NUTRITIONAL DEFICENCYS IN CHILDREN.pdf

NUTRITIONAL
DEFICIENCIES IN
CHILDREN
D R . K U N A L B H AT I A
I - M D S

OUTLINE
• Keywords
• Introduction
• Paediatric Undernutrition
• Protein Deficiency
• Vitamin Deficiency
• Mineral Deficiency
• Lipid Deficiency
• Obesity
• Conclusion
• References

KEYWORDS
• Nutrition
• Balanced Diet
• Macronutrients
• Micronutrients

INTRODUCTION
• High nutritional requirements of the infant- vulnerable to
undernutrition
• Proper nutrition- essential for normal growth, resistance to
infection, long term adult health and for optimal neurologic
and cognitive development
Current Paediatric Diagnostic and Treatment, 16th edition. William W. Jay, Jr. “Nutritional Childhood Nutrition
and its Disorders”. Pages 277-283

TYPES OF MALNUTRITION
Protein-energy malnutrition
Acute
Chronic
Micronutrient deficiency
Deficiency of
specific
micronutrients
London School of Hygiene and Topical Medicine; lshtm.ac.uk

INDIAN ACADEMY OF PAEDIATRICS (IAP)
CLASSIFICATION OF MALNUTRITION
• 71-80% of expected weight for age
Grade I (Mild)
Grade II (Moderate)
Grade III (Severe)
• <50% of expected weight for age
Grade IV (Severe)

MALNUTRITION…
Severe Acute Malnutrition (SAM)
• Mid-upper arm circumference <115 mm, above 6 months of age
Moderate Acute Malnutrition (MAM)
• MUAC between 115 and 125 mm
In India, SAM affects approximately 8.1 million children with 0.6 million deaths per year

PAEDIATRIC UNDERNUTRITION
Inadequate
food supply
Diseases
Poor access
to food
Inadequate
dietary intake
Nelson’s Essentials of Paediatrics, 1st South Asia Edition. “Paediatric Nutrition and Nutritional
Disorders” pages 88-93

FAILURE TO THRIVE
• Circumstances in which a child fails to gain weight
appropriately
Ref:
• Acute loss of weight or failure to gain
weight
• Reduced weight for height
Wasting
• Chronic malnutrition
• Reduction in height for age
Stunting

PROTEIN DEFICIENCY-
MARASMUS
Ref:
Inadequate caloric
and nutrient intake
Large,
disproportionate
head
Dry and thin skin
Hair is thin, sparse
and easily pulled out
Apathic, weak,
irritable children
Bradycardia and
Hypothermia (severe
cases)

PROTEIN DEFICIENCY-
KWASHIORKOR
• Decreased dietary protein as
well as increased insulin levels
• Free radical damage and failure
of sodium-potassium pump
leading to oedema
• Body weight is normal for age
• Apathy
• Disinterest in eating
Current Paediatric Diagnostic and Treatment, 16th edition. William W. Jay, Jr. “Nutritional Childhood Nutrition and its
Disorders”. Pages 277-283

Parotid Enlargement, Angular
Cheilitis
Stomatitis, Atrophy of filiform
papillae
“Flag Sign” “Flaky Paint” rash, Macular rash
Sparse Hair, Distended Abdomen

ORAL HEALTH CHANGES IN PROTEIN
DEFICIENCY
• On jaws and teeth:
– Crowded and rotated teeth in mouth-breathing adolescents (Thomaz
E et al, 2010)
– Inadequate development or retarded growth of jaw bone (Luke DA
et al, 1981)
– Delayed eruption and hypoplasia (Sheetal A et al, 2013)
– Decreased function of salivary glands (Sheetal A et al, 2013)

ORAL HEALTH CHANGES IN PROTEIN
DEFICIENCY
• On Dental Caries
– No direct evidence of a correlation between dental caries experience
and dietary supplementation of protein
– Protein deficiency after tooth eruption- increased ingestion of
carbohydrates which increases caries incidence
Nizel AE, Papas AS. Nutrition in Clinical Dentistry, 3rd edition. WB Saunders Co.; 1989. Pages 74-77

