VITAMIN A

A A Ngr Prayoga, dr, SpA

Learning resources
Nelson Essentials of Pediatrics p 79 - 80 Krause's Food, Nutrition & Diet Therapy p 72 - 75

Vit A (retinoids)
Three preformed compounds that exhibit metabolic 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)

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

Dietary Reference Intakes

Life-stage Group
Infants 0 0.5 0.5 1 Children 13 48 Males/females 9 13 Pregnant 18 -50 Lactating 18 50 RDA (g RAE/day) UL (mg RAE/day)

400 400 300 400 600 750-770 1200-1300

600 600 600 900 1700 2800-3000 2800-3000

ABSORPTION, TRANSPORT & STORAGE

Functions
Vision Vit A pigments integrity of photoreception in the rods & cones Retinal + opsin rhodopsin ~ night vision iodopsin ~ day light Normal cell differentiation & cell surface function Growth and development Immune functions Reproduction

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 carotenoids 3,33 IU vit A activity from retinol 10 IU vit A activity from carotene

Deficiency
Inadequate intake Malabsorption caused by insuff dietary fat, biliary or pancreatic insuff, impaired transport from abetalipoproteinemia, liver ds, PEM, Zn deff. Blindness in developing world, 250 million at risk 250,000 500,000 cases of blindness annually 14 million preschool xerophthalmia, 2/3 going blindness

 Eye Xerophthalmia periocular glands atrophy hyperkeratosis of conjunctiva and cornea keratomalacea blindness

Classification (WHO) Classification X1A XIB X2 X3A X3B Classification XN XF XS Primary Xerosis conjunctiva Bercak bitot + xerosis conjunctiva Xerosis cornea Corneal ulceration Keratomalacea Secondary Night blindness/nyctalopia Xeropthalmia fundus Cicatrix cornea

X 1A (xerosis conjunctiva)
Kekeringan pada konjungtiva

Kekeringan pada konjungtiva

Bercak Bitot

X 2 (Xerosis Cornea)

Kerutan dan hiperpigmentasi

X 3A (Ulcerasi Cornea)

X 3B (Keratomalacea)

XS (Cicatrix Cornea)

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

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

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

Prevention
Oral dose of vit A < 5 years : 200,000 IU (60,000 RAE) < 1 years : 100,000 IU Public Health Knowledge and Services PROGNOSIS St < X2 good St > X2 irreversible

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

Toxicity..
Induced by single doses of retinol > 200,000 RAE in adult or > 100,000 RAE in children Daily intake of carotenoids 30 mg of carotene hypercarotenodermia lung cancer

IODIUM

Learning resources
Nelson Essentials of Pediatrics p 87 KrauseS Food, Nutrition & Diet Therapy p 128 130 Soetjiningsih, Tumbuh Kembang Anak p 203 - 210

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

RDA
Infants up 6 months : 110 g older : 130 g Children : 90 120 g Adult & adolescents : 150 g Pregnant & lactating women : 220 290 g

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

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

ETIOLOGI
Cretin endemic high endemic goiter def iodine Cretin Sporadic disorder of physiologic thyroid glands : Embryo Disorder congenital functions Hypothyroid hypothalamic-hypofisis

Clinical manifestations
Nervosa type early fetal iodine deff * CNS : RM, deafness, ataxia, spasthic * Normal body * Normal function of thyroid gland Papua Nugini Hipotiroidy type (Myxedematous syndrome) late fetal & post natal iodine deff * Kerdil, sex development disorder, RM, myxedema * Neurology : N Kongo

DIAGNOSIS
Anamnesis Sign and symptom Laboratories examination

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

Treatment
L-thyroxin 0 1 years 9 g/kg BW/day 1 5 years 6 g/kg BW/day 6 10 years 4 g/kg BW/day 11 20 years 3 g/kg BW/day Protein Vit Stimulation

Preventions
Iodine salt Lipiodol 0-6 years 95,0-180,0 mg 6-12 y 142,5-285,0 mg 1-6 y 232,5-465,0 mg 6-45 y 475,0-950,0 mg

0,2-0,4 ml 03,-0,6 ml 0,5-1,0 ml 1,0-2,0 ml

PROGNOSIS
Early diagnosis Early treatment ~ mental abnormal < 3bl 80 % IQ > 85 > 3bl 45%

Toxicity
Wide margin of safety Adult have a UL of 1100 g/day young children : 200 300 g/day Some people with underlying thyroid pathologic conditions, excessive iodine in diet hypothyroidism or hyperthyroidism goiter formation

IRON

Human body contains iron

Functional iron in: hemoglobin myoglobin enzyme Storage iron in : ferritin hemosiderin transferrin

Functions
Respiratory transport of O2 & CO2 Active component of enzymes in the processes of cellular respiration and energy generation Immune function and cognitive performance

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

Absorption, transport, storage, excretion

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 7 10 mg/day Pregnancy 15 30 mg/day

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 : chronic inflammation/disorders

Stage of deficiency
Stage 1 : Moderate depletion of iron store no dysfunction Stage 2 : Severe depletion of iron stores no dysfunction Stage 3 : Iron deficiency Stage 4 : Iron deficiency dysfunction and anemia

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

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 ( serum iron/total iron binding capacity ) < 16 % : inadequate for erythropoiesis Percent saturation of ferritin with iron Serum transferin receptor (STFR) A hematology profile : microcytic, hypochromic anemia, HB, hematocrit

MANAGEMENT
MEDICAL Oral iron salt Oral iron Oral sustained release iron Iron dextran by parenteral administration NUTRITIONAL Increased absorbable iron in diet Vitamin c at every meal Meat, fish, poultry Decrease tea and coffee

Treatment
Children : Premature babies : 3 6 mg element iron/kg/day Older than 6 months : 1-2 mg element iron/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

Prevention
Maximized iron absorption and prevent iron deficiency 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 meal 4.Avoid drinking large amounts of tea or coffee with meals

Toxicity
Hemosiderin Hemosiderosis Hemochromatosis Abnormal accumulation of iron in the liver Excessive tissue ferritin levels Elevated serum transferrin levels Oxidation of LDL cholesterol Cardiovasculer complications

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