Bitot's Spots Research Articles

Xerophthalmia in Malnourished Sudanese Children

Two hundred and thirteen Sudanese children (4-60 months old) with malnutrition were examined for signs of xerophthalmia. Sixty-three (29%) 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.

Breast feeding and vitamin A deficiency among children attending a diarrhoea treatment centre in Bangladesh: a case-control study.

To determine the effect of breast feeding on the risk of xerophthalmia in children aged 6 months to 3 years attending a diarrhoea treatment centre in Bangladesh. Case-control study based on stratified analysis (Mantel-Haenszel) and multivariate analysis (logistic regression) of data from a treatment centre based surveillance system. A large diarrhoea treatment centre in Dhaka, Bangladesh. 2687 children aged 6 months to 3 years representing a 4% systematic sample of all children in this age group treated yearly at the centre over three consecutive years. 66 of the children were cases of xerophthalmia (that is, they had Bitot's spots or corneal lesions or night blindness or night blindness plus conjunctival xerosis or any combination of these) and the remaining 2621 did not have signs or symptoms of vitamin A deficiency. This second group served as controls. Xerophthalmia and breast fed at onset of diarrhoea or presentation. The odds ratio relating breast feeding to vitamin A deficiency after adjustment for a large number of confounding variables (0.26 (95% confidence interval 0.14 to 0.49); p less than 0.001) reflected a 74% reduction in the risk of vitamin A deficiency among breast fed children. The estimated reduction of risk did not decline with age, and some 49% of children aged 24-35 months were still being breast fed. The odds ratio relating breast feeding to xerophthalmia in the third year of life (0.35 (95% confidence interval 0.35 to 0.86) reflected a 65% reduced risk of vitamin A deficiency. Other important risk factors or prognostic indicators for xerophthalmia as identified by multivariate analysis were recent measles, prolonged diarrhoea, severe protein energy malnutrition, and poor socioeconomic state. These results indicate that breast feeding was associated with a substantial reduction of the risk of vitamin A deficiency extending to the third year of life and support the recommendation that mothers in developing countries should be advised to breast feed for as long as possible.

Nutritional and household risk factors for xerophthalmia in Aceh, Indonesia: a case-control study

Risk factors for xerophthalmia were assessed in 466 subjects [38% with night blindness (XN), 60% with Bitot's spots (X1B), 2% with corneal xerophthalmia (X2 or X3)] under age 6 y and their village-age-sex-matched control subjects during a community trial. Socioeconomic status and hygiene standards were lowest for households of xerophthalmic children and highest for nonstudy households in the trial population, with values for control households lying in between (P less than 0.001 by linear trend). Risk of xerophthalmia increased with less frequent consumption of dark green leaves, yellow fruits, or egg during weaning, adjusted for current intake and present age [odds ratio (OR) = approximately 3.5]. Exclusion of these same foods from the current diet (except for mango and papaya in older children) was associated with a two- to ninefold excess risk of xerophthalmia, adjusted for weaning influences. Xerophthalmic children aged less than 3 y were generally at higher risk of dietary imbalance than were older children. Xerophthalmia is associated with a chronic, infrequent consumption of key vitamin A foods from weaning through early childhood.

Prevalence of malnutrition and vitamin A deficiency in the Diourbel, Fatick, and Kaolack regions of Senegal: epidemiological study

The purpose of our study was to determine the prevalence of protein-calorie malnutrition (PCM), ocular diseases, and vitamin A deficiency in preschool children selected at random in a rural zone of the groundnut belt of Senegal. The prevalence of PCM was 37.1% (95% CI 33.8-40.2%) according to the Waterlow classification, with a majority of stunting, and prevalence of hypovitaminosis A was estimated to be 11.4% (95% CI 9.3-13.5%) by using impression cytology. Furthermore, 19.4% (95% CI 15.8-22.0%) of the children might be defined at risk of deficiency. The prevalence of Bitot's spots was equal to 0.2% (95% CI 0.03-0.9%). A problem of PCM associated with a health-endangering vitamin A deficiency existed.

