Vitamin

 

Function

Dietary sources

Causes of deficiency

Risk groups, prevalence

Clinical findings

Screening and management

A

Forms - retinol, retinal, retinoic acid or retinyl ester

 

 

Fat soluble vitamin - Epithelial cell function, vision, immune function, embryo development

Preformed in animal foods (liver, fish, butter, cheese, whole milk, egg yolk), carotenoids in plant based foods (orange/ yellow fruits and vegetables)

Low vitamin A content in breast milk, restricted food access, alcoholism

Infants, children, pregnant/lactating women, alcoholism

Intestinal failure, biliary, pancreatic disease, PEM

Anecdotal reports Rohingya populations

Dry eyes, night blindness, increased infections, hyperkeratotic rash (goose bump rash), Bitots spots on conjunctivae, corneal ulceration and scarring, blindness; anaemia, poor growth

Screen if:

Clinical signs deficiency

Post arrival in children from refugee camps or situations with poor access to food, or

where fat malabsorption suspected. See:

Vitamin A guidelines

B1

Thiamine

Water soluble vitamin - role in oxidative phosphorylation and pentose phosphate pathway (carbohydrate metabolism)

Cereal foods, including wheat germ, wheat bran, wholemeal flour, pork, beef, liver, kidney, legumes, nuts, yeast extract, (Vegemite), nuts, peas, sesame seeds

Rice based diets, foods with thiaminases/anti-thiamine compounds, ­reqmts pregnancy lactation

Endemic in areas with rice based diets, anecdotal reports in Karen refugee children pre-arrival with polished rice diet

Alcoholism, HIV, jejunal disease (site absorption)

Weakness with intercurrent illness, anorexia; irritability; beri-beri - cardiovascular symptoms and/or symmetric peripheral neuropathy, Wernicke encephalopathy (confusion, reduced consciousness, ataxia, ophthalmoplegia) Korsakoff syndrome (memory disorder, confabulation)  - beri-beri and WKS do not usually occur together

Screen if:

History weakness with intercurrent illness

Thiamine dosing

 

Water-soluble vitamin - coenzyme in TCA, fatty acid synthesis, synthesis of B3, conversion B6 to active form

Milk, dairy, fortified bread/cereal, eggs, pulses, green vegetables, almonds, yeast extract

Corn based diets

Corn based diets (Africa, India, parts of China)

Angular stomatitis, cheilitis, glossitis, dermatitis, elevated homocysteine, normocytic anaemia

 

Not usually measured

Riboflavin dosing

B3

Niacin

Nicotinic acid and nicotinamide

Water soluble vitamin - coenzyme dehydrogenase-reductase reactions including glycolysis, and fatty acid metabolism

Beans, milk, beef, pork, liver, eggs, wheat,

Restricted food access

Maize based diets

Restricted food access, rice based diets

Pellagra – dermatitis (hyperpigmented skin and mucosal changes, photosensitivity), diarrhoea, dementia, glossitis, anorexia, weakness, irritability

 

Not usually measured

Niacin dosing – see NRV

Part of coenzyme A, reactions involving CHO, protein and lipid metabolism

Organ meat, chicken, beef, potatoes, oats, grains, tomatoes, eggs, peanuts, green vegetables

Restricted food access

Restricted food access, rice based diets

Very rare – gastrointestinal Sx, depression, irritability, burning sensation feet, low BSL,

Not usually measured

B5 dosing – see NRV

 

B6

Pyridoxine

Cofactor enzymes in aminotransferase reactions inc. aminolevulinic acid and serotonin

All food groups esp. legumes, nuts, wheat, meat, bananas

Restricted food access

Isoniazid treatment (­urine excretion)

Restricted food access, rice based diets

Microcytic, hypochromic anemia (heme synthesis), dermatitis, cheilitis, stomatitis, peripheral neuropathy, seizures, AST and ALT

