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  5. FP1138 : Vitamin A deficiency among slum children of Mumbai suburbs.

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Dr. Radhika Krishanan, R15839, Dr. Natarajan S

Abstract:

 Purpose: Vitamin A deficiency is one of the major public health issues in the third world. This study was done to determine the prevalence of Vitamin A deficiency among school children in Mumbai Suburbs.

Methods: A school-basedcross-sectional study design was adopted to examine children aged 6 – 16 years in randomly selected urban schools of Mumbai from February 2015 to March 2015. After informing the parents and teachers, 2468 children from seven different schools in slum area were screened for vitamin A deficiency and other eye diseases. An optometrist did the vision, refraction, and a detailed eye examination. The children needing further assessment were referred to a pediatric ophthalmologist.  Socio-economic and demographic information was collected from the family. Assessment of Vitamin A deficiency was done according to ocular signs. Data was analyzed by a statistician.

Results:Out of a total of 2468 children screened; 1157 (46.88 %) were boys and 1311 (53.11 %) were girls. Out of 2468, a total 1050 (42.5%) were referred for cycloplegic refraction and of this 583 (55.5%) were girls and 467 (44.47%) were boys. Of 2468 children, 93 (3.76 %) had xerosis and 67 (2.71 %) children had Bitot’s spot. These children can be considered as being Vitamin A deficient. Therefore, 160 (6.48 %) children had vitamin A deficiency according to ocular signs.

Conclusion: There is a high prevalence of Vitamin A deficiency among school children in Mumbai Suburbs.

Key Words: Vitamin A deficiency, school children, night blindness

 Introduction:Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, growth and development, maintenance of epithelial cellular integrity, immune function and reproduction. Severe deficiency of vitamin A is known to produce corneal xerophthalmia, keratomalacia and blindness in children. Vitamin A deficiency (VAD) is mainly seen amongst the young children as they have high requirements due to increased physical growth and have low dietary intake. Further, episodes of illnesses such as acute respiratory tract infection and measles, which deplete vitamin A reserves from the body, are common in this age group. [1] According to WHO, around the world, approximately 5.2 million preschool-age children and 9.8 million pregnant women are affected by night blindness.[2] This blindness is completely avoidable and therefore we designed this study to assess the prevalence of vitamin A deficiency among school children in Mumbai Suburbs.

Materials and Methods: A cross-sectional study was done to find out the prevalence of vitamin A deficiency. 2468 children from seven different schools in slum area were screened for vitamin A deficiency and other eye diseases. Seven schools were selected conveniently to get the optimum sample size. Teachers and parents were informed before the eye screening. A team from our organization screened all the children. The eyes of the children were checked using HEINE® HSL150 hand-held slit lamp 3.5 V. Socio demographic information was collected from the family. Assessment of Vitamin A deficiency was done according to WHO classification of xerophthalmia by ocular signs.

Examination was done in the respective school campuses in clean, quiet and well-lit rooms. Only children present on the day of examination were screened. Visual Acuity (VA) was measured using the Snellen’s VA chart at 6 meters. Children with VA < 6/9 underwent a pinhole vision to differentiate refractive errors from pathological conditions. Refractive error was diagnosed when a VA worse than 6/9 improved on pinhole test. Undilatedretinoscopy and subjective correction for children with uncorrected VA < 6/6 were done. Ocular movements were checked and convergence insufficiency testing was done. Anterior segment examination including lids, lacrimal sac, conjunctiva, cornea, anterior chamber, pupil, iris, lens was done using a torch light and a hand-held slit lamp. Children not improving to 6/6 with a pinhole underwent a dilated fundus examination after cyclopentolate + tropicamide drops instillation. A pro forma was used for documentation. Data was analyzed by a statistician.

 Children needing specialized evaluation and management were referred to a higher center. Children who needed treatment were managed appropriately further.

 WHO Classification of xerophthalmia by ocular signs [3]

Night blindness (XN)

Conjunctivalxerosis (X1A)

Bitot spots (X1B)

Corneal xerosis (X2)

Corneal ulceration/keratomalacia  <⅓ corneal surface (X3A)

Corneal ulceration/keratomalacia ≥⅓ corneal surface (X3B)

Corneal scar (XS)

Xerophthalmic fundus (XF)

 Results: A total of 2468 children were screened. Of these, 1157 (46.88 %) were boys and 1311 (53.11 %) were girls. Of 2468, we found that 93 (3.76 %) had xerosis and 67 (2.71 %) children had Bitot’s spot. These children can be considered as deficient with vitamin A. Therefore, 160 (6.48 %) children had vitamin A deficiency according to ocular signs. Out of 2468, 102 (4.13 %) children had blepharitis. Out of 2468, a total 1050 (42.5%) patients referred for cycloplegic refraction, of theses 583 (55.5%) were girls and 467 (44.47%) were boys.

