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6 MICRONUTRIENT DEFICIENCY 73$.ppt

The document discusses common micronutrient deficiencies in children, focusing on vitamins A and D deficiencies. It defines micronutrients and explains that vitamins and minerals are essential for growth, health, and normal functioning. Children are particularly susceptible to micronutrient deficiencies which can impact growth and development. Specific details provided include clinical manifestations, causes, diagnosis, and treatment of vitamin A and D deficiencies. Vitamin A deficiency can cause night blindness and xerophthalmia, while vitamin D deficiency results in rickets, characterized by bone deformities and softening of bones.

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Birhanu G. Pediatrics and Child Health Resident COMMON MICRONUTRIENT DEFICIENCIES IN CHILDREN 4/23/2023 1
 Micronutrients include vitamins and minerals. Vitamins –organic compounds - growth ,health and reproduction Minerals – inorganic elements ,from earth’s crust - form 5% of typical human diet. - growth and normal functioning  important public health problems in a number of developing countries  30% of world’s population unable to use their full mental and physical potential as a result of micronutrient deficiencies  children are susceptible to micronutrient deficiency. CONT’D… 4/23/2023 2 Getnet A.
 A vitamin can have several functions & involved in fundamental functions in the body, such as growth, maintenance of health, and metabolism.  Based on their chemical properties, they are classified as either water-soluble or fat-soluble.  The water-soluble vitamins (except vitamin C) are members of the B complex.  Gross vitamin deficiency may be recognized by obvious clinical syndromes  Minerals: iron, Zinc ,copper, iodine ,selenium , manganese, chromium CONT’D… 4/23/2023 3 Getnet A.
4/23/2023 4 Getnet A.
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 Vitamin A is an essential micronutrient because it cannot be biogenerated de novo by animals.  Vitamin A (retinol) is fat soluble vitamin found widely in animal tissue  Retinol and its naturally occurring relatives are member of a large class known as retinoid  There are now over 1000 new retinoid VITAMIN A DEFICIENCY 4/23/2023 9 Getnet A.
 Vitamin A exists in two forms  Preformed vitamin A and  Provitamin A form  Vitamin A has role in:  Vision  Reproduction  Growth & embryonic & fetal development  Bone development  Respiratory, gastrointestinal, hematopoietic, and immune functions. CONT’D… 4/23/2023 10 Getnet A.
EPIDEMIOLOGY  Is a major public health problem in developing countries  More than 350,000 cases of childhood blindness are reported annually due to severe vitamin A deficiency  Improving Vit.A status reduce young child mortality by 25% diarrhea-specific mortality by 30%. 4/23/2023 11 Getnet A.
 Infants and young children under 5 year of age are at highest risk because  Poor stores at birth  Milk and supplementary food ( low vit.A)  Infection including diarrheal disease and  Growth sets requirement high  In Ethiopia it is a major public health problem  The prevalence bitot’s spots is 1% nationwide(1990)  In Harerge and Tigray – as high as 2% CONT’D… 4/23/2023 12 Getnet A.
4/23/2023 13 Getnet A.
SOURCES Source (per 100gm) vit.A(mic.gm)  Fish liver oil 145,000  Liver, ox 840  Butter, cow’s 730  Kidney, ox 300  Egg, hen 200  Chicken 85  Milk, whole cow’s 40  Milk, gout 25 4/23/2023 14 Getnet A.
PLANT SOURCE Source (per 100gm) vit.A(mic.gm)  Carrot, raw 1100  Mango 400  Lettuce 325  Sweet potato, raw 510  Avocado, raw 90  Tomatoes, raw 75  Papaya, raw 75 4/23/2023 15 Getnet A.
CAUSES  Inadequate consumption of vitamin A  Problem of absorption, like disorders associated with fat malabsorption  Problem in conversion or utilization of vitamin A  Repeated infections or diseases such as measles or diarrhea  Absence of food containing oil or fat in the diet 4/23/2023 16 Getnet A.
CLINICAL MANIFESTATION Eye  Functional retinal rod cell changes occur before structural lesion  Night blindness –failure of the eye to adapt to dim light  Epithelial changes lead to-  Conjunctival xerosis –earliest lesion  Bitot’s spots – foamy, bubbly, or cheesy accumulation, (triangular areas of abnormal squamous cell proliferation and keratinization of the conjunctiva) 4/23/2023 17 Getnet A.
4/23/2023 18 Getnet A. BITOT’S SPOT
 Xerosis of the cornea - haziness due to stromal infiltration, epithelial keratinization and often early vascularization  Corneal ulcer - followed by scar which is irreversible  Keratomalacia - implies deformity and loss of corneal substances leading to eye ball infection and corneal opacity CONT’D… 4/23/2023 19 Getnet A.
CONT’D… 4/23/2023 20 Getnet A.