Not usually measured

Pyridoxine dosing

B7

Biotin

Water-soluble vitamin, cofactor for carboxylases

Organ meat, eggs, dairy, synthesis by intestinal bacteria

Anticonvulsants, hemodialysis, parenteral nutrition large amounts raw egg whites

Haemodialysis, PN dependent patients

Dermatitis, glossitis, alopecia, poor growth, ataxia, weakness, depression and seizures

Not usually measured

Biotin dosing

B12

Cyanocobalamin

Water-soluble vitamin - DNA synthesis, branched chain amino acid metabolism

Animal based foods, muscle meat, fish, eggs, dairy, yeast, synthesis by intestinal bacteria

Vegan diets

Vegans, restricted food access

Breastfed infants of mothers with deficiency

Gastric atrophy

People from Iran, Iraq, Afghanistan, Bhutan

 

glossitis, stomatitis, weakness, Megaloblastic anaemia, hypersegmented neutrophils, ­homocysteine, ­methylmalonic acid

Consider screen – Iran, Bhutan, Afghanistan, Iran

Screen in exclusively breastfed infants where maternal deficiency suspected, or where deficiency suspected

Vitamin B12 guideline

C

Ascorbic acid

Water-soluble vitamin, antioxidant collagen synthesis, neurotransmitter and carnitine production, enzyme fn

Citrus fruits, broccoli tomatoes, potatoes, berries, guava, mango, capsicum, pawpaw, parsley, pineapple, spinach and cabbage

Diets without fruit and vegetables

Restricted eating/food access, sometimes seen in autism

absorption iron, collagen formation,immune function, wound healing
Scurvy: perifollicular haemorrhage, gum bleeding, bruising, oedema, weakness, bony changes on XR

Screen if clinical signs deficiency, poor fresh food access

Vitamin C dosing

D

Cholecalciferol (D3) or ergocalciferol (D2)

Fat soluble vitamin - calcium and phosphate balance

Bone health, emerging evidence influences cardiovascular health, pregnancy outcomes and immunity/atopy

Skin synthesis - most important source of vitamin D for all ages, diet is a poor source of vitamin D for all ages, (generally 10 – 25%) – found in some fatty fish, added to margarine, breast milk content ~25 IU/L, formula 380 – 520 IU/L

Lack of skin exposure to UVB in sunlight

Dark skin

Conditions/medications affecting D metabolism

Infants: maternal deficiency and BF with one or more other risk factors

Lack of skin exposure to sun, dark skin

Medications/conditions affecting vit D metabolism inc obesity

Exclusively breastfed Infants born to deficient mothers, who have at least 1 other risk factor

Bone pain

Muscle pain

Delayed dental eruption

Poor growth

Late motor milestones

Rickets

Screen if at least one risk factor

Vitamin D guideline

E

Alpha-tocopherol and other forms

 

Fat soluble vitamin - antioxidant esp. for PUFA, protects cell membranes, regn prostaglandin synthesis

Plant oils, including wheat germ, sunflower, canola, olive, less in corn oil and soy oil

Fat malabsorption

Intestinal failure, biliary, pancreatic disease, PEM

Peripheral neuropathy, reduced DTR, impaired balance/gait, myopathy, pigmented retinopathy, RBC fragility (acanthocytes) and haemolysis

 

Screen if fat malabsorption suspected

Vitamin E dosing

Folate

Water soluble vitamin, DNA/RNA synthesis and amino acid metabolism

Green leafy vegetables, fortified bread/cereals

Restricted food access, Methotrexate, phenytoin and sulfasalazine, cotrimoxazole antagonize folate utilization

Restricted food access, lack of fresh food intake

Glossitis, stomatitis, poor growth and fetal neural tube defects, Macrocytic anemia, hypersegmented neutrophils

Screen if clinical deficiency suspected, poor fresh food access, macrocytosis,

K

Phytomenadione

Clotting factors 2, 7, 9, 10 protein C and S; cofactor for g-glutamyl carboxylase

Green leafy vegetables, vegetable oils (especially soy) eggs, meat, dairy

Liver failure

Intestinal failure, biliary, pancreatic disease, PEM

Bleeding/bruising

Not measured, check INR

Vitamin K dosing