Lecturer: prof. Pavlyshyn G.A.Lecturer: prof. Pavlyshyn G.A.

Prevention of rickets in children. Prevention of malnutrition

and anemia in children.

Rickets is a childhood disorder involving softening and weakening of the bones.

It is primarily caused by lack of vitamin D, calcium, phosphate.

Sunlight as a source of vitamin D

Adequate supplies of vitamin D3 can be

synthesized with sufficient exposure to solar

ultraviolet B radiation

Melanin, clothing or sunscreens that absorb

UVB will reduce cutaneous production of vitamin D3

• What are the causes for deficiency of Vitamin D?

Reasons of vitamin D deficiency

• Environmental conditions where sunlight exposure is limited like indoor confinement or working indoors during daylight hours may reduce source of vitamin D;

• Inadequate daily consumption - a lack of vitamin D, calcium and phosphorous in the diet, have trouble digesting milk products, people who are lactose intolerant;

Reasons of deficiency vitamin D • Result of digestive disorders - problem of

malabsorption called steatorrhea, in which the body is unable to absorb fats. The result of this problem is that Vitamin D, which is usually absorbed with fat and calcium are poorly absorbed.

• Liver, kidney failure (congenital or acquired disorders) - due to tubular acidosis in which there is an increased amount of acid in the body;

• Dark Pigmentation

Etiology

1. Lack of sunshine due to:

• 1) Lack of outdoor activities

• 2) Lack of ultraviolet light in fall and winter

• 3) Too much cloud, dust, vapour and smoke

Etiology

2. Improper feeding:

1) Inadequate intake of Vitamin D

• Breast milk 0-10IU/100ml

• Cow’s milk 0.3-4IU/100ml

• Egg yolk 25IU/average yolk

• Herring 1500IU/100g

2) Improper Ca and P ratio

Etiology

3. Fast growth, increased requirement (relative deficiency)

4. Diseases and drug:

• Liver diseases, renal diseases

• Gastrointestinal diseases

• Antiepileptic

• Glucocorticosteroid

Pathophysiology - Metabolism of vitamin D

Vitamin D passes the next transformation in the body

Pathway of Vitamin D Production

Clinical signs

Rickets

is a systematic disease with

skeletons involved most, but the

nervous system, muscular system

and other system are also involved

• Generalized muscular hypotonia is observed in the most patients with clinical signs of rickets.

• Craniotabes manifests early in infants, although this feature may be normal in infants, especially for those born prematurely.

Clinical signs

• If rickets occurs at a later age, thickening of the skull develops. This produces frontal bossing and delays the closure of the anterior fontanelle.

Frontal bossing

Protruding foreheadasymmetrical or odd-shaped skull

• Skeletal deformities including Bow legs, Forward projection of the breastbone - pigeon chest or pectus carinatum),Funnel chest(pectus excavatum), "Bumps" in the rib cage (rachitic rosary) and asymmetrical or odd-shaped skull;

Chest deformity

Funnel chest – pectus excavatum

Pigeon chest

Clinical signs

• In the chest, knobby deformities results in the rachitic rosary along the costochondral junctions.

Rib beading (rachitic rosary)

Clinical signs

• The weakened ribs pulled by muscles also produce flaring over the diaphragm, which is known as Harrison groove.

• The sternum may be pulled into a pigeon-breast deformity.

Pigeon chestHarrison groove

Pathway of Vitamin D Production

• Bowlegs and knock-knees.

Clinical signs

Knock knee deformity (genu valgum)

Bowleg deformity (genu varum)

• Spine deformities (spine curves abnormally, including scoliosis or kyphosis). • In more severe instances in children older than 2 years, vertebral softening leads to kyphoscoliosis

Clinical signs

• Progressive weakness• Decreased muscle tone (loss of muscle

strength)• Muscle cramps• Impaired growth• Short stature (adults less than 5 feet tall)• Fever or restlessness, especially at night

Clinical signs

Decreases

in serum calcium, serum phosphorus, calcidiol, calcitriol, urinary calcium.

The most common laboratory findings in nutritional rickets are:

Parathyroid hormone, alkaline phosphatase,

urinary phosphorus levels are elevated.

Classic radiographic findings include

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the

metaphyseal region

• Classic radiographic findings include:

Radiographs of the knee of a 3-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.

Diagnosis

Assessed according to the followings:

• 1. History

• 2. Physical examination

• 3. Laboratory findings

• 4. Roentgen-graphic changes

What's the treatment for rickets?