CLASSIFICATION  Classification XN X1A X1B X2 X3A X3B XF XS  Primary sign  Night blindness  Conjunctival xerosis  Bitot’s spots  Corneal xerosis  Corneal ulceration  Keratomalacia  Xerophthalmia  Corneal scar 4/23/2023 21 Getnet A.
 Lesions due to vitamin A deficiency develop insidiously and rarely occur before 2 yr of age  An early symptom is delayed adaptation to the dark; later when vitamin A deficiency is more advanced, it leads to night blindness  Mental retardation  Retardation of physical growth  Apathy  Follicular hyperkeratosis of the skin  Susceptibility to infections  Anemia CONT’D… 4/23/2023 22 Getnet A.
DIAGNOSIS  Clinical  Laboratory test - Plasma vitamin A level – low ( normal 20 -50 microgram/dl) 4/23/2023 23 Getnet A.
THERAPY  Vitamin A capsule on two consecutive days immediately and another dose within 1-4 weeks Dose -200,000IU above one year -100,000IU 6 – 12 month -50,000IU less than 6 months 4/23/2023 24 Getnet A.
PREVENTION  Increase consumption of dark green leafy vegetables, Egg, livers, fat of fish and meat and cod liver oil can be provided  Vitamin A should be supplemented in malnutrition, diarrhea, measles and acute respiratory infection.  Distribution of vitamin A capsule should be given to the community.  One capsule every 6 months up to 6 year of age  One drop of vitamin A (25,000IU) for every child with immunization schedule 4/23/2023 25 Getnet A.
RICKETS OF VITAMIN D DEFICIENCY 4/23/2023 26 Getnet A.
RICKETS  Bone consists of a protein matrix called osteoid and a mineral phase, principally composed of calcium and phosphate, mostly in the form of hydroxyapatite.  Rickets refers to deficient mineralization at the growth plate, as well as architectural disruption of this structure.  Osteomalacia refers to impaired mineralization of the bone matrix. 4/23/2023 27 Getnet A.
 Rickets and osteomalacia usually occur together as long as the growth plates are open; only osteomalacia occurs after the growth plates have fused.  Because growth plate cartilage and osteoid continue to expand but mineralization is inadequate, the growth plate thickens.  There is also an increase in the circumference of the growth plate and the metaphysis increasing bone width at the location of the growth plates. CONT’D… 4/23/2023 28 Getnet A.
 Mineralization defects are classified according to the predominant mineral deficiency.  Calcipenic rickets is caused by calcium deficiency, which usually is due to insufficient intake or metabolism of vitamin D, and insufficient intake or absorption of calcium in the setting of normal vitamin D levels.  Phosphopenic rickets usually is caused by renal phosphate wasting. CONT’D… 4/23/2023 29 Getnet A.
PATHOGENESIS  Growth plate thickness is determined by two opposing processes:  chondrocyte proliferation and hypertrophy on the one hand, and  vascular invasion of the growth plate followed by conversion into primary bone spongiosa on the other .  Vascular invasion requires mineralization of the growth plate cartilage and is delayed or prevented by deficiency of calcium or phosphorus. 4/23/2023 30 Getnet A.
 In these circumstances, growth plate cartilage accumulates and the growth plate thickens.  In addition, the chondrocytes of the growth plate become disorganized, losing their columnar orientation with characteristic expansion of the hypertrophic zone. CONT’D… 4/23/2023 31 Getnet A.
CAUSES OF RICKETS 4/23/2023 32 Getnet A.
4/23/2023 33 Getnet A.
NUTRITIONAL VITAMIN D DEFICIENCY  Nutritional rickets – Calcipenic rickets is usually caused by dietary deficiency of vitamin D.  Occasionally, nutritional rickets is caused by deficiency of dietary calcium or a mixed deficiency of vitamin D and calcium.  Vitamin D deficiency remains the most common cause of rickets globally and is prevalent, even in industrialized countries. 4/23/2023 34 Getnet A.
 Vitamin D-deficiency rickets typically presents between 3 months and 3 years of age, when growth rates (and calcium needs) are high, and exposure to sunlight may be limited.  The recommended intake of vitamin D to prevent deficiency is 400 international units daily in healthy infants and 600 int. units daily for children 1 to 18 years. CONT’D… 4/23/2023 35 Getnet A.
 Risk factors  Maternal vitamin D deficiency  Breast feeding  Skin pigmentation & low sunlight exposure  Malabsorptive disorders  Anti-convulsant drugs CONT’D… 4/23/2023 36 Getnet A.
Vitamin D3  Naturally present in human skin as 7-dehydrocholestrole activated photochemically to cholecalciferol and transferred to the liver  In the liver by 25-hydroxylase to 25-OH cholecalciferol then  In the renal cortical cells by1,25 hydroxylase to 1,25 - OHcholecalciferol CONT’D… 4/23/2023 37 Getnet A.
