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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=49108/12/2019 Lecture 9 Vit a, Iodine, Iron Deficiency
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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
15 years 6 g/kg BW/day
610 years 4 g/kg BW/day
1120 years 3 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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