MICRONUTRIENTS DISORDERS

DR. COURAGE/ DR. OTACHE

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PRESENTATION

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INTRODUCTION

• Micronutrients are nutrients required in very small quantities but are essential for their roles in the growth, metabolic processes and physiologic functions of organ-systems in the body.

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• Micronutrients include vitamins and trace elements required for the production of various hormones and enzymes useful in the development and maintenance of organ-systems including the immune and reproductive system.

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MICRONUTRIENT DEFCIENCIES

• Micronutrient deficiencies, is defined as a lack of essential vitamins and minerals required in small amounts by the body for proper growth and development.
• it could be primary or secondary
• Primary deficiency results from poor intake
• Secondary deficiency occurs due to unmet needs due to increased requirement e.g growth or disease state

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MICRONUTRIENT DEFCIENCIES

• The World Health Organization (WHO) estimate that more than two billion people suffer from micronutrient deficiency globally.
• According to WHO ,deficiencies in iron, vitamin A and iodine are the most common around the world, particularly in children and pregnant women.
• Low- and middle-income counties bear the disproportionate burden of micronutrient deficiencies. 

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FAT SOLUBLE VITAMINS

• Fat soluble vitamins include Vitamin A,D,E and K
• They are mostly found in fatty foods
• Absorption from gut occurs along with dietary fat
• Deficiencies are due to fat malabsorption syndrome
• Because they are stored and not rapidly excreted in the urine, clinical manifestation donot develop early and toxicity occurs more often

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VITAMINS

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VITAMIN A: INTRODUCTION

• According to WHO, Vitamin A deficiency is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections such as diarrhoeal disease and measles.

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• Vitamin A deficiency may also occur in women during the last trimester of pregnancy in high-risk areas.

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VITAMIN A: INTRODUCTION

• Breastfeeding is the best way to protect babies from vitamin A deficiency and, in areas where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children 6-59 months of age.

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VITAMIN A: INTRODUCTION

Retinol( vitamin A alcohol)

-Retinal( Vitamin A aldehyde)

-Retinoic acid(vitamin A acid)

-Retinyl ester(Vitamin A ester)

•In diet, Retinol is the main form of Vitamin A

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VITAMIN A DEFICIENCY: SOURCES

• Sources of vitamins A include; red palm oil, cheese, eggs, oily fish, fortified low-fat spreads milk, yoghurt liver, yellow, red and green (leafy) vegetables, such as spinach, carrots, sweet potatoes and red peppers,fruit such as mango, papaya and apricots

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VITAMIN A: FUNCTION

Biochemical function

1. Needed for the formation of eye pigment, rhodopsin and iodopsin, essential for night vision

2.Development and maintenance of the epithelial cells

3. Normal formation of bone and teeth

4 Assist in the normal functional activities of the immune system and participate in spermatogenesis an synthesis of protein and glycogen

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VITAMIN A DEFICIENCY: CAUSE

• Results from low diet intake or diseases like measles (increased demand)

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VITAMIN A DEFICIENCY: CLINICAL FEATURES

• Clinical manifestations;

- reduced dark adaptatio or night blindness

- Xerosis conjunctival or xerosis cornea

-kerotomalacia

-Bitot's spot

-pethidine bulbae

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VITAMIN A DEFICIENCY: CLINICAL FEATURES

• Extraocular manifestation
• Suspectibility to infection, particularly mealses
• Anaemia
• Growth retardation
• Skeletal and CNS abnormalities
• Follicular hyperkerqtosis
• Sterility

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VITAMIN A DEFICIENCY: LABORATORY INVESTIGATION

• Serum Retinol and Retinol binding protein level are reduced
• Conjunctival cytology - used for early detection

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VITAMIN A DEFICIENCY: TREATMENT

• Oral administration of Vitamin A on days 1,2 and 14
• Children under 6 months, should be given 50,000IU
• 6-12 months 100,000 IU
• >12months 200,000IU

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VITAMIN A EXCESS

Clinical manifestation

• Thickening of long bones
• Deceleration of growth
• Skin changes
• Hair loss
• Liver enlargement
• Increased intracranial pressure with vomiting and headache (pseudotumor cerebri)