Response of Bitot's Spots in Preschool Children to Vitamin A Treatment

In a double-masked, placebo-controlled, clinical trial in Indonesia, 88 preschool children between the ages of 36 and 72 months with Bitot's spots were randomly assigned to 200,000 IU of oral vitamin A or placebo and followed up for five weeks. Baseline and follow-up serum vitamin A levels were obtained. Of the 45 children receiving vitamin A, 33 (73.3%) showed complete cure and disappearance of Bitot's spots, six (13.3%) had disappearance of some but not all Bitot's spots, and six (13.3%) were unresponsive to treatment. The nonresponsive children were older, all male, and had higher initial mean serum vitamin A levels, 23.0 micrograms/dl, compared to 15.9 micrograms/dl in the cured group (P = .017). These data suggest that normal vitamin A status may be found in approximately 13% of children with Bitot's spots before vitamin A intervention and that one fourth of those who had Bitot's spots originally will not be cured of all Bitot's spots after intervention. These are important factors to consider when using Bitot's spots in prevalence surveys as a clinical sign of vitamin A deficiency.

Ocular Manifestations and Impression Cytology of Anorexia Nervosa

A prospective age- and sex-controlled study of seven anorexia nervosa patients and seven normal control patients was conducted to determine the ocular manifestations of anorexia nervosa. Slit-lamp examination of the anorexic patients demonstrated a high incidence (4/7) of multiple episcleral capillary aneurysms and subconjunctival hemorrhages. Two of seven anorexia nervosa patients had bilateral superficial punctate keratopathy. Anesthetized Schirmer tear testing demonstrated a significantly (P < 0.005) reduced mean tear production in the anorexia nervosa group (11.3 mm) compared with the control group (22.4 mm). Masked interpretation of conjunctival impression cytology demonstrated moderate to severe conjunctival squamous metaplasia in the majority of the anorexia nervosa group (5/7) compared to normal conjunctival epithelium in the majority of the control group (5/7). Absence of nyctalopia, Bitot's spots, and xerosis, and lack of conjunctival goblet cell loss indicate that the anorexia nervosa group did not have vitamin A deficiency.

Economic and Health Consequences of Undernutrition

An adequate variety of food necessary to provide a proper nutritional balance has always been a topic of prime concern for social economists. Moral and political concern caused the initiation of a series of studies focusing on the magnitude and causes of undernutrition. This article addresses concerns about some economic and health consequences of undernutrition and discusses some adverse health effects that may be associated with improper food balances. Findings suggest that a high percentage of undernutrition in the USA is concentrated in areas where social and economic deprivation is most prevalent, and shows that a complex of factors in the culture of poverty appear to be linked to undernutrition and non‐organic retardation. Two farm work crews were tested over a year with the objective of gaining more information about their dietary habit and nutritional status. Dietary deficiencies expressed as Bitot Spots (27.7 per cent) Visible Caries or ulceration (21.6 per cent) were found consistently among workers in the study sample population. Using F statistics and controlling for sex, male workers were found to be more adversely affected by dietary deficiencies than female workers.

Bitot's spots

Bitot's spots

Maternal-Neonatal Serum Vitamin A Concentrations

Summary: Prevention of neonatal vitamin A deficiency is related to the adequacy of maternal vitamin A stores. In this study we investigated maternal and cord serum vitamin A and retinol-binding protein (RBP) values in an Indian population including, for the first time, clinically vitamin A-deficient mothers. Twenty-eight maternalneonatal pairs were selected from maternal cohorts of high socioeconomic status without clinical evidence of vitamin A deficiency (group I) and low socioeconomic status with conjunctival xerosis and Bitot's spots (group II). Maternal education, caloric and vitamin A intakes, weight, height, hemoglobin, and birth weight were significantly lower in group II. Serum vitamin A levels were significantly higher in group I mothers and newborns as were RBP levels in group I mothers. However, a significant difference between groups I and II in cord blood RBP was not observed. Upon correlation of maternal vitamin A levels with cord blood vitamin A levels, a logarithmic relationship was revealed, suggesting saturable transplacental transport of vitamin A.

