New Vitamin D Recommendation for Children

Dr. Janesta Noland, our guest pediatrician blogger, has provided a summary of the new recommendation for vitamin D supplementation in children.

New data reveal many ways in which vitamin D is important in overall health and prevention of disease requiring higher levels than those which cause clinically evident rickets. Additionally, data show that the previously recommended 200 IU daily will not maintain levels above 11ng/ml in a significant proportion of children. As a result of these findings on dose and medical importance of vitamin D, the American Academy of Pediatrics (AAP) is changing its recommendation to a higher dose of 400 IU daily in all infants, children and adolescents not taking 1000mL (33oz.) daily of fortified formula or milk.

For lots (and I mean lots) more detail on vitamin D read on....

The American Academy of Pediatrics has recommended since 2003 that all breastfeeding infants be supplemented with 200 IU of vitamin D daily1. Vitamin D is essential in calcium absorption in the gut and in bone metabolism including growth and remodeling. Vitamin D production occurs in the skin after exposure to UVB radiation and is affected by latitude, air pollution, time in the sun, season, cloud cover, body mass and amount of body exposure. Dietary sources of vitamin D are not generally significant: the only foods that contain meaningful amounts are fatty fish, fish oils, liver, fat from marine mammals and eggs from chicken fed vitamin D.

For current typical lifestyles, and given recommendations by the AAP and American Cancer Society to avoid sun exposure because of the risk of skin cancer, children may not have adequate levels of vitamin D. Profound deficiency of vitamin D can cause rickets and continues to be reported in the US despite the current recommendations. The peak incidence is between 3 and 18 months of age. The risk is higher in infants who are exclusively breastfed and infants with darker skin pigmentation.2,3,4,5,6,7

Long before vitamin D deficiency rickets is evident, insufficiency may occur and may appear as growth failure, lethargy, irritability, and hypocalcemic seizures8,9,10. New evidence in adults suggests that vitamin D also plays a role in preventing autoimmune disease such as rheumatoid arthritis11 and multiple sclerosis12, some forms of cancer13,14,15,16,17,18,19,20,21 (breast, ovary, prostate and colorectal) and may diminish the incidence of Type 2 diabetes22,23,24. Some evidence in children suggests vitamin D supplements in infancy may decrease type 1 diabetes25,26,27.

Vitamin D must by hydroxylated in the body to be active. Serum levels of 25[OH]vitamin D are the best indicator of vitamin D status. The level of vitamin D in the blood that constitutes deficiency has only recently been defined for adults (12-15 ng/ml and insufficiency at <20>

Given the now better-understood risks of vitamin D insufficiency in children that precedes the development of clinically evident rickets, supplementation with vitamin D is important. 400 IU daily is known to be safe, and both prevent and treat rickets. An AAP clinical report is in press32 which will establish this new recommended dose which should be initiated as soon as breastfeeding is well established.

All infant formula in the US is fortified to 400 IU per liter (about 33 ounces). Exclusively formula-fed infants who take this amount of formula do not need supplementation. However, infants who are breastfed or who are taking both formula and breast milk require supplementation.

Vitamin D can be taken in two forms: ergocalciferol (D2 – plant-based) or cholecalciferol (D3 – fish-based). D3 has greater efficacy in raising serum levels33 and thus is the recommended and most commonly used form. It is available both in multivitamin form and alone in liquid or drops. (Because of the potential for overdose with the concentrated drop form, liquid is recommended.)

The vitamin D status of pregnant and lactating mothers greatly impacts vitamin D levels in their infants. Fetal vitamin D levels appear to have both short and long-term consequences – one study showed an increase in birth weight when mothers have levels above 20 ng/ml34, and another showed increased bone density in 9 year old children whose mothers were supplemented during pregnancy35. No consensus exists on the dose of vitamin D supplementation in these women, despite the fact that studies show that on average pregnant women are deficient without supplementation (13 ng/ml in one study and <10>

The Canadian Paediatric Society recommends 2000 IU daily for pregnant and breastfeeding women31. Two pilot studies of high-dose vitamin D supplementation in lactating mothers (6400 IU) showed serum levels in their infants equivalent to levels in infants taking 300-400 IU supplements41,42. Safety of the long-term use of such high levels of supplementation in women has not been studied, however, and cannot be recommended. Since vitamin D deficiency is not limited to infancy but persists throughout the lifespan, particularly during phases of rapid growth, supplementation is important in children and adolescents as well. Consumption of 32oz/day of vitamin D fortified milk would provide the required 400 IU, but dietary practices make that difficult to achieve. Thus a multivitamin with 400 IU of vitamin D is appropriate.

Excellent links:

http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908(This is the old policy – new is in press)

http://www.nih.gov/news/pr/aug2007/od-17.htmhttp://ods.od.nih.gov/factsheets/vitamind.asp

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