Micronutrients

(Vitamin & Trace Elements)

Deficiencies

Jimmy Lee, Paeds

Monash Year 4 students
Large group tutorial – ‘Lecture’

2020 Jan
1
What are
• Micronutrients?

• Trace elements?
• Vitamins?

2
Micronutrients
• a chemical element or substance required in trace amounts for
physiologic function, normal growth and development of living
organisms

• Include minerals and vitamins

3
Minerals
• inorganic nutrients include the trace elements copper, iodine, iron,
manganese, selenium and zinc

• Note: macro elements calcium, magnesium, potassium and sodium.

4
Vitamins
• any of a group of organic compounds that are essential for normal
growth and nutrition and are required in small quantities in the diet
because they cannot be synthesized by the body

• You cannot store the vitamins in your body, excess vit A, B, D can lead
to toxicity

5
How many types of vitamin?
• In humans there are 13 vitamins:
• 9 water-soluble: 8 B vitamins (types later) and
vitamin C
• 4 fat-soluble: A, D, E, and K

6
Learning Objectives
• Know the common clinical causes of trace element and vitamin
deficiencies

• Investigation and treatment of the above conditions

7
Clinical Scenarios
• Aaron, 2 years old • Dennis
• takes breast and fresh milk, • Crohn’s disease, right hemi-
reluctant to take meat colectomy
• Brandon, 3 years old • Edward
• vegetarian diet • Rickets
• Chris, 9 months old • Francis
• born preterm, NEC with short • Biliary atresia, post-Kasai
segment gut resection including
ileo-caecal junction

8
Aaron
• 2 years old

• History
• c/o insidious pallor past 3 months noticed by relatives, otherwise well

• What further history you want to take?

9
History
• Approach to pallor
• inadequate production
• increase destruction
• acute blood loss

• Headings
• Feeding
• Birth
• Immunisation
• Development
• Family
10
Positive history
• Picky eater
• Breast feeding till 1 year old
• Refuses formula feeding, drinks fresh cow’s milk 200 mls 4 times per day
• Does not like to try new food, reduced soft diet intake

• Occasional plays bare-footed in garden

• Family history of mild pallor on mother’s side

11
Examination - what would you like to look for?
• Satisfactory growth parameters
• Mild pallor
• No bruises
• No lymphadenopathy, no hepatosplenomegaly

12
Group Discussion 01
• Diagnosis
Iron deficiency

• Investigations
FBC, PBF
Iron studies
Haemoglobin electrophoresis
Stool ova & cyst

• Management
Diet modification

Medication
Syrup haematinic (ferrous, gluconate, sulphate)
Folate
Vitamin C to enhance iron absorptionI=

13
Investigations – what would you like to do?

14
Management?

15
Iron deficiency in developing countries
• most common nutritional disorder in the world
• affects at least half of all pregnant women and young children in
developing countries

• Iron deficient diet especially during rapid growth

• Worsened by worm infestation

16
Causes of Iron Deficiency Anaemia
• Toddler
• Excessive consumption of fresh cow’s milk (low iron content, blood loss from
milk protein colitis). Should limit to <24 oz (720 mls) / 24 hours
• GIT problem
• Occult bleeding from GIT esp older children: peptic ulcer, haemangioma,
inflammatory bowel disease (Crohn’s disease)
• coeliac disease (iron malabsorption)

17
Brandon
• 3 years old
• Playgroup parents noticed him to be pale in the past 3 months
• They are careful not to give him any meat as requested by his parents.

18
History
• Parents are on vegan vegetarian diet since adults
• Brandon has been on lacto-ovo vegetarian diet for the past 1 year

19
Examination
• Growth parameters alright
• Mild pallor, otherwise well

20
Group Discussion 02
• Diagnosis

• Investigations
Blood count
Serum B12
Serum folate

• Management

21
Investigations – what would you like to do?

22
Management

23
Vegetarian diet
• By choice (herbivores*)
• healthy (no animal fat, <calories)

• However strict vegetarians, esp vegans should consider the following

supplements:
• Vitamin B12 Vit B12
Calcium

• Calcium
Zinc
Iron

• Iron
• Zinc

24
Charles
• 9 months old, corrected age 6.5 months
• Born 29w, birthweight 1.10 kg
• Stormy neonatal period
• CPAP, ventilated 5 days
• Nosocomial infection at 1 week of life
• NEC at 33 weeks, pneumatocoele intestinalis, gut perforation, resection of
terminal ileum
• Feeds
• Formula, just started on weaning diet

