Lecture 9 Vit a, Iodine, Iron Deficiency

8/12/2019 Lecture 9 Vit a, Iodine, Iron Deficiency

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VITAMIN A

A A Ngr Prayoga, dr, SpA


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Learning resources

Nelson Essentials of Pediatrics p 79 - 80

Krause's Food, Nutrition & Diet Therapy p

72 - 75


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Vit A (retinoids)

Three preformed compounds that exhibitmetabolic activity :

Alcohol (retinol), stored retinol esterified

to fatty acid retinyl-palmitate complexed with prot in foods

animal products

Aldehyde (retinal or retinaldehyde)

Acid (retinoic acid)


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Sources

Animal product

Plants (carotenoids) metabolized retinoids

-carotene

Depends on absorption and conversion

5 50% ~ protein complex & fat in diet

Carrots, greens, spinach, orange juice, sweet

potatoes, cantaloupe


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Dietary Reference Intakes

Life-stageGroup RDA (g RAE/day) UL (mg RAE/day)

Infants

00.5 400 600

0.51 400 600

Children13 300 600

48 400 900

Males/females

913 600 1700

Pregnant

18 -50 750-770 2800-3000Lactating

1850 1200-1300 2800-3000


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ABSORPTION, TRANSPORT & STORAGE


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Functions

VisionVit A pigments integrity of photoreception in

the rods & cones

Retinal + opsin

rhodopsin ~ night visioniodopsin ~ day light

Normal cell differentiation & cell surface function

Growth and development

Immune functions

Reproduction


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Measurement

Internasional Unit (IU)

Activity in chemical terms : g

Calculating vit A value in diet : RE (retinol

equivalents) 1 RE = 1 g retinol

6 g carotene

12 g other provit A carotenoids3,33 IU vit A activity from retinol

10 IU vit A activity from carotene


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Deficiency

Inadequate intake

Malabsorption caused by insuff dietary fat, biliary

or pancreatic insuff, impaired transport fromabetalipoproteinemia, liver ds, PEM, Zn deff.

Blindness in developing world, 250 million at risk

250,000500,000 cases of blindness annually 14 million preschool xerophthalmia, 2/3 going

blindness


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Eye Xerophthalmia periocular glands atrophy hyperkeratosis of conjunctiva and cornea keratomalaceablindness

Classification (WHO)

Classification Primary

X1A Xerosis conjunctivaXIB Bercak bitot + xerosis conjunctiva

X2 Xerosis cornea

X3A Corneal ulceration

X3B KeratomalaceaClassification Secondary

XN Night blindness/nyctalopia

XF Xeropthalmia fundus

XS Cicatrix cornea


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X 1A (xerosis conjunctiva)

Kekeringan pada konjungtiva

Kekeringan pada konjungtiva


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Bercak Bitot
http://www.atlasophthalmology.com/bin/atlas?id=115343726-2162453&nav=4910


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X 2 (Xerosis Cornea)

Kerutan dan hiperpigmentasi


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X 3A (Ulcerasi Cornea)


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X 3B (Keratomalacea)


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XS (Cicatrix Cornea)


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Deficiency

Impaired embryonic development, impaired

spermatogenesis or spontaneous abortion,

anemia, impaired immunocompetence

Change in skin texture, the skin becomes

dry, scaly, rough

Loss of mucous membrane integrity

increases susceptibility to bacterial, viral and

parasitic infection


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DIAGNOSIS

Anamnesis

PD Biochemistry : vit A plasma < 10g/100ml


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TREATMEN

Vitamin A oral/injection

First day : 100.000 IU / inj

200.000 IU oral

Second day : same dose

Before discharge : < 1 th 100.000 IU oral

> 1 th 200.000 IU oral

Ab, antihelmintik, causative therapy

Diet


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Prevention

Oral dose of vit A

< 5 years : 200,000 IU (60,000 RAE)

< 1 years : 100,000 IU

Public Health Knowledge and Services

PROGNOSISSt < X2 good

St > X2 irreversible


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Toxicity

Serum Vit A of 75-2000 RAE/100ml

Bone pain and fragility

Hydrocephalus and vomiting

Dry, fissured skin Brittle nail

Hair loss

Gingivitis, cheilosis, anorexia, irritability, fatigue Hepatomegaly and abnormal liver function

Ascites and portal hypertension


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Toxicity..

Induced by single doses of retinol > 200,000

RAE in adult or > 100,000 RAE in children

Daily intake of carotenoids 30 mg ofcarotene hypercarotenodermia

lung cancer


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IODIUM


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Learning resources

Nelson Essentials of Pediatrics p 87

KrauseS Food, Nutrition & Diet Therapy p128130

Soetjiningsih, Tumbuh Kembang Anak p

203 - 210


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INTRODUCTION

Normal : 20-30 mg

75 % in the thyroid gland synthesis T3& T4

Absorber easily as iodide In circulation iodine exists freely and protein

bound

Excretion > urine

< feces


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RDA

Infants up 6 months : 110 g

older : 130 g

Children : 90120 gAdult & adolescents : 150 g

Pregnant & lactating women : 220290 g


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Sources

Seafoods : clams, lobsters, oysters,

sardines & other saltwater fish 300-3.000

g/kg, freshwater fish 20-40 g/kg

Cow milks and eggs

Vegetable

Iodized salt


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Deficiency

Decreased of intake endemic goiter

enlarge of thyroid glands

Goitrogens absorption Severe deficiency during pregnant and soon

after birth cretin 1-6 % in endemic goiter

area


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ETIOLOGI

Cretin endemic high endemic goiter def iodine

Cretin Sporadic disorder of physiologic

thyroid glands :Embryo

Disorder congenital functions

Hypothyroid hypothalamic-hypofisis


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Clinical manifestations

Nervosa type early fetal iodine deff* CNS : RM, deafness, ataxia, spasthic

* Normal body

* Normal function of thyroid glandPapua Nugini

Hipotiroidy type (Myxedematous syndrome)

late fetal & post natal iodine deff* Kerdil, sex development disorder, RM, myxedema

