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Studies of Vitamin a Deficiency in Children View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Publications of the IAS Fellows Studies of Vitamin A Deficiency in Children C. GOPALAN, M.D., PH.D.,* P. S. VENKATACHALAM, M.D.t AND BELAVADY BHAVANI, D.SC.t A MONG THE clinical manifestations of mal- clinical examination of cases, a survey of dietary nutrition in Indian children, those at- intake with special reference to vitamin A and tributable to deficiencies of protein and vitamin carotene, estimation of serum vitamin A and A are the most widespread. While a great deal carotene levels before and after treatment and of attention has been devoted in recent years determination of the in vitro destruction of to the study of the problem of protein malnu- vitamin A by the patients’ lysed red blood trition, the problem of vitamin A deficiency corpuscles. In addition, data on the incidence which is no less important and more easily of vitamin A deficiency, obtained from the preventable has not attracted the same interest. records of the Niloufer Hospital, Hyderabad Downloaded from It has been our experience (in Coonoor and for the five year period of 1954 to 195S, have Hyderabad, South India) that patients with also been considered. The assessment of die- vitamin A deficiency account for 25 to 30 per tary intake was carried out using the oral cent of all cases of clinical malnutrition in questionnaire method. children. Serum vitamin A and carotene were esti- www.ajcn.org Although the clinical manifestations of vi- mated spectrophotometrically as follows. The tamin A deficiency have been recognized absorption at 460 m and the difference in and described, there are still many aspects of absorption at 328 mt before and after irradia- the problem which would appear to require tion were taken as measures of the carotene by on October 7, 2010 elucidation. For example, the frequent asso- and vitamin A, respectively. Three ml. of ciation of clinical signs of vitamin A deficiency serum or plasma was hydrolyzed with alcoholic with kwashiorkor suggests a possible interrela- KOH and extracted with petroleum ether. tionship between protein malnutrition and The layer of petroleum ether was washed and vitamin A deficiency. The relationship be- dried under vacuum and taken up in cyclo- tween dietary intake of vitamin A and carotene, hexane. After the initial readings were taken the levels of vitamin A in the serum, and the on the cyclohexane solution, it was irradiated incidence and severity of clinical manifestations for half an hour and a second measure of of vitamin A deficiency would seem to merit absorbance at 328 mu was taken. The calcula- further investigation. In this paper the results tions were made as usual, taking the conversion of investigations of these and some other factors into account. aspects of the problem of vitamin A deficiency The time required for the irradiation and the in children are presented. lower limit of the method were determined with solutions of pure vitamin A. All the MATERIAL AND METHODS solvents were specially purified and a reagent The material for this investigation consisted blank was carried out with every set of samples. of 319 cases of vitamin A deficiency, observed It was found that a concentration below 10 in Coonoor over a five year period (1952 to I.U. per 100 ml. could not be estimated prop- 1956) and forty-nine cases studied in Hyder- erly. The correction of Morton and Stubbs abad over an eight month period in 1959. gave values in agreement with the aforemen- The investigation included the following: tioned procedure only in samples of serum which had a high concentration of vitamin A. From the Nutrition Research Laboratories, Indian Council of Medical Research, Hyderabad, India. The destruction of vitamin A by hemolyzed * Deputy Director; t Research Officer. red blood cells was determined by the following A merican Journal of Clinical Nutrition 833 Vol. 8, November-December 1960 834 Gopalan, Venkatachalam and Bhavani TABLE I Age and Sex Incidence of Subjects with Vitamin A Deficiency Age Sex (per cent) (per cent) . No. of City Patients Less than 1 to 3 3 to 5 6 to 10 Over 10 Males Females 1 Year Years Years Years Years Coonoor 319 0.2 17.9 39.0 31.4 11.5 58 42 Hvderabad 551 3.8 26.8 48.7 18.2 2.5 60 40 procedure. The erythrocytes were separated The treatment in cases of kwashiorkor with- from oxalated blood and washed with saline. out vitamin A deficiency signs (Group 2) con- Four volumes of water were added and the lysis sisted of the administration of a high protein was completed by freezing and thawing. diet without a vitamin A supplement (the pro- Five ml. of the lysed solution equivalent to 1 tein being almost solely derived from skim Downloaded from ml. of red blood cells was used. Concentrated milk to which no vitamin A was added). emulsion of vitamin A acetate was prepared, Subjects with kwashiorkor and with signs of according to Pollard and Bieri.’ It was suit- vitamin A deficiency (Group 4) received a ably diluted on the day of estimation so that high protein diet and, in addition, supplements 0.5 ml. of emulsion would be equivalent of vitamin A daily. The vitamin A deficiency www.ajcn.org to about 25 I.U. of vitamin A. The lysed cells observed in nine of the seventeen children in and 0. 5 ml. of the emulsion were incubated at this group was of the severe type involving the 370 c. Alcoholic KOH was added at the end of cornea, necessitating parenteral (in preference fifteen minutes. Vitamin A was extracted and to oral) administration of vitamin A. These by on October 7, 2010 estimated with antimony trichloride solution. patients received 200,000 U. of vitamin A The vitamin A concentration in the emulsion parenterally each day for eight to ten days; was checked at the time of each estimation. they subsequently were given 90,000 U. of The reduction in the vitamin A content of the vitamin A orally each day for approximately a incubated sample was taken as the amount of fortnight. The remaining eight persons in this vitamin A destroyed and expressed as a per cent group, showing only conjunctival signs of of the actual amount incubated. vitamin A deficiency, were treated orally. The estimations of serum vitamin A and Thirteen of the subjects with vitamin A de- carotene and the determination of the in vitro ficiency and without kwashiorkor in Group 3a destruction of vitamin A by the patient’s lysed exhibited only conjunctival manifestations red blood cells were carried out in cases of while four had keratomalacia. Patients with vitamin A deficiency studied in Hyderabad. conjunctival manifestations received oral treat- The estimations were repeated after treatment ment, while those with keratomalacia received in a number of cases. For purposes of com- 200,000 U. parenterally. All children in parison, similar estimations were also carried Group 3b presented conjunctival manifesta- out in apparently normal children of the same tions, only. age group and socio-economic status in Hyder- All patients studied were afebrile at the time abad and in children with kwashiorkor who of the investigation. did not show clinical signs of vitamin A de- Incidence and Clinical Features ficiency. Data concerning the different groups of children from whom these estimations were The age and sex incidence of the children with made, their clinical condition and the plan of vitamin A deficiency are indicated in Table i, treatment adopted are included in this report. and the clinical features of the subjects studied (See Table III.) (319 in Coonoor and forty-nine in Hyderabad) Vitamin A Deficiency in Children 835 TABLE II Main Clinical Features of Vitamin A Deficiency in Children Clinical Features Total Number City Conjunctival of Night Conjunctival Lesion and Blindness Keratoinalacia Patients Lesion Only Only Night Blindness Coonoor 319 113 850 98 23 Hyderabad 49 14 2 33 are given in Table II. The maximal incidence described by Oomen2 (viz., “multiple erosions was observed in the age period between three of the conjunctiva leading to mummification of and five years. Nearly 60 per cent of the sub- the cornea but without loss of general shape jects were boys and 40 per cent were girls. of the cornea” and “colliquative necrosis of the However, this difference in sex incidence may whole cornea leading to shrinkage of the eye Downloaded from reflect the general attendance of the two sexes ball”). From the etiologic viewpoint and from in the clinic and may possibly be related to the the responses obtained through treatment, tendency of poor women to seek medical advice there seemed to be no clear-cut distinction be- more promptly and frequently for their boys tween these two types as they appeared to be than for their girls. It may thus have no merely clinical variations related to the speed www.ajcn.org etiologic significance. and the severity of the same disease. Of the 319 children observed in Coonoor, Of the forty-nine patients studied in Hydera- only twenty-three showed corneal involvement bad, thirty-three had the severe type of vitamin (7.2 per cent). In the great majority of pa- A deficiency involving the cornea. In only by on October 7, 2010 tients, the signs of hypovitaminosis A were of sixteen cases were the lesions of the conjunctival the milder type, involving only the conjunc- type. The preponderance of corneal involve- tiva. Bitot’s spots were encountered in 102 ment in this particular investigation is in of the 21 1 subjects showing conjunctival mani- contrast to the low incidence (7.
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