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. 2 per cent) of festations, and were invariably bilateral and keratomalacia found in Coonoor. It was quite situated on the lateral side of the cornea. The clear that the vitamin A deficiencies in the remaining children showed conjunctival xerosis children of Hyderabad were of a more severe characterized by dryness, discoloration and type than those observed in the children of wrinkling of the bulbar conjunctiva without Coonoor. The age of the subject did not ap- Bitot’s spots. pear to be a factor in determining whether An interesting feature was the lack of as- the site of the lesion occurred on the conjunc- sociation between the presence of night blind- tiva or the cornea. A possible objection to the ness and the incidence of visible signs in the assessment of the incidence of keratomalacia, eye of vitamin A deficiency. Eighty-five in relation to the total incidence of vitamin A children had night blindness without any other deficiency, purely on the basis of hospital ad- clinical manifestation of vitamin A deficiency, missions might be that only persons with severe for the conjunctiva and cornea were clear and vitamin A deficiency may be admitted, while normal. In 1 13 subjects showing conjunctival those with the milder conjunctival type may lesions, no history of night blindness could be have received treatment as outpatients. To obtained, even after leading questions were obviate this possible objection, the incidence of posed. Keratomalacia observed in twenty- manifestations of vitamin A deficiency in a three patients was invariably bilateral with series of patients admitted to the hospital in one eye being more affected than the other, and Hyderabad for kwashiorkor was compared included lesions conforming to both the types with a series of patients with kwashiorkor 836 Gopalan, Venkatachalam and Bhavani

TABLE III Serum Carotene, Vitamin A and the In Vitro Destruction of Vitamin A by the Red Blood Cells in Different Groups of Children.

Serum Vitamin A (I.U./100 mi.)5 Serum mn vitro Carotene5 Destruction (ratio/100 ml.) Before After of Vitamin A5 (per cent) Group Clinical Treatment t Treatment t Treatment No. Condition No. No. Before After Before After Below Below Treat- Treat- Treat- Treat- 0 Mean 0 Mean inent ment ment ment I.U. I.U.

1 Apparently 50(6) 0 80(6) 28 (4) normal 2 Kwashiorkor High protein 22(13) 19(7) 5 52(9) 0 71(7) 28(5) only diet with no vitamin A

3a Vitamin A Vitamimi A 18(13) 26(11) 6 32(7) 0 102(11) 52(8) 30(3) Downloaded from deficiency only 3b Vitamin A High protein 12(4) 11(3) 2 45(2) 2 59(1) 62 (4) 79(3) deficiency diet with no only vitamin A 4 Kwashiorkor High protein 13(14) 19(9) 12 17(2) 0 74(10) 45(4) 34(2)

with diet with www.ajcn.org vitamnin A vitamin A deficiency

S The values given are the mean values of the number of samples indicated in parentheses. The number of patients

