Epidemiology of vitamin D deficiency in children presenting to a paediatric outpatient service in th...
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Epidemiology of vitamin D deficiency in children presenting to a paediatric outpatient service in the UK J M Reed, J H Davies, L Blake, A Jackson, N M P Clarke Southampton General Hospital & University of Southampton. Background. Vitamin D3 (cholecalciferol) is obtained from 2 sources:

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Background

Epidemiology of vitamin D deficiency in children presenting to a paediatric outpatient service in the UKJ M Reed, J H Davies, L Blake, A Jackson, N M P Clarke Southampton General Hospital & University of Southampton


Background

Background

  • Vitamin D3 (cholecalciferol) is obtained from 2 sources:

    • Sunlight exposure (UV-B rays)

    • Dietary intake: oily fish products, fortified products and supplements.


Formation of cholecalciferol

Formation of cholecalciferol

7-dehydrocholesterol


Background1

Background


Definitions

Definitions

Davies et al, Arch Dis Child 2010; Cheetham et al, BMJ 2010; Misra et al Pediatrics 2008


Prevalence of vitamin d deficiency in developed countries adults vs children

Prevalence of vitamin D deficiency in developed countries, adults vs. children

Hypponen et al, Am J Clin Nutr, 2007

n=7347, age 45 y, UK, all white, winter/ spring 25-OHD measurement

87.1% < 75 nmol/l

46.6% < 40 nmol/l

15.5% < 25 nmol/l

Ford et al, Ann Clin Biochem, 2006

n=830, UK adults, multicultural inner city, Sept 25-OHD measurement

< 25 nmol/l:1 in 8 White

1 in 4 Black Afro-Caribbean

1 in 3 Asians

Kumar et al, Pediatrics, 2009

n=6275, USA, age 1-21 y, NHANES 2001-2004, 25-OHD measurement

61%, 37.5-72.5 nmol/l

9%, < 37.5 nmol/l

association with cardiovascular risk factors

what is the prevalence of vitamin D deficiency in UK children?


Mode of presentation of symptomatic vitamin d deficiency in the uk

Mode of presentation of symptomatic vitamin D deficiency in the UK

  • 16 infants (6 Asian, 10 Black) from UK

  • all breast fed

  • 6 cardiac arrest

  • 3 died

  • 8 ventilated

  • 2 required by-pass

  • 12 required IV support

  • 2 referred for cardiac transplant

    Heart 2006


Background

Recent trends & clinical features of vitamin D deficiency presenting to a children’s hospital in Glasgow

Ahmed et al, Arch Dis Child, 2010


Methods

Methods

  • Prospective study to investigate the prevalence of deficiency in our patient population

    • Vitamin D level in known bone pathologies

      - or

    • Requested as part of investigative work-up for unexplained bone pain


Background

Stages of Tibia Vara

1 2 3 4 5 6


Changing incidence of slipped capital femoral epiphysis a relationship with obesity

Changing incidence of slipped capital femoral epiphysis: A relationship with obesity

JBJS Br. 2008; 90: 92-4


Background

31.1.10

2.6.10


Vitamin d deficiency in children presenting to the paediatric orthopaedic clinic southampton 1

Vitamin D deficiency in children presenting to the paediatric orthopaedic clinic, Southampton (1)

25-OHD measured in those with bone pain or deformity

187 children from 2008 – 2010

75 deficient (60 insufficiency, 15 severe deficiency)


Vitamin d deficiency in children presenting to the paediatric orthopaedic clinic southampton 2

Vitamin D deficiency in children presenting to the paediatric orthopaedic clinic, Southampton (2)


Further analysis

Further analysis

No specific diagnosis was associated with a high or low vitamin D level

There was a lower vitamin D level found in children with unexplained joint pain (mean 22.5) compared to those with other diagnoses (mean 30.7). This was significant p<0.05.


Prevention

Prevention

Infant vitamin D RNIs

8.5 ug/d up to 6 months age

7 ug/d up to age 3 years

Chief Medical Officer, 20/1/2011, DOH website

“children from the age of six months to five years old should be given a daily 7 micrograms vitamin D supplement”


Background

Prevention: Healthy Start

  • 7.5 ug vitamin D3

  • Free for some from age 6 months

    • can be given from age 1 month on doctor’s advice

  • Also contain vitamin A and vitamin C

  • Can be bought £1.78/bottle


Healthy start uptake south east 2010

Healthy start uptake South East 2010


Significance

Significance

Sunlight exposure

15 – 20 minutes uninterrupted sunlight 3 times per week

Vitamin D supplements

Vitamin D status sought prior to commencing ‘observation or orthopaedic surgical intervention’


Background

Fractures

in 348 children

Femur

4.9%

Hand

7.5%

Tibia/fibula

7.8%

Ankle

9.8%

Radius/ulna

54.9%

Other

1.7%

Humerus

13.5%


Fat mass substantially inhibits bone accrual in children with prior fracture

Fat mass substantially inhibits bone accrual in children with prior fracture

JBMR 2009


Summary

Summary

Majority of active vitamin D from sunlight

Increase in cases of symptomatic vitamin D deficiency (not exclusive to poverty/ethnic minorities)

Need for raised awareness and improved public health measures


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