Dr.V.Akila Devi DNB PG Southern Railway Headquarters Hospital Chennai

Transcription

1 Dr.V.Akila Devi DNB PG Southern Railway Headquarters Hospital Chennai

2 9 /12, male infant 3 rd born, NCM Not gaining motor mile stones appropriate for age Recurrent respiratory tract infections x 3 months Recurrent diarrhoea x 3 months

3 Recurrent Respiratory infection / Diarrhoea Initially warranted op basis treatment Later RRTI - asso with fever, chest indrawing Diarrhoea severe dehydration Required hospitalisation, IVF & IV antibiotics

4 HOSPITALISED SEVEN TIMES IN THE PREVIOUS TWO MONTHS & HAD SPENT AROUND TWO LAKHS FOR THE SAME BEFORE COMING TO OUR HOSPITAL.

5 In view of recurrent RTI & Diarrhoea,the child was investigated for Immunodeficiency outside which was not contributing

6 Uneventful antenatal period Term,NVD B.Wt kg Neonatal period no events Breast feeding initiated within 1 hr Immunised for age Anthropometry normal till 3 months as documented during vaccine visits

7 FAMILY HISTORY Mother s age at the time of conception - 27 yrs 1 st sibling, female,2 ½ yrs 2 nd sibling, female, 1 ½ yrs Father - Unemployed Mother Sole earning member

8 EBF -5 mo Complementary feeds from 5 th month No vitamin supplementations

9 DEVELOPMENT: Social smile -2/12 Head control -5/12 Rolling over -7/12 Sitting with support - not attained Monosyllables -8/12 No DENTITION

10 O / E Irritable, Undernourished infant, Sick looking No pallor,cyanosis,clubbing,pedal edema, significant LN VITALS: Temp : 101 degree F HR : 124 / min RR : 62 / min BP : 80 /70 mmhg RUL Supine position

11 HEAD TO FOOT EXAMINATION NORMAL EXCEPT FOR

12 RACHITIC ROSARY

13 ANTHROPOMETRY : Wt : 6.5 kg Below 3 rd centile Length : 64 cm Below 3 rd centile HC : 42 cm B/W 3 rd & 15 th centile CC : 40cm

14 SYSTEMIC EXAMINATION: RS : BAE / SCR + /ICR + / B/L Crackles + CVS: S1 S2 + / No Murmur P/A : Soft /Mild protrusion + / No palpable organomegaly CNS: NAD

15 INVESTIGATIONS

16 CBC TC 31, HG PLT 5,41,000 4,12,000 DC 26/3/8/63 24/0/6/68

17 ABG, LFT, RFT, ELECTROLYTES - WNL HIV Serology Mx Stool Exam Urine R/E & C/S - Negative - Negative - N - N

18 Sr.Calcium m g / dl Phosporus inorg mg / dl SAP iu / L S. 25(OH) D - 12 ng / ml

19 CXR - Brochopneumonia Rachitic rosary

20 X-Ray Wrist

21 CUPPING FRAYING WIDENING OF GROWTH PLATE

22 DIAGNOSIS NUTRITIONAL RICKETS

23 TREATMENT IVF ANTIBIOITICS SUPPORTIVE TREATMENT FOR DIARRHOEA VIT D INJ 6,00,000U 1 Dose along with calcium supplementation.

24 IN THE FOLLOW UP.. After 3 weeks Alert & Well looking Gained wt around 1 kg Sitting without support Standing with support Waving Bye Bye Decreasing SAP levels

25 Follow up X ray Zone of calcification

26 DISCUSSION

27 VITAMIN D FAT SOLUBLE VITAMIN STEROIDOGENIC HORMONE PLAY VITAL ROLE IN CALCIUM METABOLISM & IMMUNE REGULATION

28 RDA 0 12 months iu / day > 12 months iu / day Pregnant & lactating mothers iu / day

29 Food Cholesterol per 100 g Vitamin D per 100 g Cod liver oil 570 mg* 10,000 IU (up to 25,555 IU) Herring 12.9 mg 680 IU Oysters 54 mg 642 IU Catfish 81 mg 500 IU Sardines 142 mg 480 IU Mackerel 95 mg* 450 IU Salmon 87 mg 320 IU Caviar 588 mg* 232 IU Shrimp 173 mg 172 IU Butter 218 mg 56 IU Whole Egg (contained in Yolk only) 424 mg 49 IU All Plant Foods 0 mg 0 IU