after treatment includes some patients for which initial values were not available. by on October 7, 2010 t The number of samples having a concentration of less than 10 lU. have been indicated in this colummi, and the mean given in the next column is the average of values above 10 lU. This particular sample had a concentration of 65 lU. of vitamin A/100 ml. serum initially. observed in Coonoor. The over-all incidence carotene and vitamin A was carried out in a of vitamin A deficiency in the patients with group of children with vitamin A deficiency in kwashiorkor in both Hyderabad and Coonoor Hyderabad. A similar survey was also carried was between 32 to 36 per cent. However, while out using a control group of children of the keratomalacia accounted for only 10 per cent of same age composition and socio-economic the children with vitamin A deficiency compli- status who did not show any signs of vitamin cated with kwashiorkor in Coonoor, it accounted A deficiency. It was found that the vitamin for 62 per cent, in Hyderabad. This indicates A and carotene intakes of both the groups were that the observed differences between the in- considerably lower (250 to 300 I.U. of pre- cidence of children with keratomalacia in Hy- cursor and 100 to 150 lU. of preformed vitamin derabad and in Coonoor were real. A) than the recommended quantities. There An examination of the monthly incidence of was no significant difference between the con- cases for a five year period failed to reveal any trol and vitamin A deficiency groups regarding definite seasonal trend in both places. There carotene and vitamin A intake. It had been was no correlation between the incidence of reported earlier that the intakes of carotene and cases of vitamin A deficiency and of respiratory vitamin A of patients with kwashiorkor in or alimentary disorders. Hyderabad were not lower than those in Coonoor in spite of the fact that the incidence 7 he Dietary Situation of keratomalacia was much higher in the former.3 An assessment of the dietary intake of It was apparent from these findings that Vitamin A Deficiency in Children 837 while vitamin A deficiency signs were always tion can bring about a significant lowering of associated with a low dietary intake of carotene serum vitamin A, and treatment with a high and vitamin A, the reverse was not true. In a protein diet without vitamin A supplementa- number of patients subsisting on low dietary tion can correct this. intakes of carotene and vitamin A, no clinical In Vitro Destruction of Vitamin A signs of vitamin A deficiency could be detected. A closer examination of the diets of children In apparently normal children studied in with kwashiorkor also failed to reveal any this investigation (Group 1), the in vitro de- striking difference (with regard to dietary struction of vitamin A by the lysed red cells vitamin A and carotene intake) between pa- was approximately 28 per cent. Subjects tients with and those without complicating with kwashiorkor (Group 2) did not signifi- vitamin A deficiency signs. cantly differ from the normal children (Group 1) in this regard. However, in children with Serum Vitamin A and Carotene Levels vitamin A deficiencies with or without kwashi- The values for levels of vitamin A and caro- orkor (Groups 3 and 4) , the extent of in vitro tene in the serum of children in the four groups destruction of vitamin A appeared to be defi- Downloaded from investigated in Hyderabad are included in nitely of a much higher order than that of the

Table III. The levels of vitamin A in the normal subjects (Group 1). However, there serum of the apparently normal children was no difference between Groups 3 and 4 (Group I ) were lower than the average values which again demonstrated that the presence of reported for normal children in other parts of kwashiorkor did not influence this function. the world.2’4 This finding was not unexpected, After treatment with vitamin A, it was www.ajcn.org for although the children investigated in this noticed that the abnormally high destruction, group were free from disease, they were drawn in vitro, of vitamin A was lowered in regard to from the poor socio-economic group subsisting patients in groups 3 and 4 with vitamin A on unsatisfactory diets. As expected, the deficiencies. by on October 7, 2010 subjects with vitamin A deficiencies (Group 3) exhibited considerably lower levels of serum COMMENTS vitamin A than did those of Group 1 . It was Dietary Intake interesting that patients with kwashiorkor with no signs of vitamin A deficiency (Group 2) An important observation made in this also exhibited levels of serum vitamin A which study was that while the dietary intakes of were significantly lower than those observed in vitamin A and carotene of children with the children in Group 1 . The lowest levels of vitamin A deficiencies were low, they were serum vitamin A were observed in the subjects not significantly lower than those of other exhibiting signs of both kwashiorkor and children of the same socio-economic group vitamin A deficiency (Group 4). The values who did not show signs of vitamin A deficiency. for serum carotene were uniformly low in all This would suggest that in the development of the groups. vitamin A deficiency, factors other than the After treatment with vitamin A, a marked in- actual diets of the children at the time of the crease in the levels of vitamin A in the serum investigation also have to be considered. was observed in all subjects with vitamin A Although it is true that in a number of patients deficiencies. A striking observation was made the onset of clinical signs of vitamin A de- of the children with kwashiorkor who exhibited ficiency was preceded by episodes of fevers, low levels of serum vitamin A. Treatment of infections and alimentary disorders, such these children with a high protein diet con- episodes were apparently no more frequent in taining no vitamin A supplement brought children showing signs of vitamin A deficiency about a significant increase in the levels of than in those of the same socio-economic group vitamin A in the serum. It was apparent not suffering from this deficiency. The time from these observations that protein malnutri- at which supplementary feeding was started 838 Gopalan, Venkatachalam and Bhavani

