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(Pediatrics in Review. 2006;27:44-55.)
© 2006 American Academy of Pediatrics

Vitamins

The first 300 words of the full text of this article appear below.

	Objectives

 
After completing this article, readers should be able to:

1. Identify the symptoms and signs of deficiency of various vitamins.
   
2. Characterize the patients at risk for deficiencies and plan their treatment.
   
3. Discuss the treatment of patients at risk for vitamin deficiencies.
   

	Introduction

 
Vitamins are organic compounds required in small amounts in various cellular metabolisms that are important for overall health maintenance and normal growth of the organism. First discovered by Hopkins in 1907, they were named by Funk in 1911. McCollum and Davis later showed that some vitamins, such as A, D, E, and K, are fat-soluble, and some, such as B and C, are water-soluble (Table 1).

Table 1. Vitamins: Sources, Requirements, Action, Results, Diagnosis, and Treatment

Vitamin Sources Daily Requirement Action Deficiency Excess Diagnosis Treatment A Green leafy vegetables, carrots, sweet potatoes, liver <6 mo: 400 mcg 7 to 12 mo: 500 mcg 1 to 3 y: 300 mcg 4 to 8 y: 400 mcg 9 to 15 y: 600 mcg Vision in dim light, bone and tooth growth, epithelium maturation Nyctalopia, photophobia, keratomalacia, blindness, impaired growth, follicular hyperkeratosis Anorexia, dry skin, painful joints, increased intracranial pressure, headache, vomiting Clinical or low plasma retinol levels <9 y: 600 to 900 mcg PO q day >9 y: 1,700 mcg/d PO q day until recovery B1 (Thiamine) Liver, pork, milk, grains <6 mo: 0.2 mg 6 to 12 mo: 0.3 mg 1 to 3 y: 0.5 mg 4 to 8 y: 0.6 mg 9 to 13 y: 0.9 mg >14 y: 1.2 mg Part of thiamine pyrophosphate, which is needed for oxidative decarboxylation Beriberi, fatigue, cardiac failure, polyneuritis None Response to thiamine 10 mg IV/IM/PO for 2 wk; then 5 mg q day for 1 mo Riboflavin (B2) Milk, cheese, liver, green leafy vegetables Infants: 0.3 to 0.4 mg 1 to 3 y: 0.5 mg 4 to 8 y: 0.6 mg 9 to 13 y: 0.9 mg >14 yr: 1.3 mg Part of flavoproteins important for hydrogen transfer Blurring of vision, cheilosis None Urinary riboflavin of <30 mcg/d 3 to 10 mg PO in divided doses daily Niacin (Nicotinic acid) Liver, fish, whole grains, eggs, milk, poultry <1 y: 2 to 4 mg 1 to 3 y: 6 mg 4 to 8 y: 8 mg 9 to 13 y: 12 mg >13 y: 16 mg Forms NAD and NADP cofactors Pellagra (rash, diarrhea, stomatitis, glossitis, mental status changes) None Clinical and N'methylnicotinamid (NMN) excretion of <0.8 mg/d 10 to 50 mg PO q 6 h B12 (Cobalamine) Fish, eggs, cheese 0 to 6 mo: 0.4 mcg 6 to 12 mo: 0.5 mcg 1 to 3 y: 0.9 mcg 4 to 8 y: 1.2 mcg 9 to 13 y: 1.8 mcg >13 y: 2.4 mcg Maturation of red blood cells Juvenile pernicious anemia None Megaloblastic macrocytic anemia, hypersegmented neutrophils, high lactic dehydrogenase, excessive methylmalonic acid in the urine, serum B12 assays of <150 pg/mL, Schilling test 100 mcg/d IM for 2 wk; then q week until hematocrit normalizes; then 60 mcg/d IM q mo B6 (Pyridoxine) Meat, liver, kidneys <6 mo: 0.1 mg 6 to 12 mo: 0.3 mg 1 to 3 y: 0.5 mg 4 to 8 y: 6.0 mg 9 to 13 y: 1.0 mg >13 y: 1.3 mg Decarboxylation reactions and transaminations Seizures, irritability, sensory ataxia Neuropathy Whole blood concentration of pyridoxal phosphate Seizures: 50 to 100 mg IV or IM Folate Cauliflower, green leafy vegetables, yeast, liver, kidney <6 mo: 65 mcg 6 to 12 mo: 80 mcg 1 to 3 y: 150 mcg 4 to 8 y: 200 mcg 9 to 13 y: 300 mcg >13 y: 100 mcg Maturation of red blood cells and synthesis