Maternal‐Neonatal Serum Vitamin A Concentrations

Summary:Prevention of neonatal vitamin A deficiency is related to the adequacy of maternal vitamin A stores. In this study we investigated maternal and cord serum vitamin A and retinol‐binding protein (RBP) values in an Indian population including, for the first time, clinically vitamin A‐deficient mothers. Twenty‐eight maternalneonatal pairs were selected from maternal cohorts of high socioeconomic status without clinical evidence of vitamin A deficiency (group I) and low socioeconomic status with conjunctival xerosis and Bitot's spots (group II). Maternal education, caloric and vitamin A intakes, weight, height, hemoglobin, and birth weight were significantly lower in group II. Serum vitamin A levels were significantly higher in group I mothers and newborns as were RBP levels in group I mothers. However, a significant difference between groups I and II in cord blood RBP was not observed. Upon correlation of maternal vitamin A levels with cord blood vitamin A levels, a logarithmic relationship was revealed, suggesting saturable transplacental transport of vitamin A.

Maternal-Neonatal Serum Vitamin A Concentrations

Prevention of neonatal vitamin A deficiency is related to the adequacy of maternal vitamin A stores. In this study we investigated maternal and cord serum vitamin A and retinol-binding protein (RBP) values in an Indian population including, for the first time, clinically vitamin A-deficient mothers. Twenty-eight maternal-neonatal pairs were selected from maternal cohorts of high socioeconomic status without clinical evidence of vitamin A deficiency (group I) and low socioeconomic status with conjunctival xerosis and Bitot's spots (group II). Maternal education, caloric and vitamin A intakes, weight, height, hemoglobin, and birth weight were significantly lower in group II. Serum vitamin A levels were significantly higher in group I mothers and newborns as were RBP levels in group I mothers. However, a significant difference between groups I and II in cord blood RBP was not observed. Upon correlation of maternal vitamin A levels with cord blood vitamin A levels, a logarithmic relationship was revealed, suggesting saturable transplacental transport of vitamin A.

A prevalence study of vitamin A deficiency and xerophthalmia in northeastern Thailand.

An epidemiologic survey of the prevalence of xerophthalmia and vitamin A deficiency was conducted in May and June 1985 in a multistage random sample of 1,772 children 1-8 years of age from 16 rural villages and the capital city of the Sakon Nakhon province in northeastern Thailand. Data of clinical eye examinations were available for 92% (n = 903) of the eligible children aged 1-5 years (n = 982); history of night blindness was obtained from a reliable source from 93% (n = 1,644) of the whole sample; and biochemical data were available for 60% (1,060) of the children examined. The distribution of clinical signs of xerophthalmia and serum retinol levels differed between the rural and urban areas. In the urban area, no signs of xerophthalmia or deficient serum retinol levels were found in the preschool children examined. The prevalence of night blindness in the rural area was 1.3% in children aged 1-5 years (95% confidence interval (Cl) 0.7-1.9); Bitot's spots were seen in 0.4% (95% Cl 0.1-1.0); 12.7% (95% Cl 9.9-15.5) showed deficient serum retinol levels (less than 0.35 mumol/liter). Of the children aged 1-8 years, 9.6% (95% Cl 7.8-11.4) showed deficient serum retinol levels. In the rural area, the prevalence of night blindness, Bitot's spots, and deficient serum retinol levels indicates a problem of public health importance according to World Health Organization criteria.