VITAMIN D METABOLISM…. 4/23/2023 38 Getnet A.
Functions of 1,25-dehydroxycholecalciferol  Facilitates intestinal absorption of calcium and phosphorus  Reabsorption of phosphorus in the kidney  Control serum ca and P together with parathyroid hormone and cacitonin CONT’D… 4/23/2023 39 Getnet A.
CLINICAL MANIFESTATION  Craniotabes - softening of the cranial bones, can be detected by applying pressure at the occiput or over the parietal bones -earliest sign of rickets  Rachitic rosary -the beads of a rosary as the examiner's fingers move along the costochondral junctions  Growth plate widening is also responsible for the enlargement at the wrists and ankles  Harrison groove horizontal depression along the lower anterior chest 4/23/2023 40 Getnet A.
 Large anterior fontanell  Caput quadratum  Pigeon chest  Delayed eruption of temporary teeth  Bow leg or knock knee  Greenstick fracture  Rachitic dwarfism  Hypotonia  Sweating  Delayed tooth eruption CONT’D… 4/23/2023 41 Getnet A.
4/23/2023 42 Getnet A.
RACHITIC ROSARY IN A YOUNG INFANT 4/23/2023 43 Getnet A.
DEFORMITIES IN RICKETS SHOWING CURVATURE OF THE LIMBS, POTBELLY, AND HARRISON GROOVE 4/23/2023 44 Getnet A.
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LABORATORY FINDING  Serum Ca= normal or low  Serum Phosphorus= low  Serum alkaline phosphatase= increased  Serum 25-OH cholecalciferol decreased 4/23/2023 46 Getnet A.
Radiology  Generalized decrease in the skeletal radiodensity  Widening, capping and fraying at the end distal of the bones, best seen at the end of radius and ulna. CONT’D… 4/23/2023 47 Getnet A.
CONT’D… 4/23/2023 48 Getnet A.
DIFFERENTIAL DIAGNOSIS Craniotabes -hydrocephalus -osteogenesis imperfecta -immidiate post natal period Costochondral beading - scurvy - chondrodystrophy -PEM 4/23/2023 49 Getnet A.
TREATMENT  Vitamin D adminstration -Stoss dose of vit D 300,000-600,000 IU IM in 2-4 doses over one day or, Daily intake of 2000-5000IU of vit D for 4-6 wks -Both should be accompanied by adequate administration of Ca and P -After treatment continue with the daily requirement i.e 400IU of vit D daily 4/23/2023 50 Getnet A.
PREVENTION  Most cases of nutritional rickets can be prevented by universal administration of a daily multivitamin containing 400 IU of vitamin D to children who are breast-fed  Adequate sunlight exposure. 4/23/2023 51 Getnet A.
READING ASSIGNMENT  Rickets of Prematurity  Congenital rickets  Vitamin D–Dependent Rickets, Type 1  Vitamin D–Dependent Rickets, Type 2 4/23/2023 52 Getnet A.
 include thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, biotin, and pantothenic acid.  serve as coenzymes in many metabolic pathways that are functionally closely related VITAMIN B COMPLEX DEFICIENCIES 4/23/2023 53 Getnet A.
4/23/2023 54 Getnet A.
4/23/2023 55 Getnet A.
4/23/2023 56 Getnet A.
VITAMIN C DEFICIENCY Vitamin C  is a water-soluble micronutrient essential for human health  synthesized by plants and most animals , not by humans and other primates .  Vegetables and fruits, especially citrus, are the best food sources of vitamin C  Absorbtion (small intestine)  tissues ( pitutary ,adrenal )  Infants on cow milk or evaporated milk –need supplement 4/23/2023 57 Getnet A.
FUNCTIONS  Collagen formation  Dopamin  nor epinepherin  Cholestrol steroid  Important antioxidant  Enhances iron absorption ,transfer of iron from transferrin to ferritin , & formation of tetrahydrofolicacid affect the functions of the hematopoietic system (immune response, leukocytes, macrophages, red blood cells). 4/23/2023 58 Getnet A.
VIT. C DEFICIENCY  Very low intake of vitamin C  Scurvy  onset of clinical manifestations of scurvy is 6–24 mo  early symptoms - low-grade fever, irritability, tachypnea,  digestive disturbances, loss of appetite, and  generalized tenderness, particularly in the legs, which is noticeable when the diaper is changed.  Pseudoparalysis,( with the hips and knees semi-flexed and the feet rotated outward ) 4/23/2023 59 Getnet A.
An infant with scurvy characteristically lies with the legs flexed at the knees and the hips partially flexed and externally rotated 4/23/2023 60 Getnet A.