25
Examination
• Growth below 5th percentile
• Pallor
• No hepatosplenomegaly
• Development mild delayed

26
Group Discussion 03
• Diagnosis

• Investigations

• Management

27
Investigations – what would you like to do?
• Blood count
• Hb 10.5 g/dL
• MCV 65 fL
• MCHC 22 g/dL

• Others
• Serum Fe, ferritin, TIBC
• Serum vit B12 level

28
Causes of anaemia?

Iron deficiency anaemia

Born premature with reduced iron stores
Blood loss during neonatal period (from blood sampling)
Inadequate nutrition

Treat with haematinic, folic aicd, vit C

Risk of vit B12 deficiency

Treat with hydroxycobalamine 20mcg/kg im every 2 to 3 months

Note: in adults, vit B12 def must be exluded in folic acid def

29
Dennis – 16 years old
• Crohn’s disease diagnosed at 10 years old
• Diarrhoea, weight loss, abdominal pain
• Right hemicolectomy done 15 years old
• For unresponsive luminal and structuring disease

• Group Discussion 04
• What vitamin should be supplemented?

30
Vitamin B12 (cobalamin)
• Essential for haemopoiesis and CNS myelination

• Folic acid (vit B9) is co-factor in protein and nucleic acid biosynthesis
• Vit B12 necessary for the production of tetrahydrofolate

• Animal food sources

• Absorbed from terminal ileum with intrinsic factor (produced from

parietal cells of stomach)
31
Edward
• 6 weeks old

• Born preterm 27weeks, 900g

• Stormy neonatal period
• Ventilated for 10 days
• TPN started at 3rd day of life
• Feed intolerance, full feeding achieved at 2 weeks of life, milk not fortified
• 4 weeks of life
• ALP >1000 iu/L
• Serum phosphorus <1.8 mmol/L, serum Ca low
Text

32
Group Discussion 05
• What metabolic problem should we look for?
• Rickets of Prematurity
Rickets of prematurity

• Investigations
• Serum Ca, phosphorus, ALP
• X-ray later
Serum Ca, phosphorus, ALP
X Ray

• Management
• Fortified feeding
• Multivitamins

33
Group Discussion 04

34
Vitamin D deficiency

35
Rickets
• Growing bones, before fusion of epiphysis
• Unmineralised matrix at growth plates
• Features
• Bone deformity
• Fractures
• Hypocalcaemic tetany, seizures

Note:
• Osteomalacia: inadequate mineralisation of bone osteoid in children
(rickets) and adults, ↓Ca, ↓P, bones soft
• Osteoporosis: reduced bone density (matrix), bones porous & brittle
36
Rickets - Causes
• Vitamin D disorders
• Nutritional vit D deficiency
• Secondary vit D deficiency – G.I. malabsorption
• Vitamin D dependent rickets type 1 & 2
• Chronic renal failure
• Calcium deficiency
• Low intake – diet, preterm (rickets of prematurity)
• Malabsorption
• Phosphorus deficiency
• Inadequate intake – rickets of prematurity, aluminium-containing antacids
• Renal losses
• X-linked hypophosphataemic rickets
• AD hypophosphataemic rickets
• AR hypophosphataemic rickets
• Distal renal tubular acidosis
37
Rickets:
treatment for nutritional vit D deficiency
Adequate nutritional intake of calcium and phosphorus
Vit D

38
Francis
• 1year 6 months old

• Neonatal jaundice, pale stools, dark urine

• Biliary atresia diagnosed at 4w of life, Kasai-op at at 7w of life

• Group Discussion 06
• What vitamin deficiency is this child at risk of? ADEK

• Investigation?
• Management?

39
Vitamin deficiency
• Vitamin D
• Multivitamin supplementation

• Vitamin K
• Oral vitamin K supplement

40
Vitamin K

41
Vitamin K
• Newborn
• Breast-feeding, not on fortified formula feeding
• Give im vit K in the delivery room; consider oral vit K

• Child
• Seriously ill child – iv 2.5 – 10 mg
• GI Malabsorption, obstructive jaundice
• Oral vit K 2.5 mg 2 times per week

42
Questions or Comments

43
Clinical Scenarios
• Aaron, 2 years old • Dennis
• takes breast and fresh milk, • Crohn’s disease, right hemi-
reluctant to take meat colectomy
• Brandon, 3 years old • Edward
• vegetarian diet • Rickets
• Chris, 9 months old • Francis
• born preterm, NEC with short • Biliary atresia, post-Kasai
segment gut resection including
ileo-caecal junction

44
Termination - thanks
• End

45
Acknowledgement

46
References

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