Doctors all over the world are given the greatest respect. This is because they are lifesavers who work tirelessly for mankind. Moreover, being a doctor is one of the most sought-after professions.
Ever since my childhood I cherished the dream of becoming a doctor. I had always been fascinated about the human body and how it works and the idea of being able to help people overcome the illness and lead healthier lives is what drove me to pursue a career in medicine. I had also witnessed compassion and dedication of many doctors displaying towards their patients and I aspired to emulate the qualities in my own career.
I did my MBBS in Mumbai which had given me a solid understanding of the fundamentals. As I was enthusiastic and a keen learner, I applied and did my internship at Rajiv Gandhi Hospital Chennai (one of the pioneer hospitals at Chennai in providing medical care). I opted for being a Pediatrician as I always liked children, interacting with them gave me immense joy. However, it is also one of the most challenging fields, as the child cannot communicate directly and hence the diagnosis has to be made objectively. Many a times, the child may also require a close monitoring as he/she tend to deteriorate rapidly. The three years of MD Paediatrics was tough, but prepped me up to handle difficult situations. After MD Pediatrics, I had worked in a number of hospitals in Chennai and Pune where I was able to gain more exposure.
I have been associated with Kauvery Hospital for the past 5 years and my clinical experience has been fantastic. Working in Kauvery has taught me not only to deal with diseases but also to cater to the needs of different strata of the society. Being a paediatrician, I carry the responsibility of looking after babies/ children who come in pain or illness. What makes the job most rewarding is when the child recovers from an illness, the smile on the child as well as the parents face is priceless. The Covid 19 period proved to be challenging in ensuring that the kids stay physically and mentally healthy. I was thankful to Kauvery for extending our services through online consultations to provide best care to the patients in need, on time. I was also fortunate to take sessions and improve the awareness on the impact of COVID-19 on the mental health of children. One of the things I admire about the medical profession is its perpetual evolution and advancement. I am constantly in touch with the advancements as a part of professional updation. I strongly believe that it is crucial for doctors to be not only knowledgeable but also compassionate, ethical and culturally sensitive and I am committed to imbibing these qualities consistently. I would like to list some of the characteristics which I feel one should imbibe to succeed in his/ her profession.
Vitamin E Deficiency – A Forgotten Entity!
Vitamin E comprises a group of eight biologically active tocopherols, among which d-alpha-tocopherol has the highest antioxidant activity. It prevents the cell membranes from lipid peroxidation and is involved in eicosanoid synthesis. Preterm, especially VLBW infants are at a higher risk of developing Vitamin E deficiency because of poor intake, poor absorption, low storage and higher requirement compared to the term infants. Serum levels of vitamin E are lowest at 4 weeks of age, when a physiological drop in hemoglobin also occurs. These two factors lead to missing the diagnosis of vitamin E deficiency in many infants. We report a VLBW preterm infant who presented to us with hemolytic anemia and improved with oral administration of vitamin E.
The role of vitamin E in preterm has been a subject of considerable discussion. Iron supplementation in VLBW is evidence based and has established recommendations. Excess exogenous iron supplementation in an infant with an underlying vitamin E deficiency, can contribute to oxidative injury. This case report aims to review the current information on Vitamin E supplementation in preterm infants, prior to iron therapy.
64 days old female was born at 30 weeks, VLBW (1.15kgs), appropriate for gestational age, in a tertiary care Government hospital, to a primigravida, with placenta previa. She had perinatal hypoxia requiring resuscitation and CPAP. During the NICU stay of one month, she received multiple transfusions for anemia. During follow-up, she was transfused twice. There was no history of blood group incompatibility, phototherapy or exchange transfusion. She was exclusively breast fed with adequate weight gain and no nutritional supplements. At two months of age, she developed a sudden onset of vomiting and lethargy. She was brought to our hospital for further care.
At admission she was pale, hemodynamically stable, no icterus; anterior and posterior fontanelle were normal with no dimorphisms, cyanosis, distress, hepatosplenomegaly or hemangiomas. There was no history suggestive of delayed separation of the cord, no concealed hemorrhages or soft tissue bleeds. Investigations revealed anemia (hb-6.4g/dl) with reticulocytosis (5%). Coagulation profile was normal; sepsis and TORCH screening were negative. DCT was negative. Chest X ray, cranial and abdominal USG ruled out occult hemorrhages. Smear examination by the hematologist was reported to show polychromasia and hemozoin pigments suggestive of hemolysis. Hemoglobin electrophoresis was normal. Hemolytic anemia in a preterm, persisting despite transfusions, made us to suspect vitamin E deficiency. Serum vitamin E level was 1.71 (6-19mg/L). She was started on vitamin E orally at 25mg/kg/day which was continued for 2 months. She did not require any further transfusions. Repeat levels normalized (9.2 mg/L). An ophthalmological evaluation was done to screen for retinopathy of prematurity revealed a zone 2 stage 3 ROP with plus disease bilaterally which was treated with laser. Follow-up with the ophthalmologist showed regressing ROP. She is now one year old, developmentally normal with no visual defects.
Confirmed our suspicion of Vitamin E deficiency as the cause of anemia in this child.
VLBW infants are at a higher risk for vitamin E deficiency because of low storage, poor absorption and higher requirement than term infants. High incidence of vitamin E deficiency starts from birth, continuing through postnatal and postmenstrual age. Oski observed that the incidence of hemolytic anemia in the vitamin E sufficient babies was 9% as compared to the insufficient ones in whom the incidence was 66%. Available evidence is insufficient to assess the effect of enteral iron supplementation on the neurodevelopmental and long-term outcome of preterm infants as iron supplementation only marginally reduced the risk of iron deficiency anemia. It failed to identify any benefit from dose more than 2mg/kg/day. Large iron doses may accentuate fall in hemoglobin concentration as they act as a cofactor in the oxidative breakdown of the red cell membrane which could have been the probable reason for the exaggerated hemolysis in this baby, as she had multiple transfusions. Vitamin E is important for heme and porphyrin synthesis. In pharmacological doses, it may confer protection to the retina from developing retinopathy of prematurity. Though present evidence does not support high dose vitamin E supplementation, recommended dietary allowance of 2-11mg/kg/day of vitamin E should be provided to prevent deficiency in preterm infants. This dietary allowance is met by daily intake of human milk in term infants. But in preterm, low birth weight infants; the daily requirements are met only with fortified milk.
Our infant had a risk factor of being VLBW preterm, exclusively breast fed with no supplements. Hence in a preterm presenting with a hemolytic anemia, Vitamin E deficiency should be considered one among the causes and evaluated.
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CONFLICT OF INTEREST: NIL
Dr Pushkala. M. S. MBBS, MD (Pediatrics), PGDID, PGPN Consultant Pediatrician Kauvery Hospital Chennai
