Vitamin C Deficiency (Scurvy) in Children
Introduction to Vitamin C Deficiency (Scurvy) in Children
Scurvy is a rare but potentially severe condition caused by prolonged and severe vitamin C (ascorbic acid) deficiency. While historically associated with sailors on long sea voyages, scurvy can still occur in modern times, particularly in children with restricted diets or malabsorption disorders.
Vitamin C is crucial for various physiological processes, including collagen synthesis, immune function, and antioxidant protection. In children, its deficiency can lead to significant growth and developmental issues.
Etiology of Scurvy in Children
Scurvy in children typically results from:
- Severely restricted diets (e.g., autism spectrum disorders with food aversions)
- Malnutrition due to neglect or poverty
- Malabsorption disorders (e.g., Crohn's disease, celiac disease)
- Chronic diseases affecting nutrition (e.g., cancer, severe food allergies)
- Infants exclusively fed boiled or evaporated milk without supplementation
Risk factors include:
- Developmental disorders affecting eating behaviors
- Socioeconomic factors limiting access to fresh fruits and vegetables
- Chronic health conditions requiring specialized diets
Pathophysiology of Scurvy
The pathophysiology of scurvy revolves around the critical role of vitamin C in collagen synthesis and other metabolic processes:
- Collagen Synthesis: Vitamin C is a cofactor for prolyl and lysyl hydroxylases, enzymes crucial for collagen formation. Deficiency leads to weakened collagen, affecting:
- Blood vessel integrity (causing easy bruising and bleeding)
- Bone formation (impacting growth and bone health)
- Connective tissue strength (leading to joint pain and poor wound healing)
- Antioxidant Function: Vitamin C is a powerful antioxidant. Its deficiency results in increased oxidative stress, potentially damaging cells and tissues.
- Iron Metabolism: Vitamin C enhances iron absorption. Its deficiency can contribute to anemia.
- Neurotransmitter Synthesis: Vitamin C is involved in the synthesis of norepinephrine, affecting mood and cognitive function.
Clinical Manifestations of Scurvy in Children
Scurvy in children can present with a wide range of symptoms, often developing gradually:
- Early Signs:
- Fatigue and weakness
- Irritability and mood changes
- Weight loss or poor weight gain
- Anorexia
- Dermatologic Manifestations:
- Perifollicular hemorrhages (especially on the legs)
- Corkscrew hairs
- Easy bruising
- Poor wound healing
- Oral Manifestations:
- Gingival swelling, bleeding, and friability
- Loosening of teeth
- Delayed tooth eruption
- Musculoskeletal Manifestations:
- Joint pain and swelling
- Muscle weakness
- Bone pain, especially in the legs
- Fractures and subperiosteal hemorrhages
- Systemic Manifestations:
- Anemia (often microcytic)
- Fever
- Tachycardia and dyspnea (in severe cases)
In infants, the condition may present as "Barlow's disease" with irritability, tenderness of the legs, and pseudoparalysis.
Diagnosis of Scurvy in Children
Diagnosing scurvy in children requires a high index of suspicion, especially given its rarity in developed countries. The approach includes:
- Clinical History:
- Detailed dietary history
- Assessment of risk factors (e.g., developmental disorders, chronic illnesses)
- Physical Examination:
- Focus on dermatologic, oral, and musculoskeletal findings
- Assessment of growth and development
- Laboratory Tests:
- Serum ascorbic acid level (< 11 µmol/L suggests deficiency)
- Complete blood count (to assess for anemia)
- C-reactive protein (often elevated)
- Imaging Studies:
- X-rays may show:
- Osteopenia
- Cortical thinning
- Fractures or subperiosteal hemorrhages
- Scorbutic rosary (enlargement of the costochondral junctions)
- X-rays may show:
- Therapeutic Trial:
- Rapid improvement with vitamin C supplementation can confirm the diagnosis
Differential diagnosis includes other nutritional deficiencies, leukemia, bleeding disorders, and rheumatologic conditions.