LESSONS FROM THE THIRD WORLD

American pediatricians are often unaware of significant developments in international health, especially when they are reported in non-pediatric journals. A case in point is summarized by this abstract of a study from Java: In a controlled trial, fortification of commercially marketed monosodium glutamate (MSG) with vitamin A improved serum vitamin A levels of young children and the vitamin A content of breast milk of lactating women. These improvements in vitamin A indices were accompanied by dramatic changes in health and anthropometric status. During the course of the study, the prevalence of Bitot's spots among children in program villages fell progressively from 1.2% at base line to 0.2% 11 mo after introduction of the fortified product (p&amp;lt;0.001) xerophthalmia rates in control villages remained essentially unchanged. Linear growth was greater among program than among control children at every age. Hemoglobin levels among program children rose by ∼10 g, from 113 ± 16 g/L at base line to 123 ± 16 by 5 mo (p&amp;lt;0.0001); they remained essentially unchanged among children of control villages. Preschool children in control villages died at 1.8 times the rate of children in program villages. Am J Clin Nutr 1988;48:1271-6 These results are similar to those independently obtained in Sumatra, where Vitamin A capsules were given to preschool children at 6 month intervals (A. Sommer, et al: Impact of vitamin A supplementation on childhood mortality. Lancet 1986;1:1169) The data should stimulate inquiries into the mechanisms of the effect of Vitamin A on general health and mortality (in addition to its preventing xerophthalmia) and their relevance for nutritionally marginal children in the United States.

Vitamin A-fortified monosodium glutamate and health, growth, and survival of children: a controlled field trial

In a controlled trial, fortification of commercially marketed monosodium glutamate (MSG) with vitamin A improved serum vitamin A levels of young children and the vitamin A content of breast milk of lactating women. These improvements in vitamin A indices were accompanied by dramatic changes in health and anthropometric status. During the course of the study, the prevalence of Bitot's spots among children in program villages fell progressively from 1.2% at base line to 0.2% 11 mo after introduction of the fortified product (p less than 0.001); xerophthalmia rates in control villages remained essentially unchanged. Linear growth was greater among program than among control children at every age. Hemoglobin levels among program children rose by approximately 10 g, from 113 +/- 16 g/L at base line to 123 +/- 16 by 5 mo (p less than 0.001); they remained essentially unchanged among children of control villages. Preschool children in control villages died at 1.8 times the rate of children in program villages.

Prevalence of xerophthalmia in relation to nutrition and general health in preschool-age children in three regions of Tanzania.

Integrated nutrition/health surveys were carried out in Mbeya, Iringa and Kagera Regions in Tanzania in which a total of 12,880 children were examined for the presence of xerophthalmia. Xerophthalmia was found to be a problem of public health significance in two of the three regions surveyed where the prevalence of active corneal xerophthalmic lesions was above the criteria set by WHO. Because of clustering of the children with Bitot's spots, corneal xerosis/ulceration and corneal scarring, only certain villages or groups of villages could be regarded as areas where xerophthalmia is a problem. The results of the ophthalmological examinations are discussed in relation to the nutritional status of the children as measured by anthropometric indices, serum levels of retinol-binding protein and prealbumin, haematological parameters, and vaccination status.

Changes in clinical ocular signs of vitamin A deficiency of underprivileged school age children (7–15 years) after a mega dose of the vitamin

The changes in clinical ocular signs of vitamin A deficiency wasstudied in underprivileged school age children 7–15 years of age after a dose of the vitamin. One thousand boys and 1,100 girls were screened visually for one or more clinical ocular signs of vitamin A deficiency. Of these 219 boys and 175 girls manifesting ocular signs of vitamin A deficiency were then dosed with 200,000 IU of vitamin A palmitate and followed up at weekly intervals for a period of two months. Overall prevalence of vitamin A deficiency prior to dosing was 22% in boys and 16% in girls. There was a dramatic response of all signs taken together two weeks after the dose of vitamin A. Maximum response for active cases (night blindness + any conjunctival signs) was observed at the end of the first week for boys and third week for girls; in case of night blindness and conjuctival xerosis it was the 3rd week for both sexes and for Bitot's spots the 8th week.

