micronutrient deficiency2003
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Dr Ranjith Kumar Dr S.Balasubramanian
KKCTH
Background information:2 ½ month old female , Birth Wt:2.3kg ,Breast fed
upto 2mon Refractory seizures Intracranial Hemorrhage
Diagnosed to have Late Hemorrhagic disease of newborn discharged on AED(Phenobarbitone, Phenytoin & Levitarcetem)
Followed up by Neurologist
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
Also had diarrhea hence Soya based formula advised from 6 month
Developmental delay in the form Not able to sit with support Momentary head control was + More of motor developmental delay
• on examination : Fairly nourished Hypotonic Wide open AF Hot cross bun skull Widened wrist Prominence of costochondral junction Protuberant abdomen with Hepato-
spleenomegaly
At 7months of age infant brought to us
25/27/05/10
Diagnostic dilemma?:
Are we dealing with Vitamin D deficient Rickets Vitamin Resistant Rickets
Investigations 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
USG abdomen :Mild Hepatosplenomegaly Renal system normalRFT: normalPhenobarbitone level: 23mcg/dl (15-30)Phenytoin level: 20mcg/dl (10-20)
Management:Vitamin D 6 lacks IM followed by oral
Vitamin D 0.25mcg twice daily for 4wksFollowed with Ca, Po4-,SAP & X ray Infant showed improvement in both clinically
and laboratory wise Now :(9months)
Able to stand ,walk without support No further seizures off antiepileptic drugs
Zone of provisional calcification
Completely healed Rickets
20/7/10 12/8/10
Reasons for Rickets Anticonvulsant therapyNo routine vitamin D supplementation Soya milk Poor sunlight exposer
To our knowledge thaere was no case report of rickets due to anticonvulsant therapy
Why this presentationThough research results vary, long-term use of anticonvulsant
drugs appears to interfere with vitamin D activity, which might lead to softening of bones (osteomalacia)
*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.
#people taking anticonvulsant drugs who do not receive adequate sunlight should supplement with 400 IU of vitamin D each day to help prevent Rickets
*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.
# 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.
*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
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
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.
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
Take home massage
1. Routine Vitamin D supplementation is essential
2. Vitamin D supplementation should be recommended in children on anticonvulsant therapy
3. Children on Soya based formula should be supplemented with Vitamin D
TTHANK YOU
A day will come
From A to D
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