Monday, August 11, 2008

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:

1. Gartner LM, Greer FR. Prevention of rickets and vitamin D deficiency: New guidelines for vitamin D intake. Pediatrics 2003:111(4):908-910.
2. Thacher T, Fischer P, Strand M, Pettifor J. Nutritional rickets around the world: causes and future directions. Ann Tropical Paediatrics 2006;26(1):1-16.
3. Pettifor J. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr 2004;80(suppl):1725S-1729S
4. Kreiter SR, Schwartz RP, Kirkman HN, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr 2000;137:153-157
5. Weisberg P, Scanlon K, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr 2004;80(suppl):1697S-1705S.
6. Pettifor J. Rickets and vitamin D deficiency in children and adolescents. Endocrin Metabol Clin NA 2005;34(3):537-553.
7. Ward L. Vitamin D deficiency in the 21st century: a persistent problem among Canadian infants and mothers. CMAJ 2005;172(6):769-770.
8. Hatun S, Ozkan B, Orbak Z, Doneray H, Cizmecioglu F, Toprak D, et al. Vitamin D Deficiency in Early Infancy. J. Nutr. 2005;135(2):279-282.
9. Stearns G, Jeans P. The effect of vitamin D on linear growth in infancy. J Pediatr 1936;9:1-10. 10. Pawley N, Bishop N. Prenatal and infant predictors of bone health: the influence of vitamin D. Am J Clin Nutr 2004;80(suppl):1748S-1751S.
11. Merlino LA, Curtis J, Mikuls TR, Cerhan JR, Criswell LA, Saag KG. Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study. Arthritis Rheum 2004;50(1):72-7.
12. Munger KL. , Levin, LI,Hollis BW , Howard, NS , Ascherio A (2006). "Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis.". Journal of the American Medical Association 296 (23): 2832–2838.
13. Vitamin D The Physicians Desk Reference. 2006 Thompson Healthcare.
14. Ingraham BA, Bragdon B, Nohe A (2007). "Molecular basis of the potential of vitamin D to prevent cancer". Curr Med Res Opin 24: 139.
15. "Vitamin D 'can lower cancer risk'", BBC News 28 December 2005
16. Beer T, Myrthue A (2006). "Calcitriol in the treatment of prostate cancer". Anticancer Res 26 (4A): 2647–51.
17. Martin Mittelstaedt (28 April 2007). "Vitamin D casts cancer prevention in new light", Global and Mail.
18. Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. (2007). "Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial.". Am J Clin Nutr. 85 (6): 1586–91.
19. Skinner HG, Michaud DS, Giovannucci E, Willett WC, Colditz GA, Fuchs CS (2006). "Vitamin D intake and the risk for pancreatic cancer in two cohort studies". Cancer Epidemiol. Biomarkers Prev. 15 (9): 1688–95
20. Tuohimaa P, Pukkala E, ScĂ©lo G, et al (2007). "Does solar exposure, as indicated by the non-melanoma skin cancers, protect from solid cancers: vitamin D as a possible explanation". Eur. J. Cancer 43 (11): 1701–12.
21. Freedman DM, Looker AC, Chang SC, Graubard BI (2007). "Prospective study of serum vitamin D and cancer mortality in the United States". J. Natl. Cancer Inst. 99 (21): 1594–602.
22. Chiu K, Chu A, Go V, Soad M. Hypovitaminosis D is associated with insulin resistance and beta cell dysfunction. Amer J Clin Nutr 2004;79:820-825.
23. Pittas AG, Dawson-Hughes B, Li T, Van Dam RM, Willett WC, Manson JE, et al. Vitamin D and calcium intake in relation to type 2 diabetes in women. Diabetes Care 2006;29(3):650-6.
24. Ford ES, Ajani UA, McGuire LC, Liu S. Concentrations of serum vitamin D and the metabolic syndrome among U.S. adults. Diabetes Care 2005;28(5):1228-30.
25. The EURODIAB Substudy 2 Study Group. Vitamin D supplement in early childhood and risk for Type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1999;42:51-54.
26. Hypponen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: A birth-cohort study. Lancet 2001;358:1500-03.
27. Harris SS. Vitamin D in type 1 diabetes prevention. J Nutr 2005;135(2):323-5.
28. Greer FR, Marshall S. Bone mineral content, serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements. J Pediatrics 1989;114:204-212.
29. Gessner BD, Plotnik J, Muth PT. 25-hydroxyvitamin D levels among healthy children in Alaska. J Pediatr 2003;143(4):434-7.
30. Ziegler E, Hollis BW, Nelson S, Jeter J. Vitamin D deficiency in breastfed infants in Iowa. Pediatrics. 2006 Aug;118(2):603-10.
31. Canadian mothers and babies don't get enough vitamin D 2007 Canadian Paediatric Society Recommendation
32. Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children and adolescents. In Press.
33. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
34. Mannion C, Gray-Donald K, Koski K. Milk restriction and low maternal vitamin D intake during pregnancy are associated with decreased birth weight. CMAJ 2006 Apr 25;174(9):1273-7.
35. Wagner C, Hulsey T, Fanning D, Ebeling M, Hollis B. High dose vitamin D3 Supplementation in a cohort of breastfeeding mothers and their infants: A six-month follow-up pilot study. Breastfeeding Medicine 2006;2(59-70).
36. Cockburn F, Belton NR, Purvis RJ, Giles MM, Brown JK, Turner TL, et al. Maternal vitamin D intake and mineral metabolism in mothers and their newborn infants. Brit Med J 1980;5:11-14.
37. van der Meer I, Karamali N, Boeke A. High prevalence of vitamin D deficiency in pregnant non-Western women the The Hague, Netherlands. Am J Clin Nutr 2006;84:350-353.
38. Delvin EE, Salle L, Glorieux FH, Adeleine P, David LS. Vitamin D supplementation during pregnancy: Effect on neonatal calcium homeostasis. J Pediatr 1986;109:328-334.
39. Vieth R, Chan PCR, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level (LOAEL). Amer J Clin Nutr 2001;73(2):288-294.
40. Brooke OG, Brown IRF, Bone CDM, Carter ND, Cleeve HJW, Maxwell JD, et al. Vitamin D supplements in pregnant Asian women: Effects on calcium status and fetal growth. Brit Med J 1980;1:751-754.
41. Wagner C, Hulsey T, Fanning D, Ebeling M, Hollis B. High dose vitamin D3 Supplementation in a cohort of breastfeeding mothers and their infants: A six-month follow-up pilot study. Breastfeeding Medicine 2006;2(59-70).
42. Hollis BW, Wagner CL. Vitamin D requirements during lactation: High-dose maternal supplementation as therapy to prevent hypovitaminosis D in both mother and nursing infant. Amer J Clin Nutr 2004;80S:1752S-1758S.


Anonymous said...

Yes, children should take extra vitanins & health for their overall development.

Marcela Faul said...

Vitamin D is good for overall health. Thank you for posting this information about the new recommendation.