VITAMINS
Fat Soluble Vitamins
• Vitamin A
• Vitamin D
• Vitamin E
• Vitamin K
Water Soluble Vitamins
• Vitamin B complex
• Vitamin C (Ascorbic
Acid)
Nizel AE, Papas AS. Nutrition in Clinical Dentistry, 3rd edition. WB Saunders Co.; 1989. Page 91

VITAMIN A
Preformed
Vitamin A
Provitamin A
“Visual Purple”
Differentiation of
mucosa
Bone remodelling
Health of oral
structures
Dairy food
Fish liver oils
Animal foods
Deep yellow or
deep green
vegetables
Plant foods
Nizel AE, Papas AS. Nutrition in Clinical Dentistry, 3rd edition. WB Saunders Co.; 1989. Pages 125-
131

VITAMIN A DEFICIENCY
General Health Impaired Immunity
Periodontium Severe pocket formation
Proliferation of basal cells and decreased cellular infiltrate
Teeth No direct effect in human teeth; brittle teeth demonstrated
in rats
Increased risk of caries due to reduced saliva
Salivary Glands Atrophy
Reduced salivary flow
Oral mucosa Epithelial metaplasia
Hyperkeratinisation
Cleft Lip and
Palate
Vitamin A has a protective effect against Cleft Lip and Palate
Night Blindness and
Xeropthalmia
• Bitot’s spots
• Imtiaz’s sign
131

VITAMIN D
• Promote intestinal absorption of calcium and phosphorus
• Renal tubular transport of calcium and phosphorus
• Formation and functioning of bones, teeth, nerves and muscles
Vitamin D1
Vitamin D3
(cholecalciferol)
Vitamin D2
(ergocalciferol)
136

VITAMIN D DEFICIENCY
Rickets
• Decreased
calcification of
cartilaginous bone
Enamel Hypoplasia
• First dental change
• Rough enamel
attracts plaque
Delayed Eruption of
Teeth
• Associated with
rickets
136

• Frontal bossing and
soft skull
• “Rickets rosary”
• “Pigeon breast”
• “Harrison’s groove”
• Bow-shaped legs
Rickets
medweiser.com/clinic-hours/rachitic-rosary
pedclerk.bsd.uchicago.edu
Nizel AE, Papas AS. Nutrition in Clinical
Dentistry, 3rd edition. WB Saunders Co.; 1989.

“ C A L C I O -
T R A U M A T I C
L I N E ”
• S I G N O F A C U T E
D E F I C I E N C Y O F
V I T A M I N D
• H Y P O C A L C I F I E D
D E N T I N
Goldberg M et al. Mediators of inflammation; 2015

VITAMIN E
Functions:
• Tocopherols (α-
tocopherol- 90%)
• Biological antioxidant-
inhibits peroxidation of
poly-saturated fatty
acids of cell
membranes
Deficiency:
• Anaemia, seen in premature infants
and in children with cystic fibrosis or
congenital atresia of bile ducts
• Due to loss of stability of
erythrocytes leading to haemolysis
139

VITAMIN K
Ref:
Functions
Catalyse the synthesis of blood clotting factors- II (Prothrombin), VII
(Proconvertin), IX (Christmas factor) and X (Stuart factor)
Vitamin K1 Vitamin K2 Vitamin K3

VITAMIN K DEFICIENCY
• Dietary deficiency is rare due to intestinal synthesis
• Seen in Biliary disease, Coeliac disease, Pancreatic disease,
severe ulcerative colitis, cholecystectomy,
• Haemorrhagic disease of the new-born
– Generalised ecchymosis and gastrointestinal haemorrhage
142

VITAMIN B COMPLEX
Energy-releasing B
vitamins
• Thiamine
• Niacin
• Riboflavin
• Pantothenic acid
• Biotin
Haematopoietic B
vitamins
• Folacin
• Vitamin B12
Vitamin B6

THIAMINE (VITAMIN B1)
Functions:
• Energy metabolism (as
thiamine
pyrophosphatase)
• Coenzyme for
production of RNA and
DNA
• Carbohydrate, Protein
and Fat metabolism
• Transmission of neural
impulses
Deficiency:
• Individuals who consume polished
rice, uncooked shellfish, or who have
restricted diet
• BERIBERI- wet, dry and infantile
• Increased sensitivity of oral mucosa,
burning tongue, loss of taste

