Vitamin A and its deficiency............

..................................................................................Vitamin A and its deficiency in children. Vitamin A deficiency is the most common preventable cause of blindness in the world. ..............................................................................

1. Vitamin A

2. Can you see any abnormality?

3. Introduction Vitamin A helps in development of visual function of the eye as well as building up immunity in the body. Deficiency can cause Night blindness, which may further progress to Bitot's spot. If untreated can lead to permanent blindness. Clinical prevalence of Vitamin A deficiency is less than 1% in India but biochemical prevalence in quite high. Prevalence of Bitot’s spot is around 0.6 – 0.7% in children .

4. Recommended Daily Allowance of Vitamin A :   Infants 300- 400 mcg Children 400-600 mcg Adolescents 750 mcg Pregnant women 800 mcg

5. Dieatary Sources Fish liver oils,liver,dairy products,egg yolk …. Liver is the richest dietary source breastmilk fulfils the need of VitA entirely for the first 6 months of life.

6. Role in health and Diseases Vision Resiatance to infections Epithelial cell integrity Aging and other skin conditions Growth and development Antineoplastic activity

7. CaUSES Vit A is not synthesized in the body . Needs to be supplied by external source. Decreased intake, defective absorption, altered metabolism and increased requirement Risk Groups Vegetarians Preterms Infections (RTI, ADD) Chronic diarrhea , malabsorption syndromes, Chronic liver disease

8. CLINICAL FEATURES Ocular features Impairment of dark adaptation and night blindness Xerosis of conjunctiva is the first sign to be seen on examination. Bitot’s spots Corneal xerosis Keratomalacia

9. WHO Classification for Xerophthalmia Classification Primary Signs X1A Conjunctival xerosis X1B Bitots spot X2 Corneal xerosis X3A Corneal ulceration X3B Secondary signs XN Night blindness XF Fundal changes XS Corneal scarring

10. Extra Ocular features Dry, scaly skin called Toad skin or phrynoderma. Increased suspectibility to infections due to squamous metaplasia of respiratory, urinary and vaginal tract epithelium. Renal and vesical calculus

11. DIAGNOSIS   Presence of clinical signs and symptom Serum retinol level below 20 mcg/dl Conjuctival impression cytology: early losses of vitamin A-dependent mucus secreting goblet cells and early metaplasia of epithelium

12. MANAGEMENT < 6 months- 50,000 IU per orally 6-12 months- 1,00,000 IU per orally >1 year- 2,00,000 IU per orally The age appropriate dose is given at the time of presentation , the following day and 4 weeks later.   The parental dose is one-half of the oral dose.   The water soluble formulation should be used for treatment of deficiency state.

13. Topical Therapy Antibiotic drops/Ointment Padding the eye Mydriatics like atropine

14. PROPHYLAXIS PROGRAMM AND RECOMMONDATIONS PROPHYLACTIC Vit A to Healthy Children 1 lakh units of Vit A along with measles at 9months and 2lakh units every 6 monthly till 5yrs of age. PROPHYLACTIC Vit A to Sick Children Measles <1yr – 1 lakh units on two consecutive days >1yr – 2 lakh units on two consecutive days

15. SAM (2 nd dose only if the condition worsens) <1yr – 1 lakh units >1yr – 2 lakh units

16. Tools for screening: Under RBSK programme, deficiency of Vitamin A would be identified by Looking for Bitot’s spot and Some specific questions related to the disease.

17. Signs and symptoms LOOK - For Bitot’s spot in the eyes (examine both eyes) ASK – Is the child able to see clearly in less light or during darkness? Only if child is more than 2 years of age

18. PERFORM – Use a torch to examine the eye. Check if the white part of the eye irregular in shape? Are there any triangular shaped white foamy lesions? Does the eye appear dry?

19. Action Refer the child if there is A visible Bitot’s spot or Child gives a history of reduced vision especially during evening. If available, administer 2 lakh IU to a child with Bitot’s spot and a similar dose after 1 to 4 weeks later.

20. Counseling Regular Vitamin A supplementation is required for all children 1 lakh international units at the age of 9 months, thereafter 2 lakh IU at an interval of six months till the child reaches 5 years of age. A child with Vitamin A deficiency may lead to reduced vision (night blindness) which may further progress to Bitot’s spot. If left untreated it may lead to permanent blindness .

21. Children should be encouraged to eat food rich in Vitamin A such as green leafy vegetables, dark yellow and orange vegetables, fruits such as carrot, papaya, and guava . Parents/ guardians should be counseled to include these food items according to their seasonal availability in the daily diet of children.

22. Preventive measures Exclusive breastfeeding till six months of age and Intake of Vitamin A rich foods as part of complementary food. All parents should be informed that prolong deficiency of Vitamin A may lead to permanent blindness

23. Key messages Night blindness is easily preventable Night blindness is the earliest sign of Vitamin A deficiency and is easily treatable Untreated may lead to permanent blindness

24. Key messages Syp . Vitamin A is available with ANMs and should be given to all children at 9 months of age and Thereafter every six monthly till the child attains the age of 5 years. All children with history of night blindness and/ or Bitot spot should be immediately given 2 lakh IU of Vitamin A followed by similar dose 1 to 4 weeks later.

25. 2- Conjunctival Xerosis (Dry Eye) 3- Bitot’s spots 4- Corneal Ulceration 5- Keratomalacia