 A “rosary” and depression of the sternum  changes in the gums are manifested as bluish purple, spongy swellings of the mucous membrane, especially over the upper incisors .  Anemia - related to impaired ability to use iron or folate  swollen joints, purpura and ecchymoses, poor wound and fracture healing, petechiae, perifollicular hemorrhages , hyperkeratosis of hair follicles, arthralgia, and muscle weakness  osteoblasts cannot form osteoid  brittle bone that fracture easily  Severe vitamin C deficiency degeneration of skeletal muscles, cardiac hypertrophy, bone marrow depletion, and adrenal atrophy. CONT’D… 4/23/2023 61 Getnet A.
DIAGNOSIS  characteristic clinical picture, the radiographic appearance of the long bones, and a history of poor vitamin C intake.  distal ends of the long bones (knee)  Radiological changes – simple bone atrophy ,ground glass apperance ,thin cortex ,white line of fraenkel ,  Dx – zone of rarefaction under the white line at the metaphysis  Plasma and serum vitamin C  Scurvy is often misdiagnosed as arthritis 4/23/2023 62 Getnet A.
A, An early scurvy “white line” is visible on the ends of the shafts of the tibia and fibula; rings are shown around the epiphyses of the femur and tibia. B, More advanced scorbutic changes; zones of destruction (ZD) are evident in the femur and tibia 4/23/2023 63 Getnet A.
TREATMENT  Daily intake of 3–4 oz of orange or tomato juice produces healing in children with scurvy  Vitamin C supplements of 100–200 mg orally or parenterally  TOXICITY – limited data on children (1–3 yr, 400 mg; 4–8 yr, 650 mg; 9– 13 yr, 1200 mg, and 14–18 yr, 1800 mg. )  Daily intake of >2 g of vitamin C in adults is unsafe 4/23/2023 64 Getnet A.
ZINC DEFICIENCY  Zinc essentiality in humans was established in 1961.  Zinc deficiency is common in the developing world  often associated with malnutrition or other micronutrient deficiencies (iron).  Source -Organ and flesh of mammals, fish. -Eggs and dairy foods - Cereals and legumes contain a modest amount of Zn,but less absorbed -Fruits and vegetables are low in Zn. 4/23/2023 65 Getnet A.
 10 to 40 % is absorbed in the small bowel  The primary stores of zinc include the liver and kidney  Phytate ( cereals and legumes), irreversibly binds Zn in the intestinal  lower efficiency of absorption from plant foods  animal protein (e.g., beef, eggs, and cheese) improves the bioavailability of Zn from plant food . CONT’D… 4/23/2023 66 Getnet A.
 86 % of the total-body Zn is in skeletal muscle and bone  95% of body Zn is intracellular,  Zinc supplementation reduces the incidence and severity of diarrhea, pneumonia, and possibly malaria.  Children with diarrhea in developing countries have been treated with zinc (20 mg/day orally for 14 days), with improved morbidity and mortality rates.  Function  apoptosis regulation;  cell proliferation and growth  immune regulation. CONT’D… 4/23/2023 67 Getnet A.
DEFICIENCY Causes  inadequate intake, increased requirements, malabsorption, increased losses, or impaired utilization  True prevalence is unknown  characterized by skin lesions, reductions in growth, delayed puberty, hypogonadism, host defense defects and poor appetite  Chronic zinc deficiency is associated with dwarfism, hypogonadism, dermatitis, and T-cell immunodeficiency.  Repletion of a Zn deficiency appears to be rapid 4/23/2023 68 Getnet A.
ACRODERMATITIS ENTEROPATHICA ( ZINC MALABSORBTION) • is a rare autosomal recessive disorder caused by an inability to absorb sufficient zinc from the diet • is associated with severe zinc depletion • signs and symptoms in 1st few mo of life  cutaneous eruption ..vesiculobullous, eczematous, dry, scaly, or psoriasiform skin lesions symmetrically distributed in the perioral, acral, and perineal areas and on the cheeks, knees, and elbows 4/23/2023 69 Getnet A.
 Alopecia  Ocular manifestations include photophobia, conjunctivitis,  Associated chronic diarrhea, stomatitis, glossitis, nail dystrophy, growth retardation, irritability,  delayed wound healing, intercurrent bacterial infections, and superinfection with Candida albicans.  Impaired lymphocyte function CONT’D… 4/23/2023 70 Getnet A.
Acrodermatitis enteropathica in an infant. Moist erythematous plaques on the cheeks and buttocks. The buttock lesions are typically symmetrical 4/23/2023 71 Getnet A.
TREATMENT  Oral therapy with zinc compounds is the treatment of choice(50 mg-150mg /24hrs) . or  Replacement doses of 3 mg/kg/day of elemental zinc (13.2 mg/kg/day of zinc sulfate) are recommended.  zinc levels are measured every three to six months and the dose is adjusted up or down as needed. 4/23/2023 72 Getnet A.
4/23/2023 73 Getnet A.