of nucleic acids Megaloblastic anemia, irritability, failure to gain weight Low serum folate levels of <4 ng/mL, low red blood cell folate levels, elevated serum homocysteine levels with normal methylmalonic acid level Infants: 15 mcg/kg per day PO/IM 1 to 13 y: I mg/d followed by 0.1 mg/d until recovery >13 y: 1 mg/d Vitamin D Fortified milk, liver oils, sunlight, egg yolks <12 mo: 200 IU 1 to 15 y: 200 IU Preterm infants: 400 IU Regulates calcium and phosphorus levels, promotes endochondral growth of long bones, mineralization of zone of provisional calcification Rickets, tetany, bow legs, poor growth Diarrhea, weight loss, calcification of soft tissues Low serum calcium, phosphous, and 25 hydroxy-D3; high alkaline phosphatase and urine cyclic AMP; widened bone ends, with cupping and fraying of long bones Vitamin D3 150 to 250 mcg (5,000 to 10,000 IU) for 2 to 3 mo. After healing is complete, reduce dose to 10 mcg/d. Or a single-dose regimen of 15,000 mcg (600,000 IU) orally or parenterally Vitamin E (Tocopherol) Germ oils, green leafy vegetables <6 mo: 4 mg 7 to 12 mo: 5 mg 1 to 3 y: 6 mg 4 to 6 y: 7 mg 9 to 13 y: 11 mg >14 y: 15 mg Membrane stabilization, antioxidant Red blood cell hemolysis, muscle weakness, double vision Nausea, diarrhea, vitamin K antagonism Plasma alpha-tocopherol levels <5 mg/L 15 to 25 mg/kg per day of alpha-tocopherol PO Vitamin K Green leafy vegetables, liver <6 mo: 2 mcg 7 to 12 mo: 2.5 mcg 1 to 3 y: 30 mcg 4 to 7 y: 55 mcg 9 to 15 y: 60 to 75 mcg Prothrombin formation, factors, II, VII, IX, X Hemorrhagic manifestations Hyperbilirubinemia, hemolytic anemia, kernicterus Prolonged prothrombin and partial thromboplastin time, presence of des-gamma- carboxyprothrombin (DCP) in plasma 2 U first; further doses as needed Vitamin C Citrus fruits <6 mo: 40 mg 7 to 12 mo: 50 mg 1 to 3 y: 15 mg 4 to 8 y: 25 mg 9 to 13 y: 45 mg >14 y: 75 mg Integrity of intercellular material, absorption of iron and folic acid Scurvy, poor wound healing Oxaluria Positive capillary fragility test, ascorbic acid levels <0.1 mg/dL or white blood cell ascorbic acid level 0 to 7 mg/dL, low levels of vitamin C in urine after a test dose of vitamin C, normal bleeding time, widening of the zone of provisional calcification on radiographs of bone ends 25 mg of ascorbic acid PO q 6 h for 1 wk

	Vitamin A (Retinol)

 
     Case 1
A 5-year-old boy who recently was adopted from India is brought by his parents for his first physical examination. They report that he has been doing well except that he seems to bump into objects frequently, particularly in the evenings. On examination, his height and weight are below the 5th percentile. He has some silver-colored patches in his conjunctiva, but the rest of the examination findings are normal. A diagnosis is made clinically and treatment initiated.

     Case 2
A 3-year-old girl is brought to the emergency department for irritability. Her mother denies fever, upper respiratory tract infection symptoms, or trauma, but states that the girl has become progressively irritable over the past few days. She had been complaining of headache and nausea but had no emesis. On examination, the child is afebrile and appears irritable. Despite adequate doses of acetaminophen, she continues to complain of a headache, prompting the decision to perform a lumbar puncture. Except for an elevated opening pressure, her spinal fluid appears normal, having no white or red blood cells. Further questioning reveals that the girl has been taking her brother’s pills three to . . . [Full Text of this Article]