Vitamin D: a growing problem

Dr James BunnAlder Hey Children’s Hospital NHS FT

No commercial interestsNo conflicts of interest

Vitamin D

Deficiency causes problems in:Bone growth

Rickets and musculoskeletal paincraniotabes

Muscle functioningMyopathy/ cardiomyopathy

Calcium and phosphate regulationHypocalcaemic convulsions in infants

Susceptibility to InfectionIncreased risk of TB, and response to Rx

Metabolism of vitamin D

Potential Immunologic effects

8 interesting facts

90% of vit D comes from sunshineSeasonal pattern for deficiencyPigmented skin needs up to 6x more sunFactor 15+ sunscreen blocks >99% of sunBreast milk has limited vit D (25 IU/litre)Maternal vitamin D a good source for babyFortification is only in some foodsBME diets may not utilise fortified foods

A growing problem

Increase in the level set for sufficiencySurveys suggest highly prevalent

In Somali community 82% deficient

Associated conditions increasingChronic diseases and Obesity

Increasingly recognisedHigh profile casesAdvocacyIncreased testing

Clinical cases

3 month old, 5th childAfro-Carribean parentsBreastfed5 minute convulsion,

calcium 1.8mmol/l, PTH 48.1Reduced bone density

Family historyhypocalcaemic convulsion in 12 y old siblingMother vitamin D deficient, no pregnancy vit D

Cardiomyopathy

16 cases at Great Ormond StreetPresenting with heart failureInfants, first year of life12 were exclusively breastfed

Case study

4 year old with aches and painsSome splaying of wrists

X ray changes of ricketsVitamin D deficient 15nmol/lRx cholecalciferol 200,000 units total dose

Choice of 6,000 units daily for 1 monthOr 20,000 units for 10 doses

Check symptomatic response, and bottleRepeat blood biochemistryConsider family members vit D risk

Case study

10 year old Caucasian child referred by GPInsufficient vit D3 (37pmol/l), vit D2 <4 Blood tested as abdominal painAsymptomatic

Vit D probably not cause of symptoms

Supplement 400 IU/ day for winter months

Co- morbidity

Renal diseaseGut malabsorptionCystic fibrosisNeuromuscular diseaseDrug interaction e.g. Anticonvulsants(Obesity)

Pathways now suggesting yearly testing

At risk groups

BMECultural

covered skin (in mother or child)Reduced use of fortified foods

Sunblocks and conflicting messagesBreastfeeding

Guidance on prevention

COMA 2003NICE (in low income households) 2008CMO 2012RCPCH 2012

All indicate children <4-5 years should be supplemented when not on formula milk, and all mothers supplemented in pregnancyBut only NICE is a required provision for CCGs and TrustsHealthy Start vitamins are the available intervention

Uptake Nationally is low, and process complex

Choices in Management

Adequate fortification for populationAdvise high vitamin D containing foodsSupplement allSupplement those on low incomesSupplement high risk groupsTest high risk groups and treatTest only when symptomatic, and treatAwait morbidity (and occasional mortality)

Who gets tested? Ealing infant hypocalcaemia cases

GP vit D tests (yellow) and top 10 vit D prescribing practices (green) in Ealing

Credit to Colin MitchieEaling Hospital for maps

Experience at Alder Hey

2007-8 2008-9 2009-10 2010-11 2011-120

200

400

600

800

1000

1200

1400

Total Tests done

Seasonality of deficiency

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

AdequateDeficientInsufficientSeverely Deficient

Proportion deficient unchanged

Toxic Adequate Insufficient Deficient Severely Deficient0%

10%

20%

30%

40%

50%

60%

70%

80%

2007-82008-92009-102010-112011-12

Increase in deficiency in those first tested

Toxic Adequate Insufficient Deficient Severely Deficient0%

10%

20%

30%

40%

50%

60%

70%

80%

2008-92009-102010-112011-12

Deficiency in older children:? related to testing protocols

<1 year 1-4 Years 5-12 Years >12 YEARS0%

10%

20%

30%

40%

50%

60%

70%

80%

Toxic Adequate

Insufficient Deficient

Severely Deficient

Which specialty is testing?

AE

Cardi

oEn

do

Gastro

Gen P

aeds

GP/Com

mun

ity

Haem

/Onc

HDU/ICU

ID/Im

mun

olog

y

Nephr

o

Neuro

Ortho

Other

Resp

Rheum

Surg

ery

Unkno

wn

0

50

100

150

200

250

2007-82008-92009-102010-112011-12

General practice is more awareand testing kids more

Challenges

What products are available

Multivitamins recommended as supplementVitamin D products +/- calciumCholecalciferol (vit D3) recommended as RxErgocalciferol (Vit D2) alfacalcidol (one alpha) only in renal disease

Drug or food supplement?Quality assurance of vit D

Does not require same level of QA as drugs

QA testing of possible Rx17% active ingredient in one liquidVariable in capsules (~25%)

Specials very expensiveUp to £500 from community pharmaciesModerately cheaper from hospitals

? QA for Healthy Start

Challenges

NICE only for low incomeHealthy Start very low uptake

Targeted v.s. Cost recovery vs Universal

Conflict with Breastfeeding messagesConflict with skin cancer avoidance message

Potential for Commercial interest Vit D supplemented ‘more healthy’ products

Some practical points

If not symptomatic - supplement, don’t testSupplement family members of cases

Under 5, growth spurt, pre pregnant, pregnant

Ensure supplementation in all pregnanciesCheck if iron deficient as wellTop up vitamin D each winter in deficiencyPublic health approaches cheaper than test and treat approaches

Cautions on measuring vitamin D supplementation programme success

Increased recognition of symptomsIncrease in testing, so may identify moreIncreasing numbers on treatment.Case reporting not helpful (eg BPSU)

Poor definition of common morbidityHypocalcaemic convulsions rare

A need for true population surveysMeasure coverage of intervention

Vitamin D: a growing problem

Better recognition of symptomsRisk groups and obesity increasingRecognition of non bony morbidityIncreased testing

? Appropriately directed

Increasing scientific publicationIncreasing public interestCommercial opportunism

Thank you