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Vitamin D deficiency in children

Vitamin D deficiency in children. Dr. Rim El-Rifai Consultant Paediatrician Queen Mary’s Hospital for Children. Dangers of Vitamin D deficiency: DOH February 2012. Up to ¼ of the population has low levels of Vitamin D in their blood

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Vitamin D deficiency in children

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  1. Vitamin D deficiency in children Dr. Rim El-Rifai Consultant Paediatrician Queen Mary’s Hospital for Children

  2. Dangers of Vitamin D deficiency: DOH February 2012 • Up to ¼ of the population has low levels of Vitamin D in their blood • The majority of pregnant women do not take Vitamin D supplements • People on lower income can get supplements through the Healthy Start Scheme

  3. Vitamin D • A prohormone essential for normal absorption of calcium from the gut • It occurs Naturally in the body following exposure to UVB sunlight, the body can also synthesize it (from cholesterol) • A group of fat-soluble Secosteroids • In humans, it can be ingested as cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2)

  4. 25-hydroxy vitamin D • The 25-hydroxy vitamin D test is the most accurate way to measure vitamin D level. • In the kidney, 25-hydroxy vitamin D changes into an active form of the vitamin.

  5. Synthesis of Vitamin D In the skin 7-dehydrocholseterol is converted to vitamin D3 In the liver vitamin D is converted to 25-hydroxycholecalciferol, or 25-hydroxyvitamin D (Calcidiol) —abbreviated 25(OH)D: the specific vitamin D metabolite measured in serum to determine a vitamin D status. Part of the calcidiol is converted by the kidneys to 1, 25- dihydroxy vitamin D3 (Calcitriol), the biologically active form of vitamin D. Calcitriolcirculates in the blood, regulating the concentration of Calcium and Phosphate in the bloodstream and promoting the healthy growth and remodeling of bone. Calcidiolis also converted to calcitriol outside of the kidneys for other purposes, such as the proliferation, differentiation and apoptosis of cells; calcitriolalso affects neuromuscular function and inflammation.[

  6. Vitamin D deficiency in Children in the UK ADCH 2007 • Survey of Paediatricians in the West Midlands in 2001 • 24 cases of Vit D deficiency under 5 years of age • Overall incidence 7.5 per 100 000 • 11/24 had bowed legs, presented at around 18 months • 6 had hypocalcemic seizures at 6 weeks of age • 4 had gross motor delay at 17.7 months of age • All were black African or African-Caribbean • Majority were beastfed • 50% of those with convulsions were formula fed suggesting inadequate Vit D content in formula milk • Advised: need to supplement vulnerable groups including pregnant women

  7. Vitamin D deficiency rickets among children in Canada • Paediatricians surveyed between 2002-2004 • 104 confirmed cases in the study period • Overall annual incidence 2.9 cases per 100 000 • Mean age at diagnosis 1.4 yrs • 65% lived in urban areas • 89% had intermediate or darker skin • 94% were breastfed • None of the breast fed babies had received a supplement according to guidelines (400 IU/day) • Maternal risk factors included: limited sun exposure, lack of Vit D from diet, lack of Vitamin supplementation during pregnancy and lactation

  8. AMERICAN ACADEMY OF PEDIATRICSPrevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake, April 2003 • Cases of rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continue to be reported in the United States. • A state of deficiency occurs months before rickets is obvious on physical examination. • Also, it is acknowledged that most vitamin D in older children and adolescents is supplied by sunlight exposure.However, dermatologists and cancer experts advise caution in exposure to sun, especially in childhood, and recommend regular use of sunscreens. • Sunscreens markedly decrease vitamin D production in the skin.

  9. People at risk of Vit D deficiency • all pregnant and breastfeeding women, especially teenagers and young women • infants and young children under 5 years of age • older people aged 65 years and over • people who have low or no exposure to the sun, for example those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods • people who have darker skin, for example people of African, African-Caribbean and South Asian origin

  10. Presentation • Extremely variable and dependent on: • age • Severity of deficiency • Underlying causes • Ranges from Biochemical to severe bony disease

  11. Rickets in 1st year of life • The most rapidly growing bones are : skull, upper limbs and ribs • Craniotabes • Widening on cranial sutures • Frontal bossing • Enlarged swollen epiphyses: particularly wrists • Bulging of costo-chondraljoints (Rachitic Rosary) • Harrison’s sulcus • Irritability • Hypotonia

  12. Bowing of legs Frontal bossing

  13. Rachitic Rosary

  14. Enlarged Swollen Epiphyses

  15. Rickets after the first year • Genu Varum, Genu Valgum • Abnormal dentition with enamel hypoplasia • Bone pain • Proxymal myopathy

  16. Genu Valgum and Genu Varum

  17. Severe Rickets In severe cases resulting from low Calcium: • Tetany • Laryngeal stridor • Paraesthesiae • Convulsions • Respiratory failure

  18. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in children • Study of 150 hospitalized Indian children in 2004 • Subclinical vitamin D deficiency and non-exclusive breast feeding in the first 4 months of age: • significant risk factors for severe acute lower respiratory infections in Indian children