may be an important factor in this connection. mm A in the livers of stillborn infants and of Mothers in Coonoor started the supplementary those dying during the neonatal period (which feeding of their infants by the sixth month, is at present being attempted) will provide while in Hyderabad supplementary feeding further information on this subject. was initiated only after the end of the first It may, however, be appropriate to em- year.3.5 This would indicate that, although phasize the fact that no case of vitamin A de- at the time of investigation the intake of vita- ficiency was encountered, in this study, in a mm A and carotene by the children in both child with a really satisfactory intake of vita- places was nearly similar, the children of mm A and carotene. Hyderabad had been on a vitamin A deficient diet for a relatively longer period of time. This Night Blindness and Other Signs might partly account for the higher incidence A lack of association between the incidence of severe types of vitamin A deficiency in of night blindness and other ocular signs of Hyderabad. The vitamin A content of the vitamin A deficiency was observed in our study. breast milk of poor Indian women in Coonoor The incidence of night blindness may be modi- has been shown to be about 70 I.U./1(H) ml.6 fled by such factors as the degree of exposure to Downloaded from The vitamin A content of the breast milk of sunlight,9”0 the degree of associated anemia” poor mothers in Hyderabad is being deter- and possibly the nutritional status with re- mined at present. The preliminary indications gard to riboflavin’2 and vitamin 14 are that the content of vitamin A in the latter is considerably lower than that observed in Protein Malnutrition and the women in Coonoor. Even assuming that Vitamin A Deficiency www.ajcn.org the vitamin A content of milk in Hyderabad The question of the relationship between mothers is the same as in the Coonoor mothers protein malnutrition and vitamin A deficiency and that the output of breast milk in the has attracted some attention in recent years.2 former women is as high as 6(R) ml. throughout In our investigation, it was observed that by on October 7, 2010 the first year of motherhood, breast milk alone serum vitamin A levels were significantly would provide only 4(h) lU. of vitamin A to lowered in patients with kwashiorkor who the infants. showed no clinical evidence of vitamin A Another important factor which might ex- deficiency ; and furthermore, that treatment plain the lack of a direct relationship between with a high protein diet without a vitamin A the dietary intake of vitamin A by the children supplement brought about an increase in the and the incidence of clinical vitamin A de- levels of vitamin A in the serum in these pa- ficiency among them is the possible variation tients. It was also found that subjects with a in the hepatic storage of vitamin A during their vitamin A deficiency complicated with kwashi- fetal periods. In human adults with presum- orkor had significantly lower levels of serum ably adequate hepatic storage of vitamin A, vitamin A than did those uncomplicated without dietary deprivation of vitamin A, extending kwashiorkor, or vitamin A deficiency. These over several months, was necessary to produce observations might suggest that protein malnu- significant depression in the levels of vitamin A trition might aggravate vitamin A deficiency. in the serum.7 The livers of newborn infants, Arroyave et found that the absorption of vi- whose mothers’ intake of vitamin A is pre- tamin A was impaired in patients with kwashior- sumably adequate, have been found to con- kor. The increase in the levels of vitamin A in tain considerable amounts of vitamin A.8 the serum, brought about in subjects with kwas- A survey* of the diets of pregnant mothers in hiorkor by a high protein diet (in this study), Hyderabad revealed gross deficiencies of vita- indicate that the effect of protein malnutrition min A and carotene. The estimation of vita- may be an impairment of the mobilization of vitamin A stored in the liver. It was demonstrated that when there is no manifest protein * This survey, taken by Dr. X. X. Kalpakum, has not yet been published. malnutrition in a child deficient in vitamin A, Vitamin A Deficiency in Children 839 the administration of a high protein diet does evidence of vitamin A deficiency) was 45 not result in an increase in the levels of vitamin I.U./100 ml. The highest level of vitamin A A in the serum. The significance of lower in the serum observed in the series of patients levels of vitamin A in the serum of patients investigated with uncomplicated vitamin A with kwashiorkor requires further study. deficiencies was 65 lU/lot) ml. Contrary to the suggestion that protein de- We have observed that the state of protein pletion may aggravate vitamin A deficiency, nutrition may also be an important factor in J agannathan’6 found that increasing the determining the levels of vitamin A in the amount of protein in the