Impression cytology: a practical index of vitamin A status

Impression cytology was performed on 148 Indonesian preschool children of whom half had mild xerophthalmia and half were age-matched control subjects. Subjects were divided into subgroups that reflected the degree of confidence in their true vitamin A status as determined by serum vitamin A levels, clinical examination, and response to therapy. Impression cytology was considered normal if goblet cells were present and abnormal if they were absent. Thirteen of 14 (93%) children with vitamin A-responsive Bitot's spots and night blindness with base-line serum vitamin A less than 20 micrograms/dL (0.70 mumol/L) (group 1, definite deficiency) had abnormal cytology. In contrast, 17 of 18 (94%) children with normal ocular exam and serum vitamin A greater than 25 micrograms/dL (0.87 mumol/L) (group 7, least likely deficient) had normal cytology. Importantly, 12 of 26 (46%) clinically normal children with serum vitamin A levels less than 20 micrograms/dL (0.70 mumol/L) had abnormal impression cytology.

Vitamin A and vitamin E status of rural preschool children in West Java, Indonesia, and their response to oral doses of vitamin A and of vitamin E

Vitamin A and E status was studied in five groups (satisfactory growth, reduced growth, night blindness, Bitot's spots, and corneal xerosis) of rural Indonesian preschool children. All groups except corneal xerosis showed satisfactory weight-height ratios. Initial serum retinol values were less than 0.35 mumol/L in 34% of all children. After oral administration of 24.4 mumol vitamin A, mean serum retinol values rose from 0.42 to 0.70 mumol/L at 10 d. After oral treatment of children with 244 or 314 mumol vitamin A, mean serum retinol remained greater than 0.56 mumol/L for 165 d. Of particular note were the low mean initial serum alpha-tocopherol concentrations (6.3 mumol/L) and alpha-tocopherol-total lipid ratios (1.5 mumol/g). Total serum lipids fell in the normal range. Oral administration of 84 mumol vitamin E raised serum alpha-tocopherol and alpha-tocopherol-total-lipid ratios by 46 and 44%, respectively. Thus, vitamin E inadequacy, which impairs vitamin A absorption and storage, may well contribute to the high incidence of clinical vitamin A deficiency in West Javan children.

The prevalence and distribution of xerophthalmia in pre-school age children of the Luapula Valley, Zambia.

Four thousand two hundred and seventy-five children aged less than 6 years were examined for signs of xerophthalmia in a population based cross-sectional study in the Luapula Valley of Zambia. The overall prevalence of xerophthalmia was 1.89 per cent. The prevalence of nightblindness (XN), Bitot's spots (X1B), severe corneal lesions (X3A, X3B), and corneal scars (XS) were 1.26, 0.44, 0.02, and 0.68 per cent, respectively. One child was totally blind and four children had unilateral blindness. Comparison is made with data from other parts of Africa. It is concluded that xerophthalmia is a public health problem in this valley and a major cause of blindness in childhood.

Early Detection of Xerophthalmia by Impression Cytology-Reply

In Reply. —Xerophthalmia (dry inflamed eye) refers to clinically detectable disease. 1-4 As defined by the World Health Organization 1-3 and the International Vitamin A Consultative Group 4 nightblindness (XN), conjunctival xerosis (X1A), and Bitot's spots (X1B) represent early, mild xerophthalmia, in contrast to corneal xerosis (X2) and, particularly, destructive corneal melting (X3). Early A deficiency is another matter, and one that is difficult to define. The work of Wolbach et al, 5 Mori, 6 and Blackfan et al 7 suggest squamous metaplasia of the respiratory and genitourinary tracts may well precede xerophthalmia. More sophisticated probes of cellular metabolism and immunologic status would likely identify earlier, milder consequences of vitamin A deficiency. Except when severely depressed, serum vitamin A levels are not a reliable index of either vitamin A stores or their consequences. We viewed impression cytology as one potential approach to the objective determination of physiologically significant vitamin