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6 MICRONUTRIENT DEFICIENCY 73$.ppt

  • 1.
    Birhanu G. Pediatrics andChild Health Resident COMMON MICRONUTRIENT DEFICIENCIES IN CHILDREN 4/23/2023 1
  • 2.
     Micronutrients includevitamins and minerals. Vitamins –organic compounds - growth ,health and reproduction Minerals – inorganic elements ,from earth’s crust - form 5% of typical human diet. - growth and normal functioning  important public health problems in a number of developing countries  30% of world’s population unable to use their full mental and physical potential as a result of micronutrient deficiencies  children are susceptible to micronutrient deficiency. CONT’D… 4/23/2023 2 Getnet A.
  • 3.
     A vitamincan have several functions & involved in fundamental functions in the body, such as growth, maintenance of health, and metabolism.  Based on their chemical properties, they are classified as either water-soluble or fat-soluble.  The water-soluble vitamins (except vitamin C) are members of the B complex.  Gross vitamin deficiency may be recognized by obvious clinical syndromes  Minerals: iron, Zinc ,copper, iodine ,selenium , manganese, chromium CONT’D… 4/23/2023 3 Getnet A.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
     Vitamin Ais an essential micronutrient because it cannot be biogenerated de novo by animals.  Vitamin A (retinol) is fat soluble vitamin found widely in animal tissue  Retinol and its naturally occurring relatives are member of a large class known as retinoid  There are now over 1000 new retinoid VITAMIN A DEFICIENCY 4/23/2023 9 Getnet A.
  • 10.
     Vitamin Aexists in two forms  Preformed vitamin A and  Provitamin A form  Vitamin A has role in:  Vision  Reproduction  Growth & embryonic & fetal development  Bone development  Respiratory, gastrointestinal, hematopoietic, and immune functions. CONT’D… 4/23/2023 10 Getnet A.
  • 11.
    EPIDEMIOLOGY  Is amajor public health problem in developing countries  More than 350,000 cases of childhood blindness are reported annually due to severe vitamin A deficiency  Improving Vit.A status reduce young child mortality by 25% diarrhea-specific mortality by 30%. 4/23/2023 11 Getnet A.
  • 12.
     Infants andyoung children under 5 year of age are at highest risk because  Poor stores at birth  Milk and supplementary food ( low vit.A)  Infection including diarrheal disease and  Growth sets requirement high  In Ethiopia it is a major public health problem  The prevalence bitot’s spots is 1% nationwide(1990)  In Harerge and Tigray – as high as 2% CONT’D… 4/23/2023 12 Getnet A.
  • 13.
  • 14.
    SOURCES Source (per 100gm)vit.A(mic.gm)  Fish liver oil 145,000  Liver, ox 840  Butter, cow’s 730  Kidney, ox 300  Egg, hen 200  Chicken 85  Milk, whole cow’s 40  Milk, gout 25 4/23/2023 14 Getnet A.
  • 15.
    PLANT SOURCE Source (per100gm) vit.A(mic.gm)  Carrot, raw 1100  Mango 400  Lettuce 325  Sweet potato, raw 510  Avocado, raw 90  Tomatoes, raw 75  Papaya, raw 75 4/23/2023 15 Getnet A.
  • 16.
    CAUSES  Inadequate consumptionof vitamin A  Problem of absorption, like disorders associated with fat malabsorption  Problem in conversion or utilization of vitamin A  Repeated infections or diseases such as measles or diarrhea  Absence of food containing oil or fat in the diet 4/23/2023 16 Getnet A.
  • 17.
    CLINICAL MANIFESTATION Eye  Functionalretinal rod cell changes occur before structural lesion  Night blindness –failure of the eye to adapt to dim light  Epithelial changes lead to-  Conjunctival xerosis –earliest lesion  Bitot’s spots – foamy, bubbly, or cheesy accumulation, (triangular areas of abnormal squamous cell proliferation and keratinization of the conjunctiva) 4/23/2023 17 Getnet A.
  • 18.
  • 19.
     Xerosis ofthe cornea - haziness due to stromal infiltration, epithelial keratinization and often early vascularization  Corneal ulcer - followed by scar which is irreversible  Keratomalacia - implies deformity and loss of corneal substances leading to eye ball infection and corneal opacity CONT’D… 4/23/2023 19 Getnet A.
  • 20.
  • 21.
    CLASSIFICATION  Classification XN X1A X1B X2 X3A X3B XF XS  Primarysign  Night blindness  Conjunctival xerosis  Bitot’s spots  Corneal xerosis  Corneal ulceration  Keratomalacia  Xerophthalmia  Corneal scar 4/23/2023 21 Getnet A.
  • 22.