diet beyond a certain serum in a malnourished population. The re- point had a hastening effect on the depletion sults of the present investigation do not permit of the stores of vitamin A in experimental any conclusions as to the critical level of serum animals. He also observed an inverse rela- vitamin A values below which it could be con- tionship between growth in young rats and sidered to be of definite pathologic significance. hepatic storage of vitamin A. The work of However, it was apparent that in children with M17 indicated that protein depletion vitamin A deficiency but without complicating actually delayed the development of signs of kwashiorkor, values for serum vitamin A below Downloaded from vitamin A deficiency in rats fed diets deficient 50 lU. were the general rule. in vitamin A. During our study, it was ob- In Vitro Destruction of Vitamin A served that six children with kwashiorkor, who had no signs of vitamin A deficiency on ad- The work of Kon et indicated the possi- mission, developed conjunctival signs of vita- ble presence of factors which cause destruction mm A deficiency after a few weeks of treatment of vitamin A in rabbits and rats. Pollard and www.ajcn.org with a high protein diet. We have frequently Bieri’ showed that the lysed red blood cells of observed patients with severe keratomalacia rats, in vitro, were most active in destroying without any evidence of kwashiorkor and pa- vitamin A. In our study, we observed that the tients with kwashiorkor with absolutely no lysed red cells from the blood of patients with by on October 7, 2010 clinical evidence of vitamin A deficiency. vitamin A deficiencies were much more potent The appa rently contradictory observations in bringing about in vitro destruction of vitamin of the relationship between protein depletion A than were those of normal subjects. Fur- and vitamin A deficiency can be explained if it thermore, we were able to correct this ab- is recognized that protein depletion may, on normality by treating these patients with the one hand, aggravate vitamin A deficiency vitamin A. Additional investigation is neces- by interfering with the absorption of vitamin A sary in order to decide to what extent this ob- and possibly with the mobilization of vitamin servation is applicable to the in vivo state. A from the liver, and, on the other hand, The significance of this observation from the mitigate vitamin A deficiency by sparing the point of view of the pathogenesis of n,anifesta- tissue requirement of vitamin A by inducing tions of vitamin A deficiency remains to be growth retardation. The degree of protein elucidated. The results obtained through depletion may well determine the direction of treatment indicate that the capacity for in- the net effect. creased in vitro destruction of vitamin A by the lysed red blood cells of patients with vitamin Serum Vitamin A and Carotene Levels A deficiency is the result rather than the cause In the subjects with vitamin A deficiency, of vitamin A deficiency. both the serum vitamin A levels as well as the serum carotene levels were low. It would thus SUMMARY appear that defective conversion of carotene The clinical features of 319 children with into vitamin A was not a factor in the develop- vitamin A deficiency observed in Coonoor and ment of this disease. The lowest value for forty-nine children studied in Hyderabad have the levels of vitamin A in the serum observed been discussed in detail. Estimations of the in an apparently normal child (without any contents of vitamin A and carotene in the serum 840 Gopalan, Venkatachalam and Bhavani and the in vitro destruction of vitamin A by 4. SZYMANSKI, B. B. and LONGWELL, B. B. Plasma vitamin A and acarotene determination in a lysed red blood cells were carried out. group of normal children. J. Nutrition, 45 : 431, There was a lack of association between the 1951. incidence of night blindness and other ocular 5. SOMESHWARA, R. K. , SWAMINATHAN, M. C., signs of vitamin A deficiency. Although signs SWARUP, S. and PATWARDHAN, V. N. Protein of vitamin A deficiency were always associated malnutrition in India. Bull. World Health Organ., with a low dietary intake of carotene and vita- 20:603, 1959. mm A, the reverse did not always occur. The 6. BELAvADY, B. and GOPALAN, C. Chemical composition of human milk in poor Indiami women. proportion of patients with vitamin A de- Ind. J. M. Res., 47: 234, 1959. ficiency who had keratomalacia was much 7. HUME, E. M. and KREBS, H. A. Vitamin A re- greater in Hyderabad than in Coonoor. quirement of human adults. In : Medical Re- Levels of vitamin A and carotene in the search Council Special Report Series No. 264. serum were low in all children with vitamin A London, 1949. H.M. Stationery Office. deficiency. Levels of vitamin A in the serum 8. MOORE, T. Vitamin A, p. 239. Amsterdam, 1957. Elsevier Publishing Company. of subjects with kwashiorkor but without 9. AYKROVD, \V. R. Proceedings of a conference on clinical signs of vitamin A deficiency were also