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VITAMIN D

• Refers to a group of chemical compounds: ergocalciferol( vitamin D2),cholecalciferol (vitamin D3),dihydrotachystero, calcitonin
• Both ergosterol and cholecalciferol are absorbed and metabolised in the liver to 25-hydroxycholecaliferol .
• It is further hydrolyzed in the kidney to 1,25-dihydroxycaliciferol
• Good sources-liver, egg yolk, milk, butter, margarine, fish oil

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VITAMIN D: FUNCTION

• Promote calcium absorption from the gut
• Assist in regulation of normal levels of calcium,phosphate needed for mineralization of bone, nerve conduction and muscular contraction.
• Deficiency (nutritional rickets) occurs in malabsorption ,chronic liver disease or people in the tropics who stay in indoors due to religion or tradition.
• Also seen in premature babies or vitamin D deficient mothers ,vitamin D concentration is variable,so low amounts may be available

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VITAMIN D: CLINICAL FEATURES

• Rickets in children
• Osteomalacia in adults
• General: lethargy, short statures, hypomania, muscle weakness
• Head and neck: bossing, craniotabes, widened or delayed closure of fontanelles, depressed nasal Bridge delayed dental eruption /malformation

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VITAMIN D: CLINICAL FEATURES

• Chest: Pectus carinatum/excavatim, scoliosis, ricket rosary, Harrison sulcus
• Abdominal distension
• MSS: Bowed, knock, windswept deformities, tabia sabre, widening of the knees/ankle/wrist

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VITAMIN D: LABORATORY FINDING

• Reduced or normal serum ca level
• Reduced ser phosphate
• Elevated alp
• Aminoaciduria

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VITAMIN D: RADIOLODIC FINDING

• Generalized osteoporosis
• Cupping
• Fraying of distal ends(metaphyses)
• Bowing of the bone shaft

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VITAMIN D: TREATMENT

• Daily oral treatment with 10,000IU for 10 days
• Single IM injection of 60000 IU

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VITAMIN D EXCESS

Clinical manifestations include;

• Hyperglycemia
• Hypercalcuria
• Metastatic calcification of soft tissues
• Cardiovascular and real impairment

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VITAMIN E

• Source-leafy vegetables,legumes,vegetables oil(palm oil)

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VITAMIN E: FUNCTION

• Antioxidant properties
• Deficiency occurs in fat malabsorption syndrome
• Clinical manifestation
• Cardiac or skeletal myopthies
• Neuropathic
• Anaemia of kwashiokor
• Retinopathy of prematurity

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VITAMIN E: TREATMENT

• Supplement for children with fat malabsorption syndrome
• Administration of large dose

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VITAMIN K

• Ñewborms lack the ability to produce vitamin less due to gut free of organisms
• Children with chronic liver disease or biliary obstruction are deficient

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VITAMIN K: CLINICAL FEATURES

• Bleeding disorders
• Hemorrhagic disease of newborn

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VITAMIN K: LABORATORY INVESTIGATION

• Prolonged clotting time and prothrombin time

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VITAMIN K: TREATMENT

• Newborns should be given prophylaxis at birth
• Children with vitamin k deficiency due to malabsortion should receive water soluble preparation such as menadione orally

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WATER SOLUBLE VITAMINS

• Water soluble vitamins include vitamins B and C.

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THIAMINE (B1)

• The body cannot produce thiamine and can only store up to 30 mg of it in tissues. Thiamine is mostly concentrated in the skeletal muscles. Other organs in which it is found are the brain, heart, liver, and kidneys.

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THIAMINE: SOURCES

• Whole-grain foods
• Meat/fish/poultry/eggs
• Milk and milk products
• Vegetables (ie, green, leafy vegetables; beets; potatoes)
• Legumes (ie, lentils, soybeans, nuts, seeds)
• Orange and tomato juices

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THIAMINE DEFICIENCY

• Thiamine deficiency, or beriberi, refers to a lack of thiamine pyrophosphate, the biologically active form of the vitamin B1

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THIAMINE DEFICIENCY

• Most patients have no symptoms and signs of thiamine deficiency; therefore, it must be suspected in the appropriate clinical setting. Early symptoms and signs are often nonspecific and vague, such as fatigue.
• Neurologic, cardiovascular and gastrointestinal signs and symptoms of thiamine deficiency are as follows