• The replacement of Vitamin D may correct rickets using methods - of ultraviolet light and medicine.

• Rickets heals promptly with 4000 IU of oral vitamin D per day administered for approximately one month.

• Parents are instructed to take their infants outdoors for approximately 20 minutes per day with their faces exposed. Children should also be encouraged to play outside.

• Foods that are good sources of vitamin D include cod liver oil, egg yolks, butter and oily fish. Some foods, including milk and breakfast cereals, are also fortified with synthetic vitamin D.

Treatment

1. Special therapy: Vitamin D therapy

A. General method: Vitamin D 2000-4000 IU/day

for 2-4 weeks, then change to

preventive dosage – 400 IU.

B. A single large dose: For severe case, or Rickets with complication, or those who can’t bear oral therapy.

Vitamin D3 200000 – 300000 IU, im,

preventive dosage will be used after 2-3 months.

Treatment

2. Calcium supplementation: Dosage: 1-3 g/day• only used for special cases, such as baby

fed mainly with cereal or infants under 3 months of age and those who have already developed tetany.

3. Plastic therapy:

In children with bone deformities after 4 years old plastic surgery may be useful.

Prevention

1. Pay much attention to the health care of pregnant and lactating women, instruct them to take adequate amount of vitamin D.

2. Advocate sunbathing

3. Advocate breast feeding, give supplementary food on time

21.04.23 32

Неспецифическая – нормальное течение

беременности, профилактика невынашивания:

- режим дня;- достаточное пребывание на воздухе;

- сбалансированное питание;- профилактика заболеваемости;

Prevention

21.04.23 33

Специфичная – витамин D3:с 28-32 нед. беременности в течение 6-8 нед в дозе – 1000- 2000 МЕ/суткиПоказания: токсикоз беременных, хрон. экстрагенитальная патология

Профилактикарахита

Антенатальная

PreventionVitamin D supplements

• Because of human milk contains only a small amount of vitamin D, the American Academy of Pediatrics (AAP) recommends that all breast-fed infants receive 400 international units (IU) of oral vitamin D daily beginning during the first two months of life and continuing until the daily consumption of vitamin D-fortified formula or milk is two to three glasses, or 500 mL.

• AAP also recommends that all children and adolescents should receive 400 IU a day of vitamin D.

21.04.23 35

Неспецифическая –- грудное вскармливание;- своевременное введение прикормов;- воздушные ванны, массаж, гимнастика;

Профилактикарахита

Постнатальная

21.04.23 36

Специфическая – УФО или вит D3

УФО – 10-15 сеансов,2 раза в год

Профилактикарахита

Постнатальна

Prevention

Vitamin D supplementation: In prematures, twins and weak babies, give

Vitamin D 800 IU per day, For term babies and infants the demand of

Vitamin D is 400 IU per day, For those babies who can’t maintain a daily

supplementation, inject muscularly Vitamin D3 100000-200000 IU.

Prevention

Calcium supplementation: 0.5-1gm/day, for premature, weak babies and babies fed mainly with

cereal

• Recommended daily intake of calcium is as follows: • 1 to 3 years of age. 500 mg (two servings of dairy products a day) • 4 to 8 years of age. 800 mg (two to three servings of dairy products a

day) • 9 to 18 years of age. 1,300 mg (four servings of dairy products a day) • 19 to 50 years of age. 1,000 mg a day (three servings of dairy products

a day)

Sources of Vitamin DSources of Vitamin D

Sunlight is the most important source

Fish liver oil

Fish & sea food (herring & salmon)

Eggs

Plants do not contain vitamin D3

Food (approximate serving)

Amount of calcium (approximate mg)

Breast milk (500 ml) 125

Formula, cow's milk-based (500 ml)

265

Dairy products

Cheddar cheese (30 g) 200

Cow's milk (1 cup) 250

Ice cream (1 cup) 150

Yogurt (120 g) 150

Fast foods

Cheeseburger 20

Chicken nuggets (four to six pieces)

13

French fries (small order) 10

Pizza (one slice) 145

Greens

Cabbage (collard) (1/2 cup, cooked)

150

Spinach (1 cup, cooked) 150

ANEMIA IN CHILDREN

Anemia is reduction of hemoglobin amount and

hematocrit value per blood volume unit below the normal

values of age.

