139
Tropical Doctor, October 1991
Xerophthalmia in malnourished Sudanese children M A M Hussain FRCP DCR E H A EI Sheikh MOSM
S M Ahmed
MB BS
MB BS DO
Department of Paediatrics, Khartoum Teaching Hospital and Eye Teaching Hospital, Khartoum, Sudan TROPICAL DOCTOR
1991, 21, 139-141
SUMMARY
Two hundred and thirteen Sudanese children (4-60 months old) with malnutrition were examined for signs of xerophthalmia. Sixty-three (29010) of these children were found to have varying stages of xerophthalmia. These included 35 (56%) patients with conjunctival xerosis, 12 (19%) with Bitot's spots, seven (11%) with corneal xerosis, seven (11%) with corneal ulceration and two (3%) with corneal scar. Direct questioning of the parents of these children revealed evidence of night blindness in nine (4%) of all patients. All nine patients had signs of xerophthalmia which showed good response to vitamin A therapy. INTRODUCTION
Xerophthalmia is always present in large series of malnutrition cases, but the frequency varies considerably'. The incidence is highest in some of the South East Asian countries, where up to 70% of malnourished children may have eye lesions and where the bulk of corneal blindness is possibly attributed to it. In the Sudan the incidence of xerophthalmia in malnutrition is not clearly known because thorough eye examination is not a routine practice. However, the standard teaching is that all children with protein-energy malnutrition (PEM) should be given oral vitamin A. The latter is not usually available in hospitals and in most situations parents have to get it privately. The aim of the present study is to detect xerophthalmic children, who actually need therapeutic doses of vitamin A, among a group of inpatient malnourished Sudanese children. PATIENTS AND METHODS
This study was done in children with malnutrition admitted to the paediatric ward (C2) at Khartoum Teaching Hospital (KTH) over a period of one year
(July 1987 to June 1988). These constituted only the children admitted on 2 days per week. Malnourished children seen on other days of the week were admitted to other paediatric wards and less serious cases of malnutrition were treated as outpatients. A total of 213 patients (120 males, 93 females) were studied during that period. According to the Wellcome classification-, there were 79 cases of kwashiorkor, 65 of marasmus, 40 of marasmic-kwashiorkor and 29 underweight. The age distribution in these patients is shown in Table 1. Two hundred and five patients came from deprived areas in Khartoum, six from the Central and two from the Northern Province of the Sudan. Clinical evidence of night blindness or xerophthalmia or both was used as the basis of diagnosing vitamin A deficiency because serum vitamin A levels are known to be depressed in the presence of PEM. The parents of these children were carefully questioned about the presence of night blindness and each of the children was subjected to careful ocular examination, using a focused light and binocular loupe. If visual loss was suspected the ocular media and the posterior pole were further examined using a hand slit lamp and either direct or indirect ophthalmoscopy. Abnormalities in the eye were classified according to standard diagnostic criteria". All children with signs of xerophthalmia were given oral vitamin A. Children above the age of one year were given 200 000 iu of vitamin A on the first day. The same dose was repeated on day 2 and 7. Children less than one year of age were given half the dose. Parents were then asked to bring their children for follow up after a period of one month. RESULTS
Sixty-three (29%) of 213 children with malnutrition were found to have varying stages of xerophthalmia. Children with signs of xerophthalmia included 35 (56%) patients with conjunctival xerosis (XIA), Table 1. Age distribution in 213 children with different types of malnutrition Type of malnutrition Kwashiorkor Marasmus MarasmicKwashiorkor Underweight
No of cases
Age range Mean age (months) (months)
79 65
7-48 4-36
27.5 19.0
40 29
7-36 13-60
21.5 33.0
Tropical Doctor, October 1991
140
Table 2. Clinical stages of xerophthalmia in 63 children with different types of malnutrition No. of cases with each type of malnutrition Stage of Xerophthalmia
No. of cases
Marasmus
Kwashiorkor
Marasmickwashiorkor