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THIAMINE DEFICIENCY

• Tachycardia
• Chest pain
• Wide pulse pressure
• Heart failure(orthopnea with or without edema)
• Hypotension, shock

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THIAMINE DEFICENCY

• Poor memory, irritability, sleep disturbance
• Wernicke encephalopathy, Korsakoff syndrome
• Bilateral, symmetrical lower extremity paresthesias
• Muscle cramps
• Absent knee and ankle jerk
• Muscle atrophy
• Foot drop (late stage)
• Nystagmus (early sign)

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THIAMINE DEFICIENCY

• Thiamine is used to replenish the body's stores of the coenzyme thiamine pyrophosphate. The duration of parenteral thiamine therapy depends on the symptoms of thiamine deficiency; treatment is administered until all symptoms are gone.

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RIBOFLAVIN (B2)

• Riboflavin, or vitamin B-2, was initially isolated from milk.it was originally called lactochrome or lactoflavin.
• Riboflavin is water soluble and heat stable
• Riboflavin is not stored in large amounts; minute reserves are stored in the liver, kidneys, and heart.

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RIBOFLAVIN: SOURCES

• Almonds
• Mushrooms
• Soybeans
• Milk, yogurt
• Eggs
• Broccoli
• Spinach

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RIBOFLAVIN DEFICIENCY

• Red, itchy eyes
• Night blindness
• Cataracts
• Migraines
• Peripheral neuropathy
• Anemia
• Fatigue
• Cheilosis

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RIBOFLAVIN DEFICIENCY: TREATMENT

• Treatment of riboflavin deficiency consists of riboflavin replenishment

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NIACIN (B3)

• Niacin, or vitamin B3, is a water-soluble B vitamin found naturally in some foods, added to foods, and sold as a supplement. The two most common forms of niacin in food and supplements are nicotinic acid and nicotinamide. The body can also convert tryptophan an amino acid to nicotinamide

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NIACIN: SOURCES

• Red meat: beef, liver, pork
• Poultry
• Fish
• Brown rice
• Fortified cereals and breads
• Nuts
• Legumes
• Bananas

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NIACIN DEFICIENCY

• Niacin deficiency is rare because it is found in many foods, both from animals and plants.

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NIACIN DEFICIENCY: CLINICAL FEATURES

• Pellagra
• Constipation /diarrhea
• Depression
• Headache
• Fatigue
• Memory loss
• Hallucinations

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NIACIN DEFICIENCY: TREATMENT

• Niacin supplements are given

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PYRIDOXINE (B6)

• Pyridoxine 5'-phosphate, vitamin B-6, is an essential vitamin that aid synthesis pathway of carbohydrate, amino acid and neurotransmitter metabolism.
• This vitamin is unique in that either deficiency or excess can cause peripheral neuropathy.

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PYRIDOXINE: SOURCES

• tuna
• salmon
• poultry
• potatoes
• fortified cereals

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PYRIDOXINE: CLINICAL FEATURES

• General symptoms - Weakness, dizziness
• Oral manifestations - Glossitis, cheilosis
• Dermatologic manifestations - Seborrheic dermatitis,
• Neurologic symptoms in adults - Distal limb numbness and weakness, sensory ataxia, generalized seizures
• Neurologic symptoms in neonates and young infants - Hypotonia; irritability; restlessness; focal, bilateral motor, or myoclonic seizures

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PYRIDOXINE: TREATMENT

• Pyridoxine, vitamin B-6 (Nestrex)

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BIOTIN (B7)

• SOURCES
• Meat
• Egg yolk
• Soyabean
• Yeast

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• RDA- Adult Males & Females- 30μg/d Children- 12 μg/d 58

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BIOTIN: FUNCTIONS

• Role in Gluconeogenesis
• Fatty Acid synthesis.
• In gene expression.

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BIOTIN: CLINICAL FEATURES

• Nausea, Anorexia, scaling seborrheic erythematous rash around eyes, nose and mouth.

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• In infants- Alopecia, Rash involving Ears and hypotonia.