Definition of anemia

RBCsRBCs Main function – the gas Main function – the gas

transport ( transport ( O2 from lung O2 from lung toto tissues and tissues and CO2 from CO2 from tissues to lung again)tissues to lung again)

Criteria of anemia Anemia should be determined in children when a Hb level falls lower than lower

limit for every age groop:

6 weeks – 6 years 11g/dL

6 years 12g/dL

?

The severity of anemia depends on hemoglobin level

Age Degree of severity I II III

From birth to 6weeks

15 - 18 10 - 15 10

From 6 weeks to 6 years

9,1- 11 7,1- 9 7

Older than 6 years 9,1- 12 7,1- 9 7

?

Severity degree of anemia( hemoglobin g per deciliter )

When anemia began?

A hereditary anemia manifests in early age

Anemia of recent onset suggests on acquired disorder

The possibility of chronic blood loss

A child may slowly lose great amounts of blood and be unaware of bleeding !!!

The possibility of episodes of hemolysis.

Episodes of weakness associated with slight icterus, dark urine, normal to dark stools show the posibility of hemolysis

Use of other drugs and exposure to toxins

Many drugs may cause anemia by a variety of

mechanisms!!!

Dietary history

Irrational feeding may cause anemia!!

Causes of anaemia in infants and children

Causes of iron deficiency anaemia in infants and children

• Low birth weight

• Perinatal hemorrhage

• Inadequate diet

• Chronic blood loss

• Hookworm infestation

• Pallor ;• blue sclerae ;• pagophagia ;• irritability, anorexia ;• xeroderma desquamation of the skin, brittleness

of the nails, laminated nails, xerasia, brittleness of the hair, alopecia ;

• smooth tongue ;• gingivitis, glossitis, stomatitis ;• tachycardia cardiac dilatation, systolic murmurs

Clinical features of iron deficiency anemia

Physical examination

The anemic patient deserves a thorough physical examination with attention focused on the

following aspects of the examination.

• Skin and tunica mucosa

• Lymph nodes

• Mouth

• Heart

• Abdomen

• Nervous system

Skin and tunica mucosa

• Pallor alone - nonhemolytic anemia, pallor plus - anemia with a hemolytic component,pallor plus petechiae or purpura - disorder with an associated thrombocytopenia.

• Xeroderma desquamation of the skin, brittleness of the nails, laminated nails,xerasia, brittlenes of the hair, alopecia - iron deficiency anemia

• A smooth tongue suggests - pernicious anemia or severe iron deficiency.

• Gingivitis, glossitis, stomatitis - iron deficiency anemia

Pallor in anaemic patient

Pallor and slight jaundice in anaemic patient

Heart

• Cardiac dilatation

• Forceful cardiac impulse

• Tachycardia

• Loud systolic murmurs may all result from severe

anemia alone

Initial laboratory evaluation

One begins the laboratory investigation of an anemia with simple procedures:• A blood count that includes

determination of the RBS count, the hemoglobin, the hematocrit, and the RBS indices.

• Study of the peripheral blood smear by the physician.

• A reticulocyte count.

The morphologic characteristics of RBCs in iron deficiency anemia:

• -microcytosis ( MCV < 80 fL);• -hypochromia ( MCH <27 pg);• -poikilocytosis;• -increased red cell distribution width (RDW)

anisocytosis;• -normal reticulocyte count RC = 6-12 %o;• -bone marrow is with low counts of

sideroblasts

RBC Hb

Peripheral blood smear in case of iron deficiency anaemia

Peripheral blood smear

Normochromic RBCs

Hypochromic RBCs

In antiquity doctors used apples with rusty nails for treatment of iron deficiency anemia

Management of iron deficiency anemia

Diet Medicine

Dietary sources of iron

Oral administration:• A daily total of 6 mg/kg of elemental iron in

three divided dosesParental administration:• Very severe anemia• Disoders of iron absobtion• Rapid chronic blood loss

SUMMARY

• To prevent rickets and vitamin D deficiency in healthy infants

and children and acknowledging that adequate sunlight exposure is difficult to determine, we reaffirm the adequate intake of 200 IU per day of vitamin D by the National Academy of Sciences and recommend a supplement of 200 IU per day for the following:

• All breastfed infants unless they are weaned to at least 500

mL per day of vitamin D-fortified formula or milk.

• All nonbreastfed infants who are ingesting less than 500 mL

per day of vitamin D-fortified formula or milk.

• Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.