* Neurology : N

Kongo


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DIAGNOSIS

Anamnesis

Sign and symptom

Laboratories examination


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Examinations

LAB :

CHolesterol , alkalin fosfatase , T3 & T4 ,

TSH

, radio iodine upteke Radologis

Disgenesis epifise, delay of ossification

deformity of L1/L2 kiphosis ECG & EEG: low voltage


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Treatment

L-thyroxin

01 years 9 g/kg BW/day




Protein

Vit

Stimulation


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Preventions

Iodine salt

Lipiodol

0-6 years 95,0-180,0 mg 0,2-0,4 ml6-12 y 142,5-285,0 mg 03,-0,6 ml

1-6 y 232,5-465,0 mg 0,5-1,0 ml

6-45 y 475,0-950,0 mg 1,0-2,0 ml


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PROGNOSIS

Early diagnosis

Early treatment

~ mental abnormal< 3bl 80 % IQ > 85

> 3bl 45%


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Toxicity

Wide margin of safety

Adult have a UL of 1100 g/day

young children : 200300 g/day

Some people with underlying thyroidpathologic conditions, excessive iodine indiet

hypothyroidism or hyperthyroidismgoiter formation


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IRON


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Human body contains iron

Functional iron in:

hemoglobin

myoglobin

enzyme

Storage iron in :

ferritin

hemosiderin

transferrin


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Functions

Respiratory transport of O2 & CO2

Active component of enzymes in the

processes of cellular respiration and energy

generation

Immune function and cognitive performance


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Food Sources and Intake

Liver, seafood, kidney, heart, lean meat,

poultry and fish

Dried beans and vegetables

Egg yolks, dried fruits, dark molasses, whole

grain, wine, cereal

Milk and milk produccts

Absorption


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Absorption

Absorption transport storage excretion


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Absorption, transport, storage, excretion


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Dietary Reference Intake

Men and postmenopausal woman : 8

mg/day

Woman of child bearing age 18 mg/day

Teenage boys 11 mg/day

1 year and older 710 mg/day

Pregnancy 1530 mg/day


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Deficiency

ETIOLOGY Inadequate iron intake : poor diet

Inadequate absorption : diarrhea, achlorhydria,intestinal ds, gastrectomy, drug interference

Increased excretion : excessive menstrual, injury Chronic blood loss : peptic ulcer, hemorrhoids,

parasites, malignancy

Increased iron requirement : infancy, adolescence,pregnancy

Defective release of iron from iron store : chronicinflammation/disorders


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Stage of deficiency

Stage 1 : Moderate depletion of iron store

no dysfunction

Stage 2 : Severe depletion of iron storesno dysfunction

Stage 3 : Iron deficiency

Stage 4 : Iron deficiencydysfunction and anemia


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CLINICAL FINDINGS

Decreased work performance & exercise tolerance Fatigue, anorexia, pica

Abnormal cognitive development

Growth abnormalities

Skin pale, lower eyelid be light pink instead of red

Fingernails : spoon-shaped nails

Glossitis

Angular stomatitis

Gastritis ~ achlorhydria Cardiac failure


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Diagnosis

Quantity of serum ferritin : < 15 g/L for adult< 12 g/L for children

Quantity of serum or plasma iron

Quantity of total circulating transferin

Percent saturation of circulating transferrin ( serumiron/total iron binding capacity ) < 16 % :inadequate for erythropoiesis

Percent saturation of ferritin with iron

Serum transferin receptor (STFR)

A hematology profile : microcytic, hypochromicanemia, HB, hematocrit


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MANAGEMENT

MEDICAL

Oral iron salt

Oral iron

Oral sustained release ironIron dextran by parenteral administration

NUTRITIONAL

Increased absorbable iron in diet

Vitamin c at every meal

Meat, fish, poultry

Decrease tea and coffee


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Treatment

Children :

Premature babies : 36 mg elementiron/kg/day

Older than 6 months : 1-2 mg elementiron/kg/day

Therapeutic dose 3-6 mg element iron/kg/day

Adult :

Ferrous sulphate 300 mg 3 tablets/day

Ferrous gluconate 300 mg 5 tablets/day

Ferrous fumarate 300 mg 2 tablets/day


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Prevention

Maximized iron absorption and prevent irondeficiency anemia :

1.Improve food choices to increase total

dietary iron intake.2.Include a source of vitamin C at every

meal.

3.Include MFP at every meal4.Avoid drinking large amounts of tea or

coffee with meals


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Toxicity

Hemosiderin Hemosiderosis

Hemochromatosis

Abnormal accumulation of iron in the liverExcessive tissue ferritin levels

Elevated serum transferrin levels

Oxidation of LDL cholesterolCardiovasculer complications


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Management

Medical :

Weekly phlebotomy (2-3 years)

Desferrioxamine-B intravenous

Nutrition :

Ingest less heme iron compare with non heme

iron

Avoid : alcohol & vit c, food highly fortified iron,

iron suplements


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Lecture 9 Vit a, Iodine, Iron Deficiency

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