     Lesions dueto vitamin A deficiency develop insidiously and rarely occur before 2 yr of age  An early symptom is delayed adaptation to the dark; later when vitamin A deficiency is more advanced, it leads to night blindness  Mental retardation  Retardation of physical growth  Apathy  Follicular hyperkeratosis of the skin  Susceptibility to infections  Anemia CONT’D… 4/23/2023 22 Getnet A.
  • 23.
    DIAGNOSIS  Clinical  Laboratorytest - Plasma vitamin A level – low ( normal 20 -50 microgram/dl) 4/23/2023 23 Getnet A.
  • 24.
    THERAPY  Vitamin Acapsule on two consecutive days immediately and another dose within 1-4 weeks Dose -200,000IU above one year -100,000IU 6 – 12 month -50,000IU less than 6 months 4/23/2023 24 Getnet A.
  • 25.
    PREVENTION  Increase consumptionof dark green leafy vegetables, Egg, livers, fat of fish and meat and cod liver oil can be provided  Vitamin A should be supplemented in malnutrition, diarrhea, measles and acute respiratory infection.  Distribution of vitamin A capsule should be given to the community.  One capsule every 6 months up to 6 year of age  One drop of vitamin A (25,000IU) for every child with immunization schedule 4/23/2023 25 Getnet A.
  • 26.
    RICKETS OF VITAMIND DEFICIENCY 4/23/2023 26 Getnet A.
  • 27.
    RICKETS  Bone consistsof a protein matrix called osteoid and a mineral phase, principally composed of calcium and phosphate, mostly in the form of hydroxyapatite.  Rickets refers to deficient mineralization at the growth plate, as well as architectural disruption of this structure.  Osteomalacia refers to impaired mineralization of the bone matrix. 4/23/2023 27 Getnet A.
  • 28.
     Rickets andosteomalacia usually occur together as long as the growth plates are open; only osteomalacia occurs after the growth plates have fused.  Because growth plate cartilage and osteoid continue to expand but mineralization is inadequate, the growth plate thickens.  There is also an increase in the circumference of the growth plate and the metaphysis increasing bone width at the location of the growth plates. CONT’D… 4/23/2023 28 Getnet A.
  • 29.
     Mineralization defectsare classified according to the predominant mineral deficiency.  Calcipenic rickets is caused by calcium deficiency, which usually is due to insufficient intake or metabolism of vitamin D, and insufficient intake or absorption of calcium in the setting of normal vitamin D levels.  Phosphopenic rickets usually is caused by renal phosphate wasting. CONT’D… 4/23/2023 29 Getnet A.
  • 30.
    PATHOGENESIS  Growth platethickness is determined by two opposing processes:  chondrocyte proliferation and hypertrophy on the one hand, and  vascular invasion of the growth plate followed by conversion into primary bone spongiosa on the other .  Vascular invasion requires mineralization of the growth plate cartilage and is delayed or prevented by deficiency of calcium or phosphorus. 4/23/2023 30 Getnet A.
  • 31.
     In thesecircumstances, growth plate cartilage accumulates and the growth plate thickens.  In addition, the chondrocytes of the growth plate become disorganized, losing their columnar orientation with characteristic expansion of the hypertrophic zone. CONT’D… 4/23/2023 31 Getnet A.
  • 32.
  • 33.
  • 34.
    NUTRITIONAL VITAMIN DDEFICIENCY  Nutritional rickets – Calcipenic rickets is usually caused by dietary deficiency of vitamin D.  Occasionally, nutritional rickets is caused by deficiency of dietary calcium or a mixed deficiency of vitamin D and calcium.  Vitamin D deficiency remains the most common cause of rickets globally and is prevalent, even in industrialized countries. 4/23/2023 34 Getnet A.
  • 35.
     Vitamin D-deficiencyrickets typically presents between 3 months and 3 years of age, when growth rates (and calcium needs) are high, and exposure to sunlight may be limited.  The recommended intake of vitamin D to prevent deficiency is 400 international units daily in healthy infants and 600 int. units daily for children 1 to 18 years. CONT’D… 4/23/2023 35 Getnet A.
  • 36.
     Risk factors Maternal vitamin D deficiency  Breast feeding  Skin pigmentation & low sunlight exposure  Malabsorptive disorders  Anti-convulsant drugs CONT’D… 4/23/2023 36 Getnet A.
  • 37.
    Vitamin D3  Naturallypresent in human skin as 7-dehydrocholestrole activated photochemically to cholecalciferol and transferred to the liver  In the liver by 25-hydroxylase to 25-OH cholecalciferol then  In the renal cortical cells by1,25 hydroxylase to 1,25 - OHcholecalciferol CONT’D… 4/23/2023 37 Getnet A.
  • 38.
  • 39.
    Functions of 1,25-dehydroxycholecalciferol Facilitates intestinal absorption of calcium and phosphorus  Reabsorption of phosphorus in the kidney  Control serum ca and P together with parathyroid hormone and cacitonin CONT’D… 4/23/2023 39 Getnet A.