10
3
XIA XIB X2 X3A XS
35 12
13
7 7
2 2
2 3
2
Total
63
1 18
15
Underweight 9
12
12 (19070) with Bitot's spots (XIB), seven (11%) with corneal xerosis (X2), seven (11%) with corneal ulceration (X3A) and two (3%) with corneal scar (XS). The eye lesions observed with the different types of malnutrition are recorded in Table 2. The children with eye signs included 25 (86%) of 29 children with underweight, 18 (28%) of 65 with marasmus, 15 (19%) of 79 with kwashiorkor and five (12%) of 40 with marasmickwashiorkor. Nine (4%) of all patients (seven underweight, one kwashiorkor, one marasmic-kwashiorkor) had night blindness (XN). These included three patients with corneal xerosis and ulcer and six with Bitot's spot. All nine patients with night blindness came for follow-up. Corneal xerosis and ulcer showed complete healing in three, Bitot's spots disappeared in four and in two the spots regressed. Other xerophthalmic children were lost to follow-up. DISCUSSION
The results of this study show that 29% of malnourished Sudanese children admitted to one of the paediatric wards at KTH have eye symptoms of vitamin A deficiency. Many of the signs and symptoms of nutritional deficiencies, particularly of vitamins, are also frequently seen in children with PEM; they are not constant and vary from one region to another according to the nature of the usual diet. Some of these deficiencies are, however, favoured by the metabolic disturbances in PEM. This seems to be the case for instance with vitamin A where its absorption and probably also its transport and utilization are impaired in kwashiorkor". This may explain the high frequency and severity of ocular lesions due to vitamin A deficiency observed in children with kwashiorkor, in areas where the deficiency of this vitamin is endemics. The severity and magnitude of xerophthalmia alone,
2
1 1 5
25
or in association with other diseases, in the Sudan and neighbouring African countries remains unclear as insufficient data are available from most countries in the regioni-". However, one study from the Sudan has shown the presence of Bitot's spots in 13.6% of children from the western region of the Sudan", The recent drought and war in the Sudan have resulted in the movement of many families from the Western and Southern parts of the country to the big towns and cities. The majority of these people settled around the most deprived areas in Khartoum. It is tempting to assume that the xerophthalmic changes observed here are mainly the result of a primary dietary deficiency more than the direct effect of PEM. In favour of the assumption is the presence of higher percentages of children with xerophthalmia among the less severe forms of malnutrition (ie underweight) compared with the severe forms (ie kwashiorkor and marasmus). It has been observed by many of the paediatricians working at KTH that the number of children with PEM has shown a considerable increase over the last few years. This has been attributed to the overall increase in the number of malnourished children. An unpublished report from the Nutrition Department of the Sudan Ministry of Health in August 1988 has shown that about 23-25% of the children in Khartoum district are suffering from moderate to severe degree of malnutrition. As a result, the incidence of vitamin A deficiency in malnourished children will probably increase as well and that is likely to increase the mortality and morbidity in these patients. A study from Jordan'? has shown that the mortality in severely malnourished children (marasmus or kwashiorkor) with xerophthalmia was four times greater than in those equally generally malnourished but without eye lesions. A more recent study has shown that even marginal deficiency of vitamin A is associated with