Discussion:

Vitamin A is essential for healthy vision and Vitamin A deficiency is one of the major public health issues in the third world. Vitamin A deficiency is one of the major public health issues in the third world. Malnutrition, malabsorption and poor nutrition during pregnancy are the common reasons for Vitamin A deficiency among children. Ocular manifestations of Vitamin A deficiency are night blindness, Bitot’s spots followed by xerophthalmia and keratomalacia. Socio-economic factors play a major role in prevalence of Vitamin A deficiency among children. Poor sanitation, inadequate nutrition and lack of awareness influence the vitamin A deficiency among children from low socioeconomic strata.

In India, vitamin A deficiency is the single most important cause of childhood blindness and severe visual impairment(SVI) in India. There are marked variations by state and also between urban and rural locations.[4]Previous research indicates that xerophthalmia, a direct ocular consequence of vitamin A deficiency, remains a public health problem in urban children of low to lower middle socioeconomic strata in India. [5]

Clinically obvious signs of vitamin A deficiency (Bitot’s spots, Cornealxerosis,keratomalacia and corneal scars) are well-established indicators of vitamin A deficiency. [6]

 Methods for assessing vitamin A status

Xerophthalmia classification was traditionally used to identify populations with vitamin A deficiency. Then night blindness and dark adaptometry have been proposed as population assessment methods. Eye signs and function tests are used in areas where vitamin A deficiency is severe, but a subclinical vitamin A deficiency is more common. Serum and breast milk retinol concentrations are used to identify vitamin A deficiency risk. Therefore, laboratory sophistication and resources available affect the choice of vitamin A assessment method. [7]

Indian Government measures for prevention of vitamin A deficiency: The National Prophylaxis Programme against Nutritional Blindness due to vitamin A deficiency (NPPNB due to VAD) was started in 1970 with the aim of preventing nutritional blindness due to keratomalacia. The Programme was launched as an urgent remedial measure to combat the unacceptably high magnitude of xerophthalmic blindness in the country seen in the 1950s and 1960s. 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. Prophylactic mega dose administration of vitamin A is primarily advocated because of the claim of 23 per cent reduction in childhood mortality. However, benefits on this scale have been found only in areas with rudimentary health care facilities where clinical deficiency is common, and there is substantial heterogeneity, especially with inclusion of all trials. [8]

 Our data indicates that despite intensive vitamin A supplementation programmes carried out in India, vitamin A deficiency is a major health issue of school children in urban area, particularly in low-class sections. To avoid invasive techniques like blood estimation of vitamin A which causes considerable discomfort to the children, we assessed vitamin A deficiency as per observation of Bitot’s spots in the eyes of the children. Bitot’s spots are the buildup of keratin located superficially in the conjunctiva, which are oval, triangular or irregular in shape. These spots are a sign of vitamin A deficiency and are associated with conjunctivalxerosis. On the basis of ocular signs, we found the prevalence of vitamin A deficiency approximately 6.48 %. If these results are extrapolated to the national level, prevalence can be enormous, considering the very high population of India. If a big city like Mumbai has such a high prevalence of vitamin A deficiency, rural and other undeveloped areas of India may have still higher prevalence of vitamin A deficiency. Collectively, vitamin A deficiency may be a huge burden on Indian children who are the future of the nation.

Conclusion: High prevalence of vitamin A deficiency in developing countries leads to increased morbidity among children. Therefore, stern efforts are needed to address these issues of public health significance at local and international level in lower and middle income countries.

References: 

  1. Geneva: WHO Press; 2002. World Health Organization (WHO). Human vitamin and mineral requirements, World Health Organization, Food and Agriculture Organization of the United Nations, Rome; pp. 22–8.
  2. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva, World Health Organization, 2009.
  3. In: WHO: Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programmes. Part III: Biological indicators of vitamin A status. Page 22
  4. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness due to vitamin A deficiency in India: regional variations. Archives of Disease in Childhood. 1995;72(4):330-333.
  5. Sinha A, Jonas JB, Kulkarni M, Nangia V. Vitamin A Deficiency in Schoolchildren in Urban Central India: The Central India Children Eye Study. Arch Ophthalmol.2011;129(8):1095–1096.
  6. https://apps.who.int/iris/bitstream/10665/133705/1/WHO_NMH_NHD_EPG_14.4_eng.pdf (Accessed 13/10/2017)
  7. Tanumihardjo SA. Assessing vitamin A status: past, present and future. J Nutr. 2004 Jan;134(1):290S-293S.
  8. Kapil U. and Sachdev HPS. Massive dose vitamin A programme in India – Need for a targeted approach. Indian J Med Res. 2013 Sep; 138(3): 411–417.

 

 

 

 

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