24.3 Vitamin Deficiencies

24.3.1 Vitamin A Deficiency (VAD)

A condition predominantly affecting the skin, mucous membranes and the eyes. It is most common in children of 1–5 years of age. If associated with measles and diarrhoea there is an increased risk of illness and death. If not identified and treated early, it can cause blindness.

Clinical features: include

• Night blindness or inability to see in the dark
• White foamy patches on the eye (Bitot’s spot) or conjunctival and corneal dryness
• keratomalacia or wrinkling and cloudiness of cornea
• Corneal ulceration or the cornea becomes soft and bulges

General measures: Dietary supplementation with vitamin-A rich food include:

• fortified maize meal and/or bread, fortified margarine
• carrots, sweet potato, mangoes and pawpaw, broccoli, sprouts
• dark green leafy vegetables e.g. matembele, mnafu and spinach
• apricots, melon, pumpkin
• liver, eggs, full cream milk and fish

Pharmacological Treatment

For Prophylaxis

Vitamin A (retinol), oral, every 6 months up to the age of 5 years.

Age range	Dose units	Capsule 100,000u	Capsule 200,000 u
Infants 6–11 months	100,000	1 capsule	–
Children 12 months–5 years	200,000	2 capsule	1capsule

For Treatment

Children 0–5 years of age, with:

• Severe under nutrition/malnutrition
• Persistent diarrheoa
• Any of the clinical signs of vitamin A deficiency
• Measles

A: Vitamin-A (retinol), oral, every 6 months up to the age of 5 years.

Age range	Dose Unit(IU)	Capsule 100,000IU	Capsule 200,000IU
Infant < 6 months	50,000	½ capsule	–
Infants 6–11 months	100,000	1 capsule	–
Children 12 months–5 years	200,000	2 capsule	1 capsule

Administration of a vitamin A capsule

• Cut the narrow end of the capsule with scissors.
• Open the child’s mouth by gently squeezing the cheeks.
• Squeeze the drops from the capsule directly into the back of the child’s mouth. If a child spits up most of the vitamin A liquid immediately, give one more dose.

Children > 5 years of age and adults with:

• Any clinical signs of vitamin A deficiency
• Measles

Note: Do NOT give the capsule to the mother or the caretaker to take home. • Children who received a prophylactic dose within the previous month should not receive the treatment dose of vitamin A. • If a child is scheduled to receive a routine prophylactic dose of vitamin A and has received a treatment dose within the past month, postpone the routine dose for approximately one month. • Wait at least one month between doses. • Children receiving routine multivitamin syrup can still receive vitamin A supplements.

Referral:

All complicated cases.

24.3.2 Vitamin B Deficiencies

A condition in which some of the B group vitamins are deficient. This occurs commonly in malnutrition and alcoholism.

General measures

• Lifestyle adjustment
• Discourage alcohol abuse

Pharmacological Treatment: For all forms of vitamin B deficiencies:

A: Vitamin B complex, oral, 2 tablets 3 times daily for one week, then 1 tablet daily for 3 months.

24.3.2.1 Vitamin B₃/Nicotinic Acid Deficiency (Pellagra)

Pellagra is a condition associated with nicotinic acid deficiency. It is usually accompanied by other vitamin deficiencies.

Clinical features: include

• diarrhoea
• dementia
• dermatitis with darkening of sun-exposed skin

General measures

Lifestyle adjustment including discouraging of alcohol abuse.

Dietary advice: Increase intake of

• liver, kidneys, other meats, poultry and fish
• peanuts
• milk
• pulses, whole meal wheat and bran

Pharmacological Treatment

For severe deficiency

Children: C: Nicotinamide, oral, 50 mg 8 hourly for one week.

Adults C: Nicotinamide, oral, 100 mg 8 hourly for one week.

For mild deficiency

Children C: Nicotinamide, oral, 50 mg daily for one week.

Adults C: Nicotinamide, oral, 100 mg daily for one week.

Referral: On failure to respond on above treatment.

24.3.2.2 Vitamin B₆/Pyridoxine Deficiency

Commonly presents as signs of peripheral neuropathy including:

• tingling sensation
• burning pain or numbness of the feet

Pyridoxine deficiency is related to:

• Malnutrition
• Alcoholism
• Isoniazid or combination TB therapy

General measures:

Dietary advice: Increase intake of pyridoxine rich foods such as:

• Liver, meat, fish and offal,
• Wholegrain cereals, fortified breakfast cereals,
• Peanuts, bananas, raw vegetables,
• Walnuts and seeds, avocados, dried fruits,
• Potatoes and baked beans.

Pharmacological Treatment

For deficiency

Children: B: Pyridoxine 12.5mg (PO) daily for 3 weeks.

Adults: B: Pyridoxine, 25 mg (PO) daily for 3 weeks.

For medicine-induced neuropathy

Children C: Pyridoxine, 50mg (PO) daily for 3 weeks.

Adults C: Pyridoxine, 200mg (PO) daily for 3 weeks.

Then followed by:

C:Pyridoxine, 25mg (PO) daily as maintenance dose (for patients on TB therapy/isoniazid)

Referral:

• Failure to respond.
• Children.

24.3.2.3 Vitamin B₁/Thiamine Deficiency (Wernicke Encephalopathy and Beriberi) Clinical features: include

• confusion
• short term memory loss
• paralysis of one or more of the ocular muscles or ophthalmoplegia
• nystagmus
• ataxia
• peripheral neuropathy
• cardiac failure

Alcoholics may present with Wernicke encephalopathy, neuropathies or cardiac failure associated with multiple vitamin deficiencies.

General Measures

Lifestyle adjustment including discouraging of alcohol abuse.

Dietary advice: to increase intake of thiamine rich foods such as:

• Whole wheat breads, oatmeal
• Pulses, nuts, yeast
• Fortified cereals
• Pork, bacon and marmite
• Potatoes and peas

Pharmacological Treatment

Peripheral neuropathy and cardiac failure

Thiamine, oral, 100 mg daily.

24.3.2.4 Vitamin B₁₂ (Cobalamin) Deficiency

(See section 24.1.2 on megaloblastic anaemia)