30 DEFICIENCY NUTRITIONAL CONGENITAL SECONDARY Malabsorption Increased Degradation Decreased liver 25 hydroxylase

31 DEFICIENCY Vitamin D Severe deficiency is typically defined as circulating 25D concentrations <10ng/ml Vitamin D deficiency is typically defined as circulating 25D concentrations 15-10ng/ml vitamin D insufficiency is for ranges that fall between ng / ml 25D concentrations >20 ng/ml vitamin D sufficient category

32 SYNTHESIS & ACTION

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34 ROLE IN IMMUNE MECHANISM

35 1,25 D binds to the vitamin D receptor (VDR) VDR expression is found in monocytes as well as stimulated macrophages, dendritic cells, natural killer cells, T cells, and B cells of the immune system. In immune cells, VDR activation elicits potent antiproliferative, prodifferentiative, and immunomodulatory effects.

36 Activation of the VDR by 1,25D, alters cytokine secretion patterns, suppresses effector T-cell activation, induces regulatory T cells. In dendritic cells, affect maturation, differentiation, and migration. 1,25D can enhance the phagocytic activity of macrophages and increase the activity of natural killer cells.

37 chemotactic activity and random motility of neutrophils will be defective in VIT D deficiency A possible relationship between defective neutrophil movement and the recurrent infections seen in these patients is suggested. The possible mechanisms responsible for the defect could be the alteration in Ca/P metabolism or a defective action of the vitamin D on the neutrophils.

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39 MECHANISM OF IMMUNITY ENTRY OF PATHOGEN ACTIVATION OF TLR & MONOCYTE / MACROPHAGE STIMULATION OF 1 ALPHA HYDROXYLASE &VDR IN MITOCHONDRIA CONVERSION OF 25 OH D TO 1,25 OH D ACTS ON VDR

40 TRANCRIPTION OF GENES PRODUCTION OF ANTIBACTERIAL PROTEIN Cathelicidin B Defensin FACILITATES AUTOPHAGOSOMES GENERATION BACTERIAL KILLING

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42 RISK FACTORS EBF WITHOUT VIT D SUPPLEMENTATION DARK SKIN DECREASED OUTDOOR PLAY COVERING OF BODY CULTURAL SUNSCREEN MALABSORBTION OBESITY DECREASED SPACING B/W PREGNANCY MATERNAL VIT D DEFICIENCY

43 RECOMMENDATIONS Vit D level in Breast Milk is around iu/l VERY LOW than the RDA of Vit D ( 400 iu / d ) AAP recommends supplementation of 400 iu of Vit D /day starting from the newborn period Also to be continued through out adolescent period Prevents RRTI s & Pneumonia Reduces Mortality & Morbidity in Infants and Children

44 MOST OF THE COMMON MV DROPS IN MARKET CONTAINS 400 IU VIT D / 1 ml SO NEWBORNS & CHILDREN SHOULD BE RECOMMENDED CORRECT AMT TO PREVENT THEM FROM VIT D DEFICIENCY

45 TAKE HOME MESSAGE In any child presenting with recurrent infections, Possibility of vit D deficiency/insufficiency should be considered SAP along with serum calcium & phosphorus may be a useful initial investigation before undertaking expensive investigation / intervention

46 REFERENCES Mol Cell Endocrinol. Author manuscript; available in PMC 2011 June 10. WHO/UNICEF. Global action plan for prevention and control of pneumonia (GAPP). Geneva, Pediatric Research:May 2009-Volume 65 - IssuePart 2 Infections and Immunity: Vaccines and Immunomodulators

47 Vitamin D Supplementation for Severe Pneumonia A Randomized Controlled TrialFrom Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India

48 PRESENTATION AND PREDISPOSING FACTORS OF NUTRITIONAL RICKETS IN CHILDREN OF HAZARA DIVISION Tahir Saeed Siddiqui, Manzoor Illahi Rai* Departments of Pediatrics, Ayub Medical College Abbottabad and *Women Medical College Abbottabad

49 NEXT CITY PEDIATRIC MEET VENUE : SOUTHERN RAILWAY HEADQUARTERS HOSPITAL, PERAMBUR CONTACT NO : kandoc@yahoo.com

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