  • 40.
    CLINICAL MANIFESTATION  Craniotabes- softening of the cranial bones, can be detected by applying pressure at the occiput or over the parietal bones -earliest sign of rickets  Rachitic rosary -the beads of a rosary as the examiner's fingers move along the costochondral junctions  Growth plate widening is also responsible for the enlargement at the wrists and ankles  Harrison groove horizontal depression along the lower anterior chest 4/23/2023 40 Getnet A.
  • 41.
     Large anteriorfontanell  Caput quadratum  Pigeon chest  Delayed eruption of temporary teeth  Bow leg or knock knee  Greenstick fracture  Rachitic dwarfism  Hypotonia  Sweating  Delayed tooth eruption CONT’D… 4/23/2023 41 Getnet A.
  • 42.
  • 43.
    RACHITIC ROSARY INA YOUNG INFANT 4/23/2023 43 Getnet A.
  • 44.
    DEFORMITIES IN RICKETSSHOWING CURVATURE OF THE LIMBS, POTBELLY, AND HARRISON GROOVE 4/23/2023 44 Getnet A.
  • 45.
  • 46.
    LABORATORY FINDING  SerumCa= normal or low  Serum Phosphorus= low  Serum alkaline phosphatase= increased  Serum 25-OH cholecalciferol decreased 4/23/2023 46 Getnet A.
  • 47.
    Radiology  Generalized decreasein the skeletal radiodensity  Widening, capping and fraying at the end distal of the bones, best seen at the end of radius and ulna. CONT’D… 4/23/2023 47 Getnet A.
  • 48.
  • 49.
    DIFFERENTIAL DIAGNOSIS Craniotabes -hydrocephalus -osteogenesisimperfecta -immidiate post natal period Costochondral beading - scurvy - chondrodystrophy -PEM 4/23/2023 49 Getnet A.
  • 50.
    TREATMENT  Vitamin Dadminstration -Stoss dose of vit D 300,000-600,000 IU IM in 2-4 doses over one day or, Daily intake of 2000-5000IU of vit D for 4-6 wks -Both should be accompanied by adequate administration of Ca and P -After treatment continue with the daily requirement i.e 400IU of vit D daily 4/23/2023 50 Getnet A.
  • 51.
    PREVENTION  Most casesof nutritional rickets can be prevented by universal administration of a daily multivitamin containing 400 IU of vitamin D to children who are breast-fed  Adequate sunlight exposure. 4/23/2023 51 Getnet A.
  • 52.
    READING ASSIGNMENT  Ricketsof Prematurity  Congenital rickets  Vitamin D–Dependent Rickets, Type 1  Vitamin D–Dependent Rickets, Type 2 4/23/2023 52 Getnet A.
  • 53.
     include thiamine,riboflavin, niacin, vitamin B6, folate, vitamin B12, biotin, and pantothenic acid.  serve as coenzymes in many metabolic pathways that are functionally closely related VITAMIN B COMPLEX DEFICIENCIES 4/23/2023 53 Getnet A.
  • 54.
  • 55.
  • 56.
  • 57.
    VITAMIN C DEFICIENCY VitaminC  is a water-soluble micronutrient essential for human health  synthesized by plants and most animals , not by humans and other primates .  Vegetables and fruits, especially citrus, are the best food sources of vitamin C  Absorbtion (small intestine)  tissues ( pitutary ,adrenal )  Infants on cow milk or evaporated milk –need supplement 4/23/2023 57 Getnet A.
  • 58.
    FUNCTIONS  Collagen formation Dopamin  nor epinepherin  Cholestrol steroid  Important antioxidant  Enhances iron absorption ,transfer of iron from transferrin to ferritin , & formation of tetrahydrofolicacid affect the functions of the hematopoietic system (immune response, leukocytes, macrophages, red blood cells). 4/23/2023 58 Getnet A.
  • 59.
    VIT. C DEFICIENCY Very low intake of vitamin C  Scurvy  onset of clinical manifestations of scurvy is 6–24 mo  early symptoms - low-grade fever, irritability, tachypnea,  digestive disturbances, loss of appetite, and  generalized tenderness, particularly in the legs, which is noticeable when the diaper is changed.  Pseudoparalysis,( with the hips and knees semi-flexed and the feet rotated outward ) 4/23/2023 59 Getnet A.
  • 60.
    An infant withscurvy characteristically lies with the legs flexed at the knees and the hips partially flexed and externally rotated 4/23/2023 60 Getnet A.
  • 61.