  19. Causes of Vitamin D deficiency • Poor dietary intake most common in Asian population • Reduced synthesis from sun exposure • Genetic: • Vitamin D dependent rickets: AR • Hypophosphataemic Rickets: x-linked dominany • Malabsorption: Coeliac disease, Cystic Fibrosis • Renal disease (low 1,25 dihydroxy vitamin D- the most active form) • Liver Disease • Medications such as Anticonvulsants induce hepatic enzymes

  20. Calciopenic: Low Ca • Dietary calcium and vitamin D deficiency • Malabsorption • Lack of sun light • Hepatic disease • Anticonvulsant treatment • Renal disease • 1-α hydroxylase deficiency • End organ resistance to vitamin D

  21. Phosphopenic:low PO4 • Fanconi Syndrome • X-linked hypoposphataemic rickets • Renal tubular acidosis • Ocul-cerebro-renal syndrome (Lowe syndrome) • Osteopenia of prematurity

  22. Biochemical • Hypocalcaemia • Hypophosphataemia • Elevated Alkaline Phosphatase • Low 1,25 – Dihydroxy vitamin D • Serum Parathyroid Hormone level may be high

  23. Radiologically • Widening of growth plate • Fraying, Cupping, and Widening of metaphyses • Pseudo fractures • Signs of secondary hyperparathyroidism : subperiosteal erosion

  24. Other investigations • Depending on underlying cause: • Acidosis • Aminoaciduria • Chronic renal failure • anaemia

  25. Treatment • Calcium, phosphate and vitamin D given in varying combinations • Underlying abnormalities need to be treated (coeliac disease) • Growth needs to be monitored • In hypophsphataemic rickets large doses of Vitamin D are required • In 1α hydroxylase deficiency or end-organ resistance to vitamin D, 1,25- dihydroxy-cholecalciferol is usually required in significant doses • Regular renal USS is important

  26. Treatment • Vitamin D 1,000 to 5,000 μg IV/ day until normal alkaline phosphatase • Then 10 μg / day and 500 ml/ day of milk for calcium requirements • Exposure to sunlight • Dietary source: oily fish, fortified margarine

  27. Dietary sources • Oily fish • Eggs • Infant formula • Some cereals, dairy products, low fat speads have a small amounts added • Difficult to get sufficient Vitamin D from diet alone

  28. Breast feeding and Vitamin D • Infants who are breastfed but do not receive supplemental vitamin D or adequate sunlight exposure are at increased risk of developing vitamin D deficiency or rickets. • Human milk typically contains a vitamin D concentration of 25 IU/L or less. • The recommended adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D for the breastfeeding infant.

  29. Formulas and Vitamin D • All infant formulas must have a minimum vitamin D concentration of 40 IU/100 kcal (258 IU/L of a 20-kcal/oz formula) and a maximum vitamin D concentration of 100 IU/100 kcal (666 IU/L of a 20-kcal/oz formula). • All formulas sold have at least 400 IU/L. • If an infant is ingesting at least 500 mL per day of formula (vitamin D concentration of 400 IU/L), he or she will receive the recommended vitamin D intake of 200 IU per day.

  30. Sunlight Exposure • Decreased sunlight exposure occurs: • during the winter and other seasons and when sunlight is attenuated by clouds, • air pollution • Lifestyles or cultural practices: • decreased time spent outdoors • increase the amount of body surface area covered by clothing when outdoors. • individuals with darker skin pigmentation • by the use of sunscreens. • Skin Cancer: • age at which direct sunlight exposure is initiated is more important than the total sunlight exposure over a lifetime in determining the risk of skin cancer. • AAP guidelines for decreasing exposure: • infants younger than 6 months should be kept out of direct sunlight, • children’s activities that minimize sunlight exposure should be selected, • protective clothing as well as sunscreens should be used.

  31. Chief Medical Officers: • “A significant proportion of people in the UK probably have inadequate levels of vitamin D in their blood. • “People at risk of vitamin D deficiency, including pregnant women and children under 5, are already advised to take daily supplements”. • DOH February 2012

  32. National Pharmacy Association • Fact sheet prepared with assistance of DOH in March 2012 • Providing advice on the prevention of vitamin D Deficiency in the at risk groups • http://www.npa.co.uk/resources/information-leaflets-and-factsheets/clinical/preventing-vitamin-d-deficiency-in-at-risk-groups/

  33. NPA Recommendations • Daily vitamin D supplementation should be taken by: • All pregnant and breastfeeding women • Breastfed infants from one month of age if mother did not take vit D supplements through pregnancy • All children aged 6 mon- 5 years (except who receive more than 500 ml of formula milk, which is fortified with Vit D) • People aged 65 and over • People who are not exposed to much sun • People with darker skins • Medical conditions (GI, renal, liver) • Medication (Carbamazepine, phenytoin, primidone, barbiturates, some anti-HIV medicines

  34. NPA Supplementation guidance

  35. prognosis • Excellent in most children • Dependent on compliance with treatment • Less certain in hypophospahtaemic rickets and severe deformities of the limbs may result

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