Treatment of Scurvy in Children
The treatment of scurvy in children focuses on vitamin C replacement and addressing underlying causes:
- Vitamin C Supplementation:
- Initial dosage: 100-300 mg daily in divided doses for 1-2 weeks
- Maintenance: 30-100 mg daily based on age
- Route: Oral preferred; parenteral in severe cases or if unable to tolerate oral intake
- Dietary Modification:
- Introduce vitamin C-rich foods gradually
- Nutritional counseling for families
- Management of Complications:
- Pain management for musculoskeletal symptoms
- Dental care for oral manifestations
- Treatment of anemia (iron supplementation if needed)
- Addressing Underlying Causes:
- Management of chronic diseases
- Behavioral interventions for feeding disorders
- Social services involvement if neglect is suspected
Most symptoms improve rapidly within days to weeks of starting treatment. However, complete resolution of all manifestations may take several months.
Prevention of Scurvy in Children
Preventing scurvy in children involves ensuring adequate vitamin C intake through diet and, when necessary, supplementation:
- Dietary Recommendations:
- Encourage consumption of fruits and vegetables rich in vitamin C
- Educate families on food sources of vitamin C
- Address cultural or socioeconomic barriers to accessing fresh produce
- Supplementation:
- For infants: Ensure vitamin C-fortified formula or breast milk
- For children with restricted diets: Consider routine supplementation
- For children with chronic diseases: Tailor supplementation based on individual needs
- Screening and Monitoring:
- Regular nutritional assessments in high-risk children
- Vitamin C level monitoring in children with chronic malabsorption or restricted diets
- Education:
- Inform healthcare providers about the continued risk of scurvy in certain populations
- Educate families about the importance of a balanced diet
By implementing these preventive measures, the risk of scurvy in children can be significantly reduced, even in high-risk populations.
Vitamin C Deficiency (Scurvy) in Children
- What is the primary function of Vitamin C in the human body?
Antioxidant and cofactor in collagen synthesis - Which of the following is NOT a common symptom of scurvy in children?
Hyperkeratosis - What is the recommended daily intake of Vitamin C for children aged 4-8 years?
25 mg - Which of the following populations is at highest risk for developing scurvy?
Children with autism spectrum disorder and severe food selectivity - What is the classic gum-related finding in scurvy?
Swollen, spongy, and bleeding gums - Which of the following is NOT a common source of Vitamin C?
Whole grains - What is the typical timeframe for the development of scurvy after complete dietary Vitamin C deprivation?
1-3 months - Which of the following laboratory findings is most specific for scurvy?
Low serum ascorbic acid level - What is the characteristic radiographic finding in scurvy?
Wimberger ring sign (dense line at the metaphyseal end of long bones) - Which of the following is NOT a potential complication of untreated scurvy?
Hypercalcemia - What is the recommended treatment dose of Vitamin C for children with scurvy?
100-300 mg daily for 1-2 weeks, followed by 50-100 mg daily for 1-3 months - Which of the following symptoms typically appears first in developing scurvy?
Fatigue and irritability - What is the term for the characteristic skin finding in scurvy?
Perifollicular hemorrhage - Which of the following conditions can mimic the presentation of scurvy in children?
Leukemia - What is the role of Vitamin C in iron absorption?
It enhances the absorption of non-heme iron - Which of the following is NOT a typical ocular manifestation of scurvy?
Cataracts - What is the term for the characteristic gait in children with severe scurvy?
Frog-leg position - Which of the following is a potential consequence of excessive Vitamin C intake?
Increased risk of kidney stones - What is the primary cause of the musculoskeletal pain in scurvy?
Subperiosteal hemorrhage - Which of the following is NOT a typical hematological finding in scurvy?
Thrombocytosis - What is the term for the characteristic hair change seen in scurvy?
Corkscrew hairs - Which of the following conditions does NOT increase the risk of developing scurvy?
Hypothyroidism - What is the primary mechanism of Vitamin C's antioxidant action?
Scavenging free radicals and regenerating other antioxidants - Which of the following is NOT a typical oral manifestation of scurvy in children?
Enamel hypoplasia - What is the half-life of Vitamin C in the human body?
Approximately 10-20 days - Which of the following factors does NOT affect Vitamin C absorption?
Gastric pH - What is the term for the bluish-purple gum discoloration seen in advanced scurvy?
Skorbutic gums - Which of the following is NOT a typical psychological manifestation of scurvy in children?
Hyperactivity - What is the primary reason humans cannot synthesize Vitamin C?
Lack of the enzyme L-gulonolactone oxidase - Which of the following is a potential long-term consequence of childhood scurvy?
Growth retardation