Tropical Doctor, October 1991 increased morbidity and mortality 1I. This raises the important question of how to detect this marginal state. The eye signs of xerophthalmia suitable for field studies (XN and XIB) are clinical evidence of quite advanced depletion. In the past decade advances have been made in both biochemical and histological techniques that make it feasible to detect marginal vitamin A status in the field. Laboratory facilities for biochemical estimation are not widely available but a new histological technique called conjunctival impression cytology (CIC), which is simple to do and relatively noninvasive has proved to be very attractive. It consists of the application of a small piece of filter paper momentarily to the bulbar conjunctiva and then removing it, when it takes with it the superficial layer of the cells. After fixation and staining, goblet cells and epithelial cells are looked for under the light microscope. Such abnormalities as loss of goblet cells and distorted shape, decrease in number and increase in size of epithelial cells indicate interference with epithelial differentiation, which is known to result from vitamin A deficiencyl-. Preliminary results suggest that CIC abnormality is about 10 times as frequent as early clinical deficiency in populations with public health problems. Regular ocular tests in patients with PEM can certainly prevent the consequences of xerophthalmia and restrict the use of therapeutic doses of vitamin A to those who really need it. The WHO treatment schedule for all stages of xerophthalmia in children between 1 and 6 years of age is an initial oral dose of 200 000 iu vitamin A. The same dose is repeated the following day and 4 weeks later. Children under one year of age and those of any age who weigh less than 8 kg are treated with half the doses. The recommendation for malnourished children with no evidence of xerophthalmia is a single oral dose of 200 000 iu for those between 1 and 6 years of age and half of that dose for those less than one year or those of any age who weigh less than 8 kg. ACKNOWLEDGMENT
This paper was written during a visit by Dr M A M Hussain to the Department of Child Health at the University of Newcastleupon-Tyne, The visit was sponsored by the Higher Education Division of the British Council. REFERENCES
Oomen HAPC. Xerophthalmia. In: Jelliffe DB, ed. Diseases ofchildren in the subtropics and tropics. London: Edward Arnold, 1970: 184-90 2 Editorial. Classification of infantile malnutrition. Lancet 1970; ii: 302-3 3 Smith FP, Goodman DS, Zaklama MS, Gabr MK, Maraghy SL, Patwardhan VN. Serum vitamin A, retinol-binding
141
4 5 6 7 8
9 10 11 12
protein and prealbumin concentrations in protein-calorie malnutrition. 1. A functional defect in hepatic retinol release. Am J C/in Nutr 1973; 26: 975-81 Sommer A. Field guide to the detection and control of xerophthalmia, 2nd edn. Geneva: WHO, 1982 Behar M. Protein-calorie malnutrition. In: Jelliffe DB ed. Diseasesofchildren in the subtropics and tropics. London: Edward Arnold, 1970: 161-84 Oomen HAPC. Xerophthalmia in the presence of kwashiorkor. Br J Nutr 1954; 8: 307-18 Tielsch JM, West KP, Katz J, et al. Prevalence and severity of xerophthalmia in Southern Malawi. Am J Epidemiol 1986; 124: 561-8 WHO. Control of vitamin A deficiency and xerophthalmia. Report of joint WHO/UNICEF/USAID/Hellen Keller International/IVACG Meeting. Tech Rep Series No 672. Geneva: WHO, 1982 Shaaban KMA. The prevalence of xerophthalmia among El Hawawir children. Thesis for Master's Degree in Community Medicine, University of Khartoum, 1987 McLaren DS, Shirajian E, Tchalian M, Khoury G. Xerophthalmia in Jordan. Am J C/in Nutr 1965; 17: 117-30 Sommer A, Tarwotjo I, Hussaini G, Susanto D. Increased mortality in children with mild vitamin A deficiency. Lancet 1983; ii: 585-8 Natadisastra G, Wittpenn JR, West KP Jr, Muhilal, Sommer A. Impression cytology for detection of vitamin A deficiency. Arch Ophthalmol 1987; 9: 1224-8
VUh International Conference on AIDS in Africa
16-19 December 1991, Dakar, Senegal Objectives of the conference: -to research for a better understanding of the specificities of AIDS in Africa. -to evaluate the development of the HIV infections in Africa. -to stimulate cooperation and sharing of experiences and scientific information on the basic, medical and social aspects of AIDS: • between African countries, • between Africa and the rest of the International Community -to take stock of prevention and struggle strategies against that disease. -to promote multisector approach and encourage collaboration among non-governmental organizations (NGOs) and National programs of struggle against AIDS. Further details/rom: Commissariat General, MCIBP, PO Box 4000, Dakar, Senegal Tel: (221) 25.55.55/24.24.00 Fax: (221) 25.55.56/24.04.63 Telex: 202139F RCINF Attn: MNSIO