THIAMINE DEFICIENCY
Wet Beriberi
• Pitting oedema in
legs or generalised
oedema
• Cardiomegaly,
systolic murmurs
• Dyspnoea
Dry Beriberi
• No oedema
• Prickling sensation
and numbness of
feet
• Leg cramps
Infantile Beriberi
• Dyspnoea
• Increased sensitivity
of oral mucosa
• Burning tongue with
loss of taste

RIBOFLAVIN (VITAMIN B2)
Functions:
• Coenzymes- Flavin mononucleotide and Flavin Adenosine
Dinucleotide (FAD) are responsible for ATP production
• Metabolism of carbohydrates, proteins and fats

RIBOFLAVIN DEFICIENCY
ARIBOFLAVINOSIS
• Cracks in the corners of the mouth (angular stomatitis),
inflammation and fissuring of the tongue (Magenta tongue)
• Eye- increase in blood vessels, opaque areas on cornea and
ulceration
• Skin- Dermatitis around the nasolabial folds
• Lesions on the canthi and lobes of the ears

http://www.infonet-biovision.org/HumanHealth/Ariboflavinosis-Vit-B2-deficiency
Magenta tongue

NIACIN (VITAMIN B3)
Functions:
• Forms active portion of coenzymes supplying oxygen and
energy to all body tissues
• Nicotinamide adenine dinucleotide (NAD) and
nicotinamide adenine dinucleotide phosphate (NADP)
• Normal functioning of CNS, integrity of skin and mucous
membranes

NIACIN DEFICIENCY
PELLAGRA
• Dermatitis, Diarrhoea, Depression, Death
• Soreness and inflammation of tongue (glossitis)
and mouth (stomatitis)
• Secondary infection with fungi or bacteria (e.g.,
fusiform bacilli and spirochetes), acute
necrotising ulcerative gingivitis (Vincent’s
infection)
• Painful eating and swallowing
• Neurodegenerative changes- depression,
confusion, hallucinations and delirium
https://ufhealth.org/pellagra

PANTOTHENIC ACID (VITAMIN B5)
Functions:
• Initiates Krebs cycle and
releases ATP
• Coenzyme A- Starting
substance for the
biosynthesis of long-
chain fatty acids,
cholesterols and other
sterols, and porphyrin
Deficiency:
• Fatigue, sleep disturbances,
headaches, malaise, nausea and
abdominal stress
• Burning, prickling sensation of hands
and feet (paraesthesia), cramping of
leg muscles and impaired
coordination

VITAMIN B6
Functions
Synthesis and breakdown of amino
acids
Conversion of tryptophan to Niacin
Metabolism of polyunsaturated
fatty acids
Normal functioning of nervous
tissue
Conversion of glycogen to glucose
Pyridoxine Pyridoxamine
Deficiency
Seen in infants and children who
are fed canned milk formula
Severe irritability, convulsions, loss
of appetite, nausea, drowsiness,
peripheral neuropathy
Cheilosis, glossitis, stomatitis,
itching and burning dermatitis in
nasolabial folds
Pyridoxal
102

BIOTIN (VITAMIN B7)
Functions:
• Coenzyme for the
formation of purines
and thus DNA and RNA
Deficiency:
• Seen in infants treated with sulpha-
drugs
• Dermatitis, Alopecia
• Loss of appetite and sleep, nausea,
muscle pain, hyperaesthesia
• Glossitis
101

FOLACIN/FOLIC ACID (VITAMIN B9)
Functions:
formation of purines
and pyrimidines
• DNA formation and
repair
• Manufacturing and
maturation of blood
cells
Deficiency:
• Most common vitamin deficiency in
humans
• Dietary insufficiency or disorders of
malabsorption in infectious diseases
• Administration of folate antagonists
(e.g. Methotrexate in leukaemia)
107

FOLACIN/FOLIC ACID
DEFICIENCY
• Principal oral symptom- burning of
oral mucosa
• Tongue- red, sore and swollen
• Angular cheilitis and gingivitis
107
step2.medbullets.com

VITAMIN B12 (COBALAMIN)
Functions:
formation of purines and
pyrimidines
• Affects rapidly dividing
cells (e.g., RBC precursor
cells)
• Maintenance of myelin
sheath
Deficiency:
• PERNICIOUS ANAEMIA
• Presence of megaloblasts in bone
marrow
• Macrocytic red blood cells
110

