Post Graduate Student , Community Medicine Department

1. PEM & Vitamin A deficiency
Dr.Praseeda.BK

2. PEM

3. The cellular imbalance between
To ensure
growth, maintenance, and
specific functions
supply of nutrients
& energy
and the body's demand
for them
Malnutrition

4. Reasons..
• Inadequate intake of food (Quality & Quantity)
• Infections

5. Malnutrition infection cycle

6. Factors related to Malnutrition
Social & Economic Biological factors
 Poverty
 Ignorance
 Female gender
Rural area
Low birth weight
Illiterate mother
Scheduled caste/
scheduled tribe
Cultural & social practices
Maternal malnutrition, prematurity
Birth spacing < 47 months
Age of mother: 18 – 23 yrs
Birth order > 3
Underweight status of
mothers
Infectious disease
Diarrhea, TB, measles,
Malaria, AIDS
Environmental
Unsanitary living,
Droughts, floods, wars, forced
migrations

7. Nutritional
intakes
Nutrition
needs
Nutritional
intakes
Nutritional status
The result is
Under- Nutrition

8. UNDERNUTRITION
ACUTE
UNDERNUTRITION
CHRONIC
UNDERNUTRITION
• Marasmus
• kwashiorkor
• Marasmic- kwashiorkor
• Wasting
• Stunting
• Underweight

10. Features Marasmus Kwashiorkor
Clinical Always Present
Muscle Wasting Obvious Sometimes hidden
by edema & fat
Fat wasting Severe Loss of
subcutaneous fat
Often retained but
not firm
Oedema None In lower legs ,face,
forearms.
Weight for height Very low Low but masked by
edema
Mental changes Quiet & Apathetic Irritable , moaning ,
apathetic

11. Features Marasmus Kwashiorkor
Clinical Sometimes Present
Appetite Usually good Poor
Diarrheoa Often Often
Skin changes None Flaky paint
dermatosis
Hair changes Seldom Sparse , silky ,easly
pulled out
Hepatic
enlargement
None Sometimes due to
fat accumulation

12. Features Marasmus Kwashiorkor
Biochemical Sometimes Present
Serum albumin Normal or slightly
decreased
Low
Urinary Urea per g
Creatinine
Normal or slightly
decreased
Low
Hydroxyproline
creatinine ratio
Low Low
Plasma aminoacid
ratio
Normal Elevated

13. Physical examination
• History- including detailed dietary history.
-Anthropometric measurements.
» Weight
»Length/height
»Mid upper arm circumference MUAC)
»Chest circumference
»Head circumference
»Anthropometric Measurements of
Nutritional Status

14. WEIGHT
At 5-6 month double of
birth weight
At 3 years weight 5 time
double of birth weight
At 6 years weight 6 times
double of birth weight.

15. HEIGHT
• 1 yr 72-75 cm
• 2 yrs 88-90 cm
• 4 yrs 100 cm.

20. >13.5
13.513.5

21. Prevention

22. 1. Health Promotion
1. Measures directed to pregnant & lactating
women
2. Promotion of breast feeding
3. Development of low cost weaning food
4. Measures to improve family diet
5. Nutrition education
6. Home economics
7. Family planning & spacing of births
8. Family environment

23. 2. Specific Protection
1. Child’s diet must contain protein & energy
rich foods
2. Immunization
3. Food fortification

24. 3. Early diagnosis & Treatment
1. Periodic Surveillance
2. Early diagnosis of any lag in growth
3. Early diagnosis & treatment of infections and
diarrhoea
4. Development of programmes for early
rehydration of children with diarrhoea
5. Development of supplementary nutrition
programmes during epidemics
6. Deworming of heavily infested children

25. Rehabilitation
• Nutritional rehabilitation services
• Hospital treatment
• Follow up care

26. Vitamin A deficiency

27. Sources
1. Animal foods – Retinol(preformed vit A)
 Liver, Eggs,Cheese,Fish, Meat
2.Plant foods – Carotene(provitamines)
 GLV ,mango, papya, carrots, yellow
pumkin, red palm oil.
3.Fortified foods –
 vanaspati, margarine, milk