Hypovitaminosis A, held at Princeton, in 1958. Downloaded from found to be significantly lower than the levels Fed. Proc., 18: 103, 1958. in apparently normal children. Treatment 10. PLATT, B. S. Personal comniunication. with a high protein diet without vitamin A 11. SONESWARA, R. K., DE, N. K. and SUBBA, R. D. supplementation brought about a significant Investigation of outbreak of night blindness in a village near Madras. Indian J. 11. Res., 41 : 349, increase in the levels of vitamin A in the serum 1953. in the latter. www.ajcn.org 12. KIMBLE, M. S. and GORDON, E. S. The importance The in vitro destruction of vitamin A by lysed of riboflavin and ascorbic acid in the utilization red blood cells of children suffering from vita- of vitamin A. J. Biol. Chem., 128: Proc. 52, mm A deficiency appeared to be higher than 1939. that of the normal controls Treatment with 13. STEWART, C. P. Experiment with dark adaptation by on October 7, 2010 test. J. Physiol., 95: Proc. 28, 1939. vitamin A lowered this abnormal in vitro 14. STEWART, C. P. Nutrition factors in dark adapta- destruction. tion. Edinburgh M. J., 48:217, 1941.

15. ARROYAVE, G., VITERI, F., BEHAR, M. and SCRIM- ACKNOWLEDGMENT SHAW, N. S. Impairment of intestinal absorption We are grateful to the Director of Medical Services, of vitamin A Palmitate in severe protein malnu- Andhra Pradesh, and to the Superintendent of Niloufer trition (kwashiorkor). Am. J. Gun. Nutrition, 7: Hospital in Hyderabad for permitting us to use their 185, 1959. facilities during this investigation. 16. JAGANNATHAN, S. N. Master’s thesis submitted to the University of Bombay, 1959. REFERENCES 17. McLAREN, D. S. Influence of protein deficiency 1. POLLARD, C. J. and BIERI, J. C. The destruction of and sex on the development of ocular lesions and vitamin A. Brit. J. Nutrition, 12: 359, 1958. survival time of the vitamin A deficient rat. 2. OOMEN, H. A. P. C. Proceedings of a conference on Brit. J. Opth., 43: 234, 1959. Hypovitaminosis A, held at Princeton in 1958. 18. KON, S. K., MCGILLYRAY, W. A. and THOMPSON, Fed. Proc., 18: 103, 1958. S. Y. Metabolism of carotene and vitamin A 3. VENKATACHALAM, P. S. and GOPALAN, C. Kwash- given by mouth or vein in oily solution or aqueous iorkor in Hyderabad and Coonoor. Indian J. dispersion to calves, rabbits and rats. Brit. J. ill. Res., in press. Nutrition, 9: 244, 1955.