Tropical Doctor, October 1991
Xerophthalmia in malnourished Sudanese children M A M Hussain FRCP DCR E H A EI Sheikh MOSM
S M Ahmed
MB BS
MB BS DO
Department of Paediatrics, Khartoum Teaching Hospital and Eye Teaching Hospital, Khartoum, Sudan TROPICAL DOCTOR
1991, 21, 139-141
SUMMARY
Two hundred and thirteen Sudanese children (4-60 months old) with malnutrition were examined for signs of xerophthalmia. Sixty-three (29010) of these children were found to have varying stages of xerophthalmia. These included 35 (56%) patients with conjunctival xerosis, 12 (19%) with Bitot's spots, seven (11%) with corneal xerosis, seven (11%) with corneal ulceration and two (3%) with corneal scar. Direct questioning of the parents of these children revealed evidence of night blindness in nine (4%) of all patients. All nine patients had signs of xerophthalmia which showed good response to vitamin A therapy. INTRODUCTION
Xerophthalmia is always present in large series of malnutrition cases, but the frequency varies considerably'. The incidence is highest in some of the South East Asian countries, where up to 70% of malnourished children may have eye lesions and where the bulk of corneal blindness is possibly attributed to it. In the Sudan the incidence of xerophthalmia in malnutrition is not clearly known because thorough eye examination is not a routine practice. However, the standard teaching is that all children with protein-energy malnutrition (PEM) should be given oral vitamin A. The latter is not usually available in hospitals and in most situations parents have to get it privately. The aim of the present study is to detect xerophthalmic children, who actually need therapeutic doses of vitamin A, among a group of inpatient malnourished Sudanese children. PATIENTS AND METHODS
This study was done in children with malnutrition admitted to the paediatric ward (C2) at Khartoum Teaching Hospital (KTH) over a period of one year
(July 1987 to June 1988). These constituted only the children admitted on 2 days per week. Malnourished children seen on other days of the week were admitted to other paediatric wards and less serious cases of malnutrition were treated as outpatients. A total of 213 patients (120 males, 93 females) were studied during that period. According to the Wellcome classification-, there were 79 cases of kwashiorkor, 65 of marasmus, 40 of marasmic-kwashiorkor and 29 underweight. The age distribution in these patients is shown in Table 1. Two hundred and five patients came from deprived areas in Khartoum, six from the Central and two from the Northern Province of the Sudan. Clinical evidence of night blindness or xerophthalmia or both was used as the basis of diagnosing vitamin A deficiency because serum vitamin A levels are known to be depressed in the presence of PEM. The parents of these children were carefully questioned about the presence of night blindness and each of the children was subjected to careful ocular examination, using a focused light and binocular loupe. If visual loss was suspected the ocular media and the posterior pole were further examined using a hand slit lamp and either direct or indirect ophthalmoscopy. Abnormalities in the eye were classified according to standard diagnostic criteria". All children with signs of xerophthalmia were given oral vitamin A. Children above the age of one year were given 200 000 iu of vitamin A on the first day. The same dose was repeated on day 2 and 7. Children less than one year of age were given half the dose. Parents were then asked to bring their children for follow up after a period of one month. RESULTS
Sixty-three (29%) of 213 children with malnutrition were found to have varying stages of xerophthalmia. Children with signs of xerophthalmia included 35 (56%) patients with conjunctival xerosis (XIA), Table 1. Age distribution in 213 children with different types of malnutrition Type of malnutrition Kwashiorkor Marasmus MarasmicKwashiorkor Underweight
No of cases
Age range Mean age (months) (months)
79 65
7-48 4-36
27.5 19.0
40 29
7-36 13-60
21.5 33.0
Tropical Doctor, October 1991
140
Table 2. Clinical stages of xerophthalmia in 63 children with different types of malnutrition No. of cases with each type of malnutrition Stage of Xerophthalmia
No. of cases
Marasmus
Kwashiorkor
Marasmickwashiorkor
