Wednesday, May 02, 2012

How much Vit D does my child need ?

I had a child from a good soci-economic status the other day with non specific body aches/ joint pains. On doing a Vit D blood test, the levels were found to be less than 5, meaning the child was severely deficient. This prompted me to look at the above mentioned question ......  How much Vit D does my child need ?
Here is what the medical literature / evidence says.
Vitamin D is essential for good bone health and insufficient levels are linked to rickets in children.[1 5] A resurgence of vitamin D insufficiency and nutritional rickets has been reported across many countries.[1] Studies in infants and children are also exploring the association between vitamin D insufficiency and type 1 diabetes mellitus as well as inflammatory diseases.[1 2] There are limited natural dietary sources of vitamin D and adequate sun exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual.[3] Therefore, the recommendations to ensure adequate vitamin D status have been revised to cover all infants, including those who are exclusively breastfed.[3]
In Europe, very few foods are fortified with vitamin D and children are at especially high risk of deficiency.[5] The most studied functional outcome of vitamin D deficiency in children has been the occurrence of vitamin D deficiency rickets.[6] Insufficiency is defined as a vitamin D level <50 nmol/l and severe deficiency as a vitamin D level <25 nmol/l.[3 4] Reports on children from around the world have not supported any absolute threshold level of vitamin D for the occurrence of rickets.[6] Studies have shown that less than 200 IU/day of vitamin D will not maintain vitamin D concentrations at >50 nmol/l in infants.[3] An intake of 400 IU/day of vitamin D has been shown to maintain serum vitamin D concentrations at >50 nmol/l in exclusively breastfed infants.[3 7 9]
Pittard et al in a randomised controlled trial demonstrated that in newborns, 400 IU/day of vitamin D3 maintains the serum concentration of vitamin D above the range classically associated with rickets (see Table 2).[7] A Cochrane Review found that 400 IU/day of vitamin D for 12 months prevented nutritional rickets in children aged 3–36 months in Turkey, and that 300 IU/day of vitamin D for at least the first 12 months reduced the risk of rickets by 24% in China. A randomised clinical trial by Shakiba et al in Iran found that administering 200 IU/day, 400 IU/day and a 2-monthly bolus injection of 50 000 IU vitamin D provides the ideal serum level (>50 nmol/l) of vitamin D and prevents nutritional rickets.[9] However, self-limiting complications such as diarrhoea and agitation were reported in the bolus injection group. No other studies have shown added benefits for doses greater than 400 IU/day in infants or children. A randomised controlled trial by Siafarikas et al in Germany demonstrated that supplementation with 250 IU/day versus 500 IU/day of vitamin D3 for breastfed infants is sufficient (serum level >50 nmol/l) and prevents nutritional rickets in the summer and winter; there was no difference in serum vitamin D levels between the 250 IU/day and 500 IU/day groups.[10]
The Institute of Medicine of the National Academies, the American Academy of Paediatrics, the Drug and Therapeutics Committee of the Lawson Wilkins Paediatric Endocrine Society, the Canadian Paediatric Society and the European Society for Paediatric Endocrinology recommend 400 IU/day of vitamin D supplementation for infants.[3 11 12] However, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition suggested 800–1000 IU/day for high-risk infants during the winter. The Irish Department of Health and Children and the Health Service Executive recommend that all infants from birth to 12 months, whether breastfed or formula fed, be given a daily supplement of 200 IU (5 μg) of vitamin D3.[13] The UK Department of Health guidelines on vitamin D supplements in infants[14] recommend that breastfed children should be given a daily vitamin D supplement from 6 months of age until the age of 5 years. However, children receiving less than 500 ml (a pint) of infant formula a day should also be given a daily vitamin D supplement. The recommended Healthy Start Children's vitamin drop in the UK[15] contains 300 IU (7.5 μg) of vitamin D3.
Source (the references are listed in the source)
Since 2000, discrepancies have arisen regarding the benefits of vitamin D and how much to take. The Institute of Medicine (IOM) has reviewed and updated the Dietary Reference Intakes (DRIs). In 2008, the American Academy of Pediatrics (AAP) increased its recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU. Exclusively breastfed infants who do not consume less than 1L of vitamin D-fortified milk daily will likely need supplementation to reach 400 IU of vitamin D daily. Although the AAP advises against keeping children in direct sunlight exposure, this may increase the risk of vitamin D deficiency. However, the IOM found that there is strong evidence to support the use of vitamin D with calcium for bone health but that it was lacking for other health conditions. The new recommended daily allowance (RDA), as set in 2010, is based on age, as follows: for those 1-70 years of age, 600 IU daily; for infants aged 0-12 months, the upper level intake is 1,000 IU daily. Other research confirms these recommendations.
My View:
As you can see above, while we have tonnes of guidelines, and though these are controversial and confusing, NONE are from India. While we are in the tropics with good sunshine, are diets are very deficient in Vitamin D (large quantities are only found in fish oil in nature (which most Indians do not consume), with some amounts being found in egg yolk, mushrooms & fortified cereals, mild, curd etc. that are not easily available in our country, or are too expensive). Given the pollution in our cities, and our propensity for staying indoors to avoid tanning and other sunlight related hazards, it is no wonder that Vit D deficiency has become an epidemic as big as obesity! It is actually worse, since it is not easily diagnosed, and the tests are relatively expensive. A calcium, phosphorus, alkaline phosphatase test costs rs. 300/- approximately and will miss many cases of Vit D deficiency, while Vit D3 levels cost upwards of Rs. 1200/-. The good news is that treatment of this condition is relatively inexpensive, with a single IM injection costing less than 100/- Rs. and even daily packets of Vit D costing 15-25/- Rs. only per packet. In my opinion we as pediatricians need to be more aggressive in looking for this condition, especially in children with non specific musculoskeletal pains, and we should also supplement all newborns & infants with around 400 IU daily for at least 1-2 years. Previously we did not have any good oral drops for infants, but now at least two companies have launched appropriate preparations, ARBIVIT D3 (400 IU/ ml) and CALSHINE-P (800 IU/ml) by Eris Pharma. I would encourage pediatricians & parents in India to use Vit D routinely, just as we recommend Iron for many of our children.
BTW here is a list of foods rich in Vit D, that should be given in addition to the supplementation too

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