Nutritional Deficiency of

Vitamin D in children

Background:

In the later part of 19th

century estimated that nearly

80-90% of children who lived

in industrialized cities of

Europe and North America

had rickets.

J Clin Invest. 2006;116(8):2062-2072

Definition:

Rickets :

It is caused by failure of osteiod to calcify in growing

person.

Failure of osteiod to calcify in adults is called

Osteomalacia.

Severe chronic vitamin D deficiency [25(OH)D level

>15 ng/ml] leads to overt skeletal abnormalities in

children that is typically defined as rickets.

Vitamin D deficiency rickets occurs when the

metabolites of vitamin D are deficient.

“Vitamin D is critical for skeletal development and

cellular function because of its effect on calcium

homeostasis by promoting intestinal calcium

absorption”

Pathophysiology:

Clinical Signs and Symptoms of

vitamin D deficiency:

Vitamin D content of common foods

Craniotabes Hair loss or alopecia

Genu varum or valgum Delayed dentintion

Costchondral swellings Refusal to walk

Growth delay Fracture

Muscle weakness Seizure

Harrison’s grooves Tetany

Micheal F. Holick. Vitamin D –Physiology, Molecular Biology, and Clinical Applications. 2nd Edition. Humana Press.

Clinical Presentation:

Radiological Image:Radiograph in a 4-year-old girl with rickets depicts bowing of

the legs caused by loading.

http://emedicine.medscape.com/article/985510-overview

Clinical Investigations:

Calcium

Phosphorous

Alkaline phosphatase

Parathyroid Hormone

25-hydroxy vitamin D

1,25 –dihydroxy vitamin D

http://emedicine.medscape.com/article/985510-overview

Serum measurement of

Vitamin D – An Introduction:

The sunshine vitamin

The primary source – exposure to ultraviolet B sunlight.

Secondary sources- Fatty fish, fish oil, eggs, from

products (such as milk and orange juice and vitamin D

supplements.

Content of Vitamin D in Foods:

Food items

Cow’s milk 3-40 IU/L

Butter (100gm) 35 IU/L

Egg yolk 20-25 IU/L

Fish (100gm) 44-624 IU

Yoghurt (100gm) 89 IU

Cheese (100gm) 12-44 IU

Ind J Endo Metab. 2012; 16(2): 164–176.

Factors associated with deficiency:

• Religious customs

• Atmospheric pollution

• Skin pigmentation

• Vegetarian diets

• Maternal vitamin D deficiency

Ind J Med Res.2008;127 (): 245-249

FACT:The high prevalence of hypovitaminosis D in a

number of developing countries exists despite the

fact that a large number of these countries lie in

zones that have sufficient sunlight for vitamin D

synthesis for most if not all of the year.

Vitamin D deficiency is now recognized

as a pandemic.

Am J Clin Nutr. 2008;87(4):1080S-6S.

Vitamin D status:

25(OH)D Level

(ng/mL)

25(OH)D Level

(nmol/L)

Health Implications

<20 <50 Deficiency

20-32 50-80 Insufficiency

32-100 80-250 Sufficiency

54-90 135-225 Normal in sunny

countries

>100 >250 Excess

>150 >325 Intoxication

Alternative Medicine Review.2008;13(1):1-20 ,Alternative Medicine Review.2005;10(2):94-111

Recommendations:Daily intake

American Academy of Pediatrics 400 IU

Canadian Pediatric Society 400 IU

Health Canada 400 IU

Health policy in North America 400 IU

Institute of Medicine , Food & Nutrition Board

0-12 months 400 IU

1-3years 600 IU

The Endocrine Society

0-12 months 400-1000 IU

1-3 years 600-1000 IU

Appl Physiol Nutr Metab. 2010;35(3):303-9, Am Fam Physician.2010;81(6):745-8. Pediatrics 2008;122;398

Institute of Medicine. Nov 2010. The Endocrine Society. 2011.

FACT:

Vitamin D deficiency in pediatric patients has

serious implications.

Several recent studies have demonstrated an

alarming prevalence of medical conditions related

to this nutritionall problem, ranging from severe

nutritional rickets to sub-clinical vitamin D

deficiency even within industrialized societies.

It is estimated that children need at least 400-1000 IU of

vitamin D a day

while teenagers and adults need at least 2000 IU of

vitamin D a day to satisfy their body's vitamin D

requirement.

Curr Drug Targets. 2011 Jan;12(1):4-18.

Subjects: 44 disabled children with cerebral palsy

Treatment: Oral vitamin D 1000 IU five days per week

Treatment Duration :10 weeks

17.6014.8

22.4

0.00

5.00

10.00

15.00

20.00

25.00

Baseline Control Group

At End of Therapy

25

(O

H)D

n

g/m

L

Neuropediatrics. 2007;38(4):167-72.

Neuromuscular Disorder

vitamin D(3) supplementation resulted in significant increase in vitamin D

level and was not associated with hypecalcemia or other adverse effect.

Seasonal Influenza ASubjects: School children (6-15yrs)

Primary outcome: Incidence of seasonal influenza A

Treatment: Oral vitamin D 1200 IU

Treatment Duration :4 months

10.8

18.6

0

5

10

15

20

Vit D Group Placebo Group

Incidence of Influenza A (%)

vitamin D(3) supplementation during the winter may reduce the

incidence of influenza A, especially in specific subgroups of

schoolchildren.

Am J Clin Nutr. 2010;91(5):1255-60.

Essential. Simple. Safe