10
3
XIA XIB X2 X3A XS
35 12
13
7 7
2 2
2 3
2
Total
63
1 18
15
Underweight 9
12
12 (19070) with Bitot's spots (XIB), seven (11%) with corneal xerosis (X2), seven (11%) with corneal ulceration (X3A) and two (3%) with corneal scar (XS). The eye lesions observed with the different types of malnutrition are recorded in Table 2. The children with eye signs included 25 (86%) of 29 children with underweight, 18 (28%) of 65 with marasmus, 15 (19%) of 79 with kwashiorkor and five (12%) of 40 with marasmickwashiorkor. Nine (4%) of all patients (seven underweight, one kwashiorkor, one marasmic-kwashiorkor) had night blindness (XN). These included three patients with corneal xerosis and ulcer and six with Bitot's spot. All nine patients with night blindness came for follow-up. Corneal xerosis and ulcer showed complete healing in three, Bitot's spots disappeared in four and in two the spots regressed. Other xerophthalmic children were lost to follow-up. DISCUSSION
The results of this study show that 29% of malnourished Sudanese children admitted to one of the paediatric wards at KTH have eye symptoms of vitamin A deficiency. Many of the signs and symptoms of nutritional deficiencies, particularly of vitamins, are also frequently seen in children with PEM; they are not constant and vary from one region to another according to the nature of the usual diet. Some of these deficiencies are, however, favoured by the metabolic disturbances in PEM. This seems to be the case for instance with vitamin A where its absorption and probably also its transport and utilization are impaired in kwashiorkor". This may explain the high frequency and severity of ocular lesions due to vitamin A deficiency observed in children with kwashiorkor, in areas where the deficiency of this vitamin is endemics. The severity and magnitude of xerophthalmia alone,
2
1 1 5
25
or in association with other diseases, in the Sudan and neighbouring African countries remains unclear as insufficient data are available from most countries in the regioni-". However, one study from the Sudan has shown the presence of Bitot's spots in 13.6% of children from the western region of the Sudan", The recent drought and war in the Sudan have resulted in the movement of many families from the Western and Southern parts of the country to the big towns and cities. The majority of these people settled around the most deprived areas in Khartoum. It is tempting to assume that the xerophthalmic changes observed here are mainly the result of a primary dietary deficiency more than the direct effect of PEM. In favour of the assumption is the presence of higher percentages of children with xerophthalmia among the less severe forms of malnutrition (ie underweight) compared with the severe forms (ie kwashiorkor and marasmus). It has been observed by many of the paediatricians working at KTH that the number of children with PEM has shown a considerable increase over the last few years. This has been attributed to the overall increase in the number of malnourished children. An unpublished report from the Nutrition Department of the Sudan Ministry of Health in August 1988 has shown that about 23-25% of the children in Khartoum district are suffering from moderate to severe degree of malnutrition. As a result, the incidence of vitamin A deficiency in malnourished children will probably increase as well and that is likely to increase the mortality and morbidity in these patients. A study from Jordan'? has shown that the mortality in severely malnourished children (marasmus or kwashiorkor) with xerophthalmia was four times greater than in those equally generally malnourished but without eye lesions. A more recent study has shown that even marginal deficiency of vitamin A is associated with