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BIOTIN: TREATMENT

• 10mg/d of biotin

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COBALAMIN (B12)

Active Form-

Methylcobalamine and Adenosylcobalamine

Sources-

Meat, Fish, Egg & Dairy Products (No known plant source)

RDA-

Adult Males & Females- 2.4μg/d

Pregnant and Lactating Females- 2.8μg/d

Children- 1.2μg/d 63

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COBALAMIN: FUNCTIONS

1. Proper nerve function.
2. Production of red blood cells.
3. DNA replication.
4. Metabolism of fats and proteins.

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COBALAMIN: CLINICAL FEATURES

• Megaloblastic Anaemia.
• Atrophic Glossitis
• Depression

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COBALAMIN: TREATMENT

• Oral doses of 5-15 mg/d for 4 months

During Pregnancy- 500μg/d to prevent Neural Tube Defects

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COBALAMIN: TREATMENT

• Six intramuscular injections of 1000μg of Hydroxocobalamin at 3 to 7 days interval to replenish body stores.

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• For maintenance therapy- 1000μg of Hydroxocobalamin every 3 months

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ASCORBIC ACID (VITAMIN C)

• Active form- L- ascorbic acid.

RDA

• Adult Males- 90mg/d
• Adult Females- 75mg/d
• Children- 15-25mg/d
• Pregnant and Lactating mothers- 120mg/d 33

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ASCORBIC ACID

• Collagen synthesis.
• Helps body to fight against infections.
• Antioxidant activity.
• Aids in the prevention of heart disease and cancer.

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ASCORBIC ACID: SOURCES

• Indian Gooseberry/Amla(Richest Source)
• Vegetables
• Tomato
• Sweet poato
• Citrus fruits
• Orange
• Lemon

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ASCORBIC ACID: CLINICAL FEATURES

• Scurvy(impaired formation of mature connective tissue)
• Skin Bleeding( petechiae, ecchymoses)
• Bleeding into Joints(haemarthrosis), Peritoneum & Pericardium
• Slow healing of wound and fractured bone.
• Fatigue and joint pain.
• Impaired Bone growth in Children.

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ASCORBIC ACID: TREATMENT

• Daily administration of 200mg/d until symptoms of deficiency are relieved

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• High dose treatment i.e. 1-2 g/d decreases symptoms and duration of upper respiratory tract infections.

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MINERALS

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CALCIUM DEFICIENCY

• Calcium is a vital mineral that is used to build strong ones and teeth
• Its usually gotten from milk, green leafy vegetables, cheese and fish.

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CALCUIM DEFICIENCY: CAUSES

• Low levels of vitamin D
• Renal failure
• Medications (corticosteroids, phenytoin)

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CALCIUM DEFICIENCY: CLINICAL FEATURES

• Poor mineralization of bones and teeth
• Rickets
• Impaired growth
• Weak brittle nails and muscle cramps

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CALCUIM DEFICIENCY: TREATMENT

This includes dietary modifications by taking more calcium-rich foods or recommended supplements like

• Calcium Carbonate
• Calcium Citrate
• Calcium Phosphate

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IODINE DEFICIENCY

Iodine is essential for normal thyroid function which controls the bodys metabolism

Its found in iodized salt, sea food, onions, fish, dairy products, nuts

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IODINE DEFICIENCY: CLINICAL FEATURES

• Swelling of the thyroid
• Reduced BMR
• Mental and growth retardation
• Fatigue and muscle weakness
• Weight gain
• Dry skin
• Puffy face

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IODINE DEFICEINCY: TREATMENT

Dietary modifications

Iodine supplements

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IRON DEFICIENCY

This is a common cause of anemia. Deficient states in Nigeria result from inadequate dietary intake, menstrual loss, chronic disease and parasitic infections.

Its found in liver, eat, egg yolk, green vegetables, legumes, whole grains, beans

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IRON DEFICIENCY: CLINICAL FEATURES

• Extreme fatigue
• Pale skin
• Strange cravings to eat weird things(pica)
• Cold extremities
• Weakness, shortness of breath

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IRON DEFICIENCY: RISK FACTORS

• Women of child bearing age
• People with poor diets(vegetarians)
• Adults over 65 years
• Premature infants
• Treatment
• Depending on how severe it is and what caused it
• Iron supplements
• Diet

