Presentation by Dr.Rajeev jain from Agra,India for pediatric group clinical meeting.

1. Nutritional Deficiency of
Vitamin D in children

2. 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

3. Definition:
Rickets :
It is caused by failure of osteiod to calcify in growing
person.
Failure of osteiod to calcify in adults is called
Osteomalacia.

4. 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.

5. “Vitamin D is critical for skeletal development and
cellular function because of its effect on calcium
homeostasis by promoting intestinal calcium
absorption”
Vitamin D deficiency rickets occurs when the
metabolites of vitamin D are deficient.

6. Pathophysiology:

7. Vitamin D content of common foods
Clinical Signs and Symptoms of
vitamin D deficiency:
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.

8. Clinical Presentation:

9. 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

10. Clinical Investigations:
Serum measurement of
 Calcium
 Phosphorous
 Alkaline phosphatase
 Parathyroid Hormone
 25-hydroxy vitamin D
 1,25 –dihydroxy vitamin D
http://emedicine.medscape.com/article/985510-overview

11. 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.

12. 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.

13. Factors associated with deficiency:
• Religious customs
• Atmospheric pollution
• Skin pigmentation
• Vegetarian diets
• Maternal vitamin D deficiency
Ind J Med Res.2008;127 (): 245-249

14. 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.

15. Vitamin D status:
25(OH)D Level 25(OH)D Level Health Implications
(ng/mL) (nmol/L)
<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

16. 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.

17. 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.

18. 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.

19. Neuromuscular Disorder
Subjects: 44 disabled children with cerebral palsy
Treatment: Oral vitamin D 1000 IU five days per week
Treatment Duration :10 weeks
25.00
20.00
25(OH)D ng/mL
22.4
15.00
14.8
17.60
10.00
5.00
0.00
Baseline Control At End of
Group Therapy
vitamin D(3) supplementation resulted in significant increase in vitamin D
level and was not associated with hypecalcemia or other adverse effect.
Neuropediatrics. 2007;38(4):167-72.

20. Seasonal Influenza A
Subjects: School children (6-15yrs)
Primary outcome: Incidence of seasonal influenza A
Treatment: Oral vitamin D 1200 IU
Treatment Duration :4 months Incidence of Influenza A (%)
20
15
18.6
10
10.8
5
0
Vit D Group Placebo Group
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.

21. Essential. Simple. Safe