Dr Ranjith Kumar Dr S.Balasubramanian

KKCTH

Background information:2 ½ month old female , Birth Wt:2.3kg ,Breast fed

upto 2mon Refractory seizures Intracranial Hemorrhage

Diagnosed to have Late Hemorrhagic disease of newborn discharged on AED(Phenobarbitone, Phenytoin & Levitarcetem)

Followed up by Neurologist

At 6month had another episodes of seizure + incidental found to have Anemia (4gm/dl)Transfused PRBC Ref. to Hematologist (BMA + P.S ) = probable nutritional anemia advised Iron + folic acid supplementation

Also had diarrhea hence Soya based formula advised from 6 month

Developmental delay in the form Not able to sit with support Momentary head control was + More of motor developmental delay

• on examination : Fairly nourished Hypotonic Wide open AF Hot cross bun skull Widened wrist Prominence of costochondral junction Protuberant abdomen with Hepato-

spleenomegaly

At 7months of age infant brought to us

25/27/05/10

Diagnostic dilemma?:

Are we dealing with Vitamin D deficient Rickets Vitamin Resistant Rickets

Investigations Tot Ca.(Mg/dl)

Po4- SAP PTH Vit D(25OH Vit D)

1,25 D OH vit D

27/04/10

11.9 3 7480

18/5/10 8.8 2.8 3000 38 76

3/7/10 10.6 7.7 1761 -- -- --

2/8/10 12 6.5 926

USG abdomen :Mild Hepatosplenomegaly Renal system normalRFT: normalPhenobarbitone level: 23mcg/dl (15-30)Phenytoin level: 20mcg/dl (10-20)

Management:Vitamin D 6 lacks IM followed by oral

Vitamin D 0.25mcg twice daily for 4wksFollowed with Ca, Po4-,SAP & X ray Infant showed improvement in both clinically

and laboratory wise Now :(9months)

Able to stand ,walk without support No further seizures off antiepileptic drugs

Zone of provisional calcification

Completely healed Rickets

20/7/10 12/8/10

Reasons for Rickets Anticonvulsant therapyNo routine vitamin D supplementation Soya milk Poor sunlight exposer

To our knowledge thaere was no case report of rickets due to anticonvulsant therapy

Why this presentationThough research results vary, long-term use of anticonvulsant

drugs appears to interfere with vitamin D activity, which might lead to softening of bones (osteomalacia)

*In a controlled study, bone strength improved in children taking anticonvulsant drugs who were supplemented with the activated form of vitamin D and 500 mg per day of calcium for nine months.

#people taking anticonvulsant drugs who do not receive adequate sunlight should supplement with 400 IU of vitamin D each day to help prevent Rickets

*Telci A, Cakatay U, Kurt BB, et al. Changes in bone turnover and deoxypyridinoline levels in epileptic patients Clin Chem Lab Med 2000 38:47–50.

# Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Effect of vitamin D and calcium on bone mineral density in children with CP and epilepsy in full-time care. Dev Med Child Neurol 2000;42:403–

5.

*children, muscle involvement due to vitamin D deficiency was reported in a 5-year-old child with cholestatic liver disease* 11-yearold girl with celiac disease

POLICY STATEMENT PEDIATRICS Vol. 101 No. 1 January 1998, pp. 148-153 AMERICAN ACADEMY OF

PEDIATRICS: Soy Protein-based Formulas: Recommendations for Use in Infant Feeding

In 1996, the American Academy of Pediatrics issued a statement on aluminum toxicity in infants and children and discussed the relatively high content of aluminum in soy-based formulas.Although the aluminum content of human milk is 4 to 65 ng/mL, that of soy protein-based formula is 600 to 1300 ng/mL. The source of the aluminum is the mineral salts used in formula production.

Because aluminum competes with calcium for absorption, increased amounts of dietary aluminum from isolated soy protein-based formula may contribute to the reduced skeletal mineralization (osteopenia) observed in preterm

infants and infants with intrauterine growth retardation

Take home massage

1. Routine Vitamin D supplementation is essential

2. Vitamin D supplementation should be recommended in children on anticonvulsant therapy

3. Children on Soya based formula should be supplemented with Vitamin D

TTHANK YOU

A day will come

From A to D