VITAMIN B12 (COBALAMIN)
Deficiency contd.:
• “Combined system syndrome”
– Neurologic symptoms- difficulty in walking, coordination of
movements, peripheral neuritis
– Lemon-yellow complexion due to haemolytic jaundice
– Fast heartbeat, ankle swelling
• Atrophic glossitis
110

ORAL SIGNS OF VITAMIN B COMPLEX
DEFICIENCY
Increased
susceptibility to
infections
Inflammatory
changes in mucosa
Softening and
fissuring of corners
of the mouth
Inflammation and
painful ulcerations
of the tongue
104

VITAMIN C (ASCORBIC ACID)
Functions:
• Formation of collagen
• Enhances iron absorption and prevents megaloblastic anaemia of
infancy
• Phagocytosis and detoxification
• Synthesis of adrenal hormones
• Metabolism of Tyrosine
115

VITAMIN C DEFICIENCY
Scurvy/ Barlow’s Disease
• Severe marginal gingivitis
• Bluish gingiva that haemorrhages spontaneously or on slight
provocation
• No mucosal changes seen in edentulous areas
• Secondary infections- ANUG
• Lack of periodontal support- premature exfoliation; interruptions in
lamina dura
119

VITAMIN C DEFICIENCY…
• Failure to grow properly, weakness, restlessness, irritability
• Aversion to moving the extremities because of painful swollen joints
• Haemorrhages in the joints- “scurvy lines”
• Odontoblasts show atrophy leading to irregular dentin or no dentin
at all
• Few odontoblasts form isolated dentin that gets trapped in the pulp
• Pulp is engorged and dilated
120

Weinstein M, Babyn P, Zlotkin S. An Orange a Day Keeps the Doctor Away: Scurvy in the Year 2000. Pediatrics Sep 2001, 108 (3); page 55
Scurvy Lines
Severe marginal gingivitis

MINERAL DEFICIENCIES
Calcium
• 99% of body calcium is stored in bones
(hydrated tricalcium phosphate) and teeth
(hydroxyapatite)
• Functions:
– Rigidity and strength to bones and teeth
– Blood coagulation, muscle contraction,
myocardial action, cell membrane integrity
• Deficiency
– Restricted milk intake in premature infants
– Enamel hypocalcification
– Decreased bone density; rickets
150

MINERAL DEFICIENCIES…
Phosphorus
• Essential for bone formation and ATP production as well as regulation of
acid-base balance
• Deficiency
– Premature infants and patients with SEM
– Muscle weakness, bone pain, respiratory insufficiency
– Decreased phosphate in premature infant causes hypercalcemia
– No correlation between calcium to phosphate ratio and dental caries
159

Magnesium
• Essential constituent of bone and soft tissues, fundamental enzymatic
reactions and protein synthesis; third most abundant mineral in teeth
• Deficiency
– Hyperexcitability, behavioural disturbances, weakness, depression, tremors
and convulsions
164

MAGNESIUM DEFICIENCY
• Degenerative changes in ameloblasts and
odontoblasts leading to enamel and
dentin hypoplasia
• Gingival hyperplasia, lower rate of alveolar
bone formation and widening of
periodontal ligament
164

Iron
• Iron Deficiency Anaemia
– Inadequate intake or excessive loss or both
– Production of small RBCs deficient in Haemoglobin
– Seen in growing infants due to high bodily requirement and low iron
content of milk
– Increased susceptibility of oral tissues to carcinoma
– Clinical features similar to those of Vitamin B complex deficiency
200

Oral manifestations- glossitis, fissures at the
corners of the mouth, atrophied and ashen-
grey oral mucous membrane
“Plummer-Vinson Syndrome”- dysphagia,
koilonychia, angular stomatitis, and
atrophic glossitis
Medicalpicturesinfo.com/koilonychia
Epomedicine.com/atrophic-glossitis
200

Zinc
• Poor diet, liver disease, chronic kidney disease and genetic disorders
(Acrodermatitis enteropathica)
• Retardation of bone growth, poor appetite, loss of sense of taste
• Slow wound healing
• Progressive pustular dermatitis of the extremities
• Emotional irritability, tremors and loss of coordination
202

