow...
<ul><li>Zone of provisional calcification </li></ul><ul><li>Completely healed Rickets  </li></ul>20/7/10 12/8/10
Reasons for Rickets  <ul><li>Anticonvulsant therapy </li></ul><ul><li>No  routine vitamin D supplementation  </li></ul><ul...
Why this presentation <ul><li>Though research results vary, long-term use of anticonvulsant drugs appears to interfere wit...
*children, muscle involvement due to vitamin D deficiency was reported in a 5-year-old child with cholestatic liver diseas...
 
POLICY   STATEMENT PEDIATRICS Vol. 101 No. 1 January 1998, pp. 148-153 AMERICAN ACADEMY OF PEDIATRICS: Soy Protein-based F...
Take home massage  <ul><li>Routine Vitamin D supplementation  is essential  </li></ul><ul><li>Vitamin D supplementation sh...
T THANK YOU A day will come  From A to D
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Micronutrient deficiency2003

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Micronutrient deficiency2003

  1. 1. Dr Ranjith Kumar Dr S.Balasubramanian KKCTH
  2. 2. Background information : <ul><li>2 ½ month old female , Birth Wt:2.3kg ,Breast fed upto 2mon </li></ul><ul><li>Refractory seizures  Intracranial Hemorrhage  Diagnosed to have Late Hemorrhagic disease of newborn  discharged on AED(Phenobarbitone, Phenytoin & Levitarcetem) </li></ul><ul><li>Followed up by Neurologist </li></ul><ul><li>At 6month had another episodes of seizure + incidental found to have Anemia (4gm/dl)  Transfused PRBC  Ref. to  Hematologist (BMA + P.S ) = probable nutritional anemia advised Iron + folic acid supplementation </li></ul><ul><li>Also had diarrhea hence Soya based formula advised from 6 month </li></ul>
  3. 3. <ul><li>Developmental delay in the form </li></ul><ul><ul><ul><li>Not able to sit with support </li></ul></ul></ul><ul><ul><ul><li>Momentary head control was + </li></ul></ul></ul><ul><ul><ul><li>More of motor developmental delay </li></ul></ul></ul><ul><li>on examination : </li></ul><ul><ul><li>Fairly nourished </li></ul></ul><ul><ul><li>Hypotonic </li></ul></ul><ul><ul><li>Wide open AF </li></ul></ul><ul><ul><li>Hot cross bun skull </li></ul></ul><ul><ul><li>Widened wrist </li></ul></ul><ul><ul><li>Prominence of costochondral junction </li></ul></ul><ul><ul><li>Protuberant abdomen with Hepato-spleenomegaly </li></ul></ul>At 7months of age infant brought to us
  4. 5. 25/ 27/05/10
  5. 6. Diagnostic dilemma?: <ul><li>Are we dealing with </li></ul><ul><ul><ul><li>Vitamin D deficient Rickets </li></ul></ul></ul><ul><ul><ul><li>Vitamin Resistant Rickets </li></ul></ul></ul>
  6. 7. Investigations USG abdomen :Mild Hepatosplenomegaly Renal system normal RFT: normal Phenobarbitone level: 23mcg/dl (15-30) Phenytoin level: 20mcg/dl (10-20) Tot Ca. (Mg/dl) Po4- SAP PTH Vit D (25OH Vit D) 1,25 D OH vit D 27/04/10 11.9 3 7480 18/5/10 8.8 2.8 3000 38 76 3/7/10 10.6 7.7 1761 -- -- -- 2/8/10 12 6.5 926
  7. 8. Management: <ul><li>Vitamin D 6 lacks IM followed by oral Vitamin D 0.25mcg twice daily for 4wks </li></ul><ul><li>Followed with Ca, Po4-,SAP & X ray </li></ul><ul><li>Infant showed improvement in both clinically and laboratory wise </li></ul><ul><li>Now :(9months) </li></ul><ul><ul><li>Able to stand ,walk without support </li></ul></ul><ul><ul><li>No further seizures off antiepileptic drugs </li></ul></ul>
  8. 9. <ul><li>Zone of provisional calcification </li></ul><ul><li>Completely healed Rickets </li></ul>20/7/10 12/8/10
  9. 10. Reasons for Rickets <ul><li>Anticonvulsant therapy </li></ul><ul><li>No routine vitamin D supplementation </li></ul><ul><li>Soya milk </li></ul><ul><li>Poor sunlight exposer </li></ul><ul><li>To our knowledge thaere was no case report of rickets due to anticonvulsant therapy </li></ul>
  10. 11. Why this presentation <ul><li>Though research results vary, long-term use of anticonvulsant drugs appears to interfere with vitamin D activity, which might lead to softening of bones (osteomalacia) </li></ul><ul><li>*In a controlled study , bone strength improved in children taking anticonvulsant drugs who were supplemented with the activated form of vitamin D and 500 mg per day of calcium for nine months. </li></ul><ul><li>#people taking anticonvulsant drugs who do not receive adequate sunlight should supplement with 400 IU of vitamin D each day to help prevent Rickets </li></ul><ul><li>* Telci A, Cakatay U, Kurt BB, et al. Changes in bone turnover and deoxypyridinoline levels in epileptic patients Clin Chem Lab Med 2000 38:47–50. </li></ul><ul><li># Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Effect of vitamin D and calcium on bone mineral density in children with CP and epilepsy in full-time care. Dev Med Child Neurol 2000;42:403–5 . </li></ul>
  11. 12. *children, muscle involvement due to vitamin D deficiency was reported in a 5-year-old child with cholestatic liver disease * 11-yearold girl with celiac disease
  12. 14. POLICY STATEMENT PEDIATRICS Vol. 101 No. 1 January 1998, pp. 148-153 AMERICAN ACADEMY OF PEDIATRICS: Soy Protein-based Formulas: Recommendations for Use in Infant Feeding <ul><li>In 1996, the American Academy of Pediatrics issued a statement on aluminum toxicity in infants and children and discussed the relatively high content of aluminum in soy-based formulas .Although the aluminum content of human milk is 4 to 65 ng/mL, that of soy protein-based formula is 600 to 1300 ng/mL. The source of the aluminum is the mineral salts used in formula production. </li></ul><ul><li>Because aluminum competes with calcium for absorption, increased amounts of dietary aluminum from isolated soy protein-based formula may contribute to the reduced skeletal mineralization (osteopenia) observed in preterm infants and infants with intrauterine growth retardation </li></ul>
  13. 15. Take home massage <ul><li>Routine Vitamin D supplementation is essential </li></ul><ul><li>Vitamin D supplementation should be recommended in children on anticonvulsant therapy </li></ul><ul><li>Children on Soya based formula should be supplemented with Vitamin D </li></ul>
  14. 16. T THANK YOU A day will come From A to D

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