Contemporary Pediatrics - September 2008 - (Page 49)

Puzzler is estimated to be 400 mg for children ages 1 to 3 years, 650 mg for children ages 9 to 13 years, 1,800 mg for young adults ages 14 to 18, and 2,000 mg for adults. The average chewable multivitamin contains 60 mg per tablet and a typical liquid vitamin formula has between 25 to 35 mg. Those who are exposed to too much vitamin C for long periods of time can develop kidney stones and increased iron levels. Particularly, patients with blood disorders such as hemochromatosis or thalassemia should avoid high doses of vitamin C. In pregnant mothers with an appropriate diet, cord blood contains two to four times the concentration of vitamin C than maternal plasma. As a result, a typical infant will have enough stores of vitamin C to be adequate for the first couple of months of his or her life.1 Breast milk and all mainstream infant formulas also contain adequate amounts of vitamin C. Among solid foods, good sources of vitamin C include citrus fruits and juices, greens, potatoes, tomatoes, and other fruits and vegetables. Meats, eggs, and milk may contain small amounts of the vitamin, while grains contain almost none unless fortified.4 Fresh fruits and vegetables are the best source for getting vitamin C, since cooking many of these foods will result in decreasing the content up to 40%.5 The anemia present in scurvy is likely multifactorial. It results from impaired absorption of iron due to a lack of vitamin C. It may also result from the bleeding, as well as multiple other vitamin deficiencies commonly seen in association with vitamin C deficiency. In general studies, patients may have mild anemia, and an ECG can show changes such as ST elevations and atrioventricular blocks. Radiologic surveys of patients with scurvy show osteopenia and enlargement of the costochon- Clinical symptoms have dral junctions. Radibeen described by the ographs may also show an irregular, thickened four H’s: hemorrhage, white line at the metaphysis of long bones hyperkeratosis, which is known as a hyperchondriasis, and white line of Fraenkel.2 During the healing hematological process, area of subpe- abnormalities. riosteal hemorrhages with periosteal elevation may be seen as they become calcified. Unfortunately, there is no perfect laboratory test to diagnose scurvy. Though a vitamin C level can be helpful, levels tend to reflect recent dietary intake, and very easily can fluctuate with minimal ingestion of vitamin C. Leukocyte ascorbate concentration levels can be more accurate, because they are related to tissue stores. However, these levels are not readily available. A third laboratory test for scurvy is checking the urinary excretion of vitamin C. After being given large amounts of vitamin C, normal children will excrete 80% of a test dose. A child who is deficient in vitamin C will excrete a percentage much lower. Thus, scurvy is a clinical diagnosis, one that should be made based on the patient presentation,a good dietary history, basic lab work, and radiographic studies. Treatment for children with scurvy involves vitamin C supplementation of between 100 to 300 mg per day. Adults may require one gram per day. In general, recovery is very rapid, and patients will The four H’s of scurvy Symptoms of scurvy begin to appear one to three months after vitamin C intake stopped. One of the earliest clinical signs of scurvy is fatigue. The clinical symptoms have often been described by the four H’s: hemorrhage, hyperkeratosis, hypochondriasis, and hematological abnormalities. Classic signs of scurvy include tissue bleeding with nonpalpable purpura, particularly of the extremities. Petechiae may also be present, and patients may also have swollen and bleeding gums. Follicular hyperkeratosis and perifollicular hemorrhages are pathognomonic for scurvy.4 Patients are often irritable and their extremity pain, as in our patient, is not pinpointed in nature. Late findings seen in our patient included extremity edema, profound non-specific tenderness, and joint effusions. Other late signs include alopecia, seizures, syncope, and sudden death. SEPTEMBER 2008 CONTEMPORARY PEDIATRICS 49

Table of Contents Feed for the Digital Edition of Contemporary Pediatrics - September 2008

Contemporary Pediatrics - September 2008 Contents Editorial Your Voice Clinical Tip News Updates Eye on Washington Puzzler Dermatology: What’s your Dx? Behavior Cover Story: ECC Epidemic Parent Guides Discipline Techniques: The 12-Month-Old Exercise-induced Bronchospasm: Keeping Our Patients Active Food Safety Parent Guide CPR--Food Safety Malnutrition Links Surgeon General Links Hospice Links Childhood Cancer Links Rx for a Healthy Practice Rx for a Healthy Practice New Products Author Guidelines Journal Club Events Calendar Classifieds Index of Advertisers Postscript

Contemporary Pediatrics - September 2008

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