     A “rosary”and depression of the sternum  changes in the gums are manifested as bluish purple, spongy swellings of the mucous membrane, especially over the upper incisors .  Anemia - related to impaired ability to use iron or folate  swollen joints, purpura and ecchymoses, poor wound and fracture healing, petechiae, perifollicular hemorrhages , hyperkeratosis of hair follicles, arthralgia, and muscle weakness  osteoblasts cannot form osteoid  brittle bone that fracture easily  Severe vitamin C deficiency degeneration of skeletal muscles, cardiac hypertrophy, bone marrow depletion, and adrenal atrophy. CONT’D… 4/23/2023 61 Getnet A.
  • 62.
    DIAGNOSIS  characteristic clinicalpicture, the radiographic appearance of the long bones, and a history of poor vitamin C intake.  distal ends of the long bones (knee)  Radiological changes – simple bone atrophy ,ground glass apperance ,thin cortex ,white line of fraenkel ,  Dx – zone of rarefaction under the white line at the metaphysis  Plasma and serum vitamin C  Scurvy is often misdiagnosed as arthritis 4/23/2023 62 Getnet A.
  • 63.
    A, An earlyscurvy “white line” is visible on the ends of the shafts of the tibia and fibula; rings are shown around the epiphyses of the femur and tibia. B, More advanced scorbutic changes; zones of destruction (ZD) are evident in the femur and tibia 4/23/2023 63 Getnet A.
  • 64.
    TREATMENT  Daily intakeof 3–4 oz of orange or tomato juice produces healing in children with scurvy  Vitamin C supplements of 100–200 mg orally or parenterally  TOXICITY – limited data on children (1–3 yr, 400 mg; 4–8 yr, 650 mg; 9– 13 yr, 1200 mg, and 14–18 yr, 1800 mg. )  Daily intake of >2 g of vitamin C in adults is unsafe 4/23/2023 64 Getnet A.
  • 65.
    ZINC DEFICIENCY  Zincessentiality in humans was established in 1961.  Zinc deficiency is common in the developing world  often associated with malnutrition or other micronutrient deficiencies (iron).  Source -Organ and flesh of mammals, fish. -Eggs and dairy foods - Cereals and legumes contain a modest amount of Zn,but less absorbed -Fruits and vegetables are low in Zn. 4/23/2023 65 Getnet A.
  • 66.
     10 to40 % is absorbed in the small bowel  The primary stores of zinc include the liver and kidney  Phytate ( cereals and legumes), irreversibly binds Zn in the intestinal  lower efficiency of absorption from plant foods  animal protein (e.g., beef, eggs, and cheese) improves the bioavailability of Zn from plant food . CONT’D… 4/23/2023 66 Getnet A.
  • 67.
     86 %of the total-body Zn is in skeletal muscle and bone  95% of body Zn is intracellular,  Zinc supplementation reduces the incidence and severity of diarrhea, pneumonia, and possibly malaria.  Children with diarrhea in developing countries have been treated with zinc (20 mg/day orally for 14 days), with improved morbidity and mortality rates.  Function  apoptosis regulation;  cell proliferation and growth  immune regulation. CONT’D… 4/23/2023 67 Getnet A.
  • 68.
    DEFICIENCY Causes  inadequate intake,increased requirements, malabsorption, increased losses, or impaired utilization  True prevalence is unknown  characterized by skin lesions, reductions in growth, delayed puberty, hypogonadism, host defense defects and poor appetite  Chronic zinc deficiency is associated with dwarfism, hypogonadism, dermatitis, and T-cell immunodeficiency.  Repletion of a Zn deficiency appears to be rapid 4/23/2023 68 Getnet A.
  • 69.
    ACRODERMATITIS ENTEROPATHICA (ZINC MALABSORBTION) • is a rare autosomal recessive disorder caused by an inability to absorb sufficient zinc from the diet • is associated with severe zinc depletion • signs and symptoms in 1st few mo of life  cutaneous eruption ..vesiculobullous, eczematous, dry, scaly, or psoriasiform skin lesions symmetrically distributed in the perioral, acral, and perineal areas and on the cheeks, knees, and elbows 4/23/2023 69 Getnet A.
  • 70.
     Alopecia  Ocularmanifestations include photophobia, conjunctivitis,  Associated chronic diarrhea, stomatitis, glossitis, nail dystrophy, growth retardation, irritability,  delayed wound healing, intercurrent bacterial infections, and superinfection with Candida albicans.  Impaired lymphocyte function CONT’D… 4/23/2023 70 Getnet A.
  • 71.
    Acrodermatitis enteropathica inan infant. Moist erythematous plaques on the cheeks and buttocks. The buttock lesions are typically symmetrical 4/23/2023 71 Getnet A.
  • 72.
    TREATMENT  Oral therapywith zinc compounds is the treatment of choice(50 mg-150mg /24hrs) . or  Replacement doses of 3 mg/kg/day of elemental zinc (13.2 mg/kg/day of zinc sulfate) are recommended.  zinc levels are measured every three to six months and the dose is adjusted up or down as needed. 4/23/2023 72 Getnet A.
  • 73.