Tropical Doctor, October 1991 increased morbidity and mortality 1I. This raises the important question of how to detect this marginal state. The eye signs of xerophthalmia suitable for field studies (XN and XIB) are clinical evidence of quite advanced depletion. In the past decade advances have been made in both biochemical and histological techniques that make it feasible to detect marginal vitamin A status in the field. Laboratory facilities for biochemical estimation are not widely available but a new histological technique called conjunctival impression cytology (CIC), which is simple to do and relatively noninvasive has proved to be very attractive. It consists of the application of a small piece of filter paper momentarily to the bulbar conjunctiva and then removing it, when it takes with it the superficial layer of the cells. After fixation and staining, goblet cells and epithelial cells are looked for under the light microscope. Such abnormalities as loss of goblet cells and distorted shape, decrease in number and increase in size of epithelial cells indicate interference with epithelial differentiation, which is known to result from vitamin A deficiencyl-. Preliminary results suggest that CIC abnormality is about 10 times as frequent as early clinical deficiency in populations with public health problems. Regular ocular tests in patients with PEM can certainly prevent the consequences of xerophthalmia and restrict the use of therapeutic doses of vitamin A to those who really need it. The WHO treatment schedule for all stages of xerophthalmia in children between 1 and 6 years of age is an initial oral dose of 200 000 iu vitamin A. The same dose is repeated the following day and 4 weeks later. Children under one year of age and those of any age who weigh less than 8 kg are treated with half the doses. The recommendation for malnourished children with no evidence of xerophthalmia is a single oral dose of 200 000 iu for those between 1 and 6 years of age and half of that dose for those less than one year or those of any age who weigh less than 8 kg. ACKNOWLEDGMENT
This paper was written during a visit by Dr M A M Hussain to the Department of Child Health at the University of Newcastleupon-Tyne, The visit was sponsored by the Higher Education Division of the British Council. REFERENCES
Oomen HAPC. Xerophthalmia. In: Jelliffe DB, ed. Diseases ofchildren in the subtropics and tropics. London: Edward Arnold, 1970: 184-90 2 Editorial. Classification of infantile malnutrition. Lancet 1970; ii: 302-3 3 Smith FP, Goodman DS, Zaklama MS, Gabr MK, Maraghy SL, Patwardhan VN. Serum vitamin A, retinol-binding
141
4 5 6 7 8
9 10 11 12
protein and prealbumin concentrations in protein-calorie malnutrition. 1. A functional defect in hepatic retinol release. Am J C/in Nutr 1973; 26: 975-81 Sommer A. Field guide to the detection and control of xerophthalmia, 2nd edn. Geneva: WHO, 1982 Behar M. Protein-calorie malnutrition. In: Jelliffe DB ed. Diseasesofchildren in the subtropics and tropics. London: Edward Arnold, 1970: 161-84 Oomen HAPC. Xerophthalmia in the presence of kwashiorkor. Br J Nutr 1954; 8: 307-18 Tielsch JM, West KP, Katz J, et al. Prevalence and severity of xerophthalmia in Southern Malawi. Am J Epidemiol 1986; 124: 561-8 WHO. Control of vitamin A deficiency and xerophthalmia. Report of joint WHO/UNICEF/USAID/Hellen Keller International/IVACG Meeting. Tech Rep Series No 672. Geneva: WHO, 1982 Shaaban KMA. The prevalence of xerophthalmia among El Hawawir children. Thesis for Master's Degree in Community Medicine, University of Khartoum, 1987 McLaren DS, Shirajian E, Tchalian M, Khoury G. Xerophthalmia in Jordan. Am J C/in Nutr 1965; 17: 117-30 Sommer A, Tarwotjo I, Hussaini G, Susanto D. Increased mortality in children with mild vitamin A deficiency. Lancet 1983; ii: 585-8 Natadisastra G, Wittpenn JR, West KP Jr, Muhilal, Sommer A. Impression cytology for detection of vitamin A deficiency. Arch Ophthalmol 1987; 9: 1224-8
VUh International Conference on AIDS in Africa
16-19 December 1991, Dakar, Senegal Objectives of the conference: -to research for a better understanding of the specificities of AIDS in Africa. -to evaluate the development of the HIV infections in Africa. -to stimulate cooperation and sharing of experiences and scientific information on the basic, medical and social aspects of AIDS: • between African countries, • between Africa and the rest of the International Community -to take stock of prevention and struggle strategies against that disease. -to promote multisector approach and encourage collaboration among non-governmental organizations (NGOs) and National programs of struggle against AIDS. Further details/rom: Commissariat General, MCIBP, PO Box 4000, Dakar, Senegal Tel: (221) 25.55.55/24.24.00 Fax: (221) 25.55.56/24.04.63 Telex: 202139F RCINF Attn: MNSIO