28. xerophthalmia
• The term xerophthalmia was given by a joint WHO
and USAID committee in 1976 to cover all ocular
manifestations of Vitamin A deficiency in human.
- Most common in children aged 1-3 years often
related to weaning.
- Marker – serum Retinol level
- Normal – 7 micromol / litre(200 micro g/ litre)

29. • Risk factors–
Ignorance
Faulty feeding practices
Infections – measles, diarrhoea, RTI
Lack of education

30. Current status of VAD in India
• Clinical VAD has declined drastically during the
last 40 years.
• There has been virtual disappearance of
keratomalacia, and a sharp decline in the
prevalence of Bitot spots .
• Prevalence of Bitot spots of 0.5 per cent and
more is limited to population groups which are
socio-economically backward, poverty stricken
and have poor health infrastructure.

31. XEROPHTHALMIA
CLASSIFICATION(modified)
• XN Night blindness
• X1A Conjunctival xerosis
• X1B Bitot’s spots
• X2 Corneal xerosis
• X3A Corneal ulceration /keratomalacia affecting less
than 1/3rd corneal surface
• X3B Corneal ulceration /keratomalacia affecting more
than 1/3rd corneal surface
• XS Corneal scar due to xerophthalmia.
• XF Xerophthalmic fundus.

32. Ocular changes.

33. 1. Night Blindness
• First symptom
• Due to impairment in dark adaptaion
• Defective rhodopsin function.
• May get worse when there is diarrhoea or
other infection

34. 2. Conjunctival xerosis
 First clinical sign
One or more patches of dry,
lustreless,nonwettable conjunctiva.
Interpalpebral conjunctiva(commonly temporal
quadrants)
Severe cases involves the entire bulbar
conjunctiva.
Desribed as ‘emerging like sand banks at
receding tide’when child ceases to cry

35. 3. Bitot’s spots
- Triangular, pearly white, yellowish foamy spots in the
bulbar conjunctiva
- Usually bilateral
- Characterised by metaplasia of conjunctival epithelium
and tangles of keratin admixed with gas forming
bacteria(corynebacterium xerosis)
- Vitamin A is essential for cell differentiation

36. 4. Corneal xerosis
- Serious stage
- Cornea become dull, dry, non-wettable
- Severe cases- ulceration leading to scars.
• Bilateral punctate corneal epithelial erosions
• Can progress to epithelial defects
• Reversible on treatment

37. 5. Keratomalacia
Liquefaction of cornea.
 Medical emergency.
Rapid process.
Stromal defects occur in late stages due to
colliquative necrosis leading to corneal
ulceration ,softening (melting) and destruction
of cornea(keratomalacia)

38. Assessment of Vit A deficiency
• Prevalence criteria for determining
xerophthalmia
Criteria Prevalence in population
at risk
Nightblindness >1%
Bitot’s spots >0.5%
Corneal xerosis/corneal
ulceration/keratomalacia
>0.01%
Corneal ulcer >0.05%
Serum Retinol(<10 mcg/dl) >5%

39. Treatment
- Should be treated urgently
- early stages reversed by massive doses (2L IU)
orally on 2 successive days.

40. Prevention

41. Short term actions
Administration of large amount of Vit A orally
to vulnerable groups in a periodic basis
Most effective strategy

42. Medium – term action
Fortification of foods –
dalda,sugar,salt,tea,margarine
Cereal based foods

43. Long term action
Elimination of Factors contributing to ocular
diseases
Persuading people to consume dark GLVS and
other Vit A rich foods.
Promotion of breast feeding
Improvement of environmental health
Dietary diversification

44. Dietary diversification
• Cultivation of variety of staple food with a high
viatmin and mineral content.
• It holds the ability to concurrently cover multiple
micronutrient deficiencies.
• If supported with a nutrition education
programme, may be more effective in the
developing countries.

45. Sanitation & hygiene
Safe water supply
Environmental sanitation
Proper hygiene
Food safety
Regular deworming
Immunization against DPT, cholera

46. National programme for prevention of
nutritional blindness 1970
• The programme is sponsored by the Ministry of
Health and Family Welfare, Government of India
- Beneficiaries children below 5 years.
- Objectives
 Promoting consumption of Vit A rich foods
 Administration of massive dose of Vit a upto 5 years
First dose of 1 L IU with measles at 9 months
Subsequent dose of 2 L IU every 6 months upto 5 years
of age
 9 mega doses

47. Thank You