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IRON DEFICENCY: TREATMENT

• Treat underlying cause of blood loss
• Iron supplements

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FLOURINE DEFICIENCY

• Fluorine is found in water, seafood and is involved in tooth and bone structure
• Features
• Weak teeth with tendency to dental caries
• Treatment
• Addition of fluoride to drinking water that is low in fluorine
• Use of fluoride toothpaste and supplements

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ZINC

• It is a dietary depletion of zinc
• It annually causes 450,000 deaths in children under the age of 5
• The body does not require a large amount of zinc, and it is not stored so therefore it is possible for a person (paediatric and non paediatric) to be zinc deficient

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ZINC: FUNCTIONS

• It support cellular function
• Boost immunity
• Help cell division
• Promote wound healing
• Support general body growth

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ZINC: CAUSES

• Lack of nutrition
• Long term exposure to environmental toxins
• Malabsorption syndrome
• Chronic diseases eg; sickle cell anaemia, wilsons disease, renal and liver disease
• Excessive alcohol intake in the adulescent

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ZINC DEFICIENCY: CLINICAL FEATURES

• Appetite loss
• Slower than expected growth
• Slower developmental milestone achievement
• Diarrhoea
• Unexplained weight loss

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ZINC: TREATMENT

To combat zinc deficiency, following intervention strategies can be used:

• Supplementation using medicine: zinc gluconate, zinc sulfate, zinc acetate
• Food fortification through incorporation of zinc additives in food
• Dietary modification: consuming zinc containing foods such as oysters, fortified breakfast cereals, baked beans, milk, plain or instant oatmeal.

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PHOSPHORUS

• It is a dietary depletion of phosphorus in which there is a low level of soluble phosphate in the blood serum and inside the cell. It is known as Hypophosphatemia
• Normal range of phosphorus in children is 4.0 – 7.0mg/dL

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PHOSPHORUS: FUNCTIONS

• It plays a major role in the structural frame work of DNA and RNA
• Living cells use phosphate to transport cellular energy in form of ATP
• Calcium phosphate salt assist in stiffening of bones

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PHOSPHORUS DEFICIENCY: TYPES

• Acute hypophosphatemia: it comes quickly and and presents quickly
• Chronic hypophosphatemia: it developes over time and gradual presentation of symptoms
• Familial hypophosphatemia: it is a rare form passing through families. This form of disease can often lead to bone disease rickets and bone softening oesteomalacia. It will present as either;
• X-linked familial hypophosphatemia(XLH)
• Hereditary hypophosphatemia

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PHOSPHORUS DEFICIENCY: CAUSES

• Severe malnutrition
• Severe burn
• Diabetic ketoacidosis
• Kidney disorder: fanconi syndrome

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PHOSPHORUS DEFICIENCY: CAUSES

• Excess parathyroid hormone (hyperparathyroidism)
• Chronic diarrhea
• Vitamin D deficiency
• Inherited conditions: x-linked familial hypophosphatemia, hereditary hypophosphatemic rickets

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PHOSPHORUS DEFICIENCY: CLINICAL FEATURES

• Muscle weakness
• Fatigue
• Bone pain
• Bone fractures
• Appetite loss

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PHOSPHORUS DEFICIENCY: CLINICAL FEATURES

• Irritability
• Confusion
• Numbness
• Late baby teeth and tooth decay

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PHOSPHORUS DEFICEINCY: TREATMENT

• If hypophosphatemia was caused by medication, cessation of medication is adviced
• One can correct mild symptoms and prevent low phosphate in the future by adding more phosphate into diet. Milk and other dairy foods are good sources of phosphate

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PHOSPHORUS DEFICEINCY: TREATMENT

• Medication:
• Give Phosphate supplement, increase intake of vitamins if vitamin D level is low
• If hypophosphatemia is severe, give high doses of phosphate through IV
• People with the familial form will need to take both phosphate and vitamin D supplements

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BIBILIOGRAPHY

• https://www.who.int/health-topics/micronutrients#tab=tab_1
• Hannah Ritchie and Max Roser (2017) - "Micronutrient Deficiency". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/micronutrient-deficiency' [Online Resource]

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BIBILIOGRAPHY

• Paediatrics and child health in a tropical region 3rd edition by Azuibike and Nkanginieme (pg 712-717)
• https://emedicine.medscape.com/article/1104623-overview#a4

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