Iodine
• Integral part of thyroid hormones- thyroxine and
triiodothyronine, which control the energy
metabolism of the body
• Hypothyroidism- occurrence of Cretinism, Goitre
– Small jaws, retarded rate of tooth eruption
– Predisposition to root resorption
• Hyperthyroidism
– Increased rate of caries development- increased
intake of sugars due to increased need for calories
208

LIPIDS
Functions:
• Fats are the main dietary source for infants; 50% of energy in
human milk
• Provide Essential Fatty Acids (EFAs)
• Brain development, phospholipids in cell membrane, synthesis of
prostaglandins and leukotrienes
• Facilitate absorption of fat soluble vitamins- A, D, E and K
• Insulation against cold and cushioning effect against injuries

DEFICIENCY OF ESSENTIAL FATTY
ACIDS
• Growth failure
• Erythematous lesions
• Decreased resistance
• Increased fragility of erythrocytes
• Thrombocytopenia
• Poor wound healing
• Increased susceptibility to
infections
Abnormal scaliness of the skin

LIPIDS AND ORAL HEALTH
Prevention of Dental
Caries
Protective coating on
tooth surface
Prevents fermentation
of sugars over tooth
surface
Interfere with growth
of cariogenic bacteria
Increased dietary fat
decreases intake of
dietary sugars

OBESITY
• Obese children become obese adults and the risk of remaining obese
increases with age
• Children born to obese mothers have a three to five times more likely to
be obese in childhood
• Clinical manifestations and complications:
– All organ systems affected
– Advanced bone age, early menarche
– Obstructive sleep apnoea
– Insulin resistance and Type 2 Diabetes Mellitus
Ref:

CONCLUSION
• The growing child requires more attention to his or her diet in order to
ensure healthy growth and lifestyle. Paediatric dentists should recognise
oral manifestations of nutritional deficiencies and must stress upon the
importance of a balanced diet to the child and the caregivers

REFERENCES
• Nizel AE, Papas AS. Nutrition in Clinical Dentistry, 3rd edition. WB Saunders Co.; 1989
– “Protein Nutrition; its role in infection” pages 74-77
– “The B Complex Vitamins” pages 91-110
– “Vitamin C (Ascorbic Acid)” pages 113-120
– “The Fat-Soluble Vitamins: A, D, E and K” pages 125-141
– “The Macrominerals Calcium, Phosphorus and Magnesium” pages 144-162
– “Lipid Nutrition in Health and Disease” pages 51-65
• Nelson’s Essentials of Paediatrics, 1st South Asia Edition
– “Paediatric Nutrition and Nutritional Disorders” pages 88-93
• Current Paediatric Diagnostic and Treatment, 16th edition. William W. Jay, Jr.
– “Nutritional Childhood Nutrition and its Disorders”. Pages 277-283

REFERENCES
• Sheetal A, Hiremath VK, Patil AG, Sajjansetty S, Kumar R. “Malnutrition and its Oral
Outcome- A Review” J Clin Diagn Res. 2013 Jan; 7(1): 178-180
• Thomaz E, Cangussu M, da Silva A, Assis A. “Is Malnutrition Associated with Crowding
in Permanent Dentition” Int J Environ Res Public Health 2010; 8: 3531-3544
• Luke DA, Tonge CH, Reid DJ. “Effects of Rehabilitation on the Jaws and Teeth of
Protein-Deficient and Calorie-Deficient Pigs” Acta anat. 1981; 110: 299-305
• Weinstein M, Babyn P, Zlotkin S. “An Orange a Day Keeps the Doctor Away: Scurvy in
the Year 2000”. Pediatrics Sep 2001;108 (3): 55

REFERENCES
• Image courtesy:
– gettyimages.com
– medweiser.com/clinic-hours/rachitic-rosary
– pedclerk.bsd.uchicago.edu
– http://www.infonet-biovision.org/HumanHealth/Ariboflavinosis-Vit-B2-deficiency
– https://ufhealth.org/pellagra
– step2.medbullets.com
– Epomedicine.com/clinical-medicine/hematological-signs-angular-stomatitis-and-atrophic-
glossitis
– Medicalpicturesinfo.com/koilonychia

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