Vitamin D status in critically ill children

Nutrition for critically ill children with congenital heart disease

Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.

Macronutrient and Micronutrient Intake in Children with Lung Disease

This review article aims to summarize the literature findings regarding the role of micronutrients in children with lung disease. The nutritional and respiratory statuses of critically ill children are interrelated, and malnutrition is commonly associated with respiratory failure. The most recent nutrition support guidelines for critically ill children have recommended an adequate macronutrient intake in the first week of admission due to its association with good outcomes. In children with lung disease, it is important not to exceed the proportion of carbohydrates in the diet to avoid increased carbon dioxide production and increased work of breathing, which potentially could delay the weaning of the ventilator. Indirect calorimetry can guide the process of estimating adequate caloric intake and adjusting the proportion of carbohydrates in the diet based on the results of the respiratory quotient. Micronutrients, including vitamins, trace elements, and others, have been shown to play a role in the structure and function of the immune system, antioxidant properties, and the production of antimicrobial proteins supporting the defense mechanisms against infections. Sufficient levels of micronutrients and adequate supplementation have been associated with better outcomes in children with lung diseases, including pneumonia, cystic fibrosis, asthma, bronchiolitis, and acute respiratory failure.

A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study)

BACKGROUND

Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU.

METHODS

We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial.

RESULTS

Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%).

CONCLUSIONS

A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up.

TRIAL REGISTRATION

CLINICALTRIALS

gov NCT02452762 Registered 25/05/2015.

Vitamin-D Status and Clinical Outcomes in Critically Ill Children

Aims and background

To study if 25-hydroxy cholecalciferol levels correlate with clinical outcomes in a cohort of critically ill children requiring pediatric intensive care unit (PICU) admission.

Materials and methods

All children between the ages of 1 month and 14 years admitted to a PICU were included in this study. The vitamin-D level was measured within 24 hours of admission to the PICU for each patient. The patient's clinical details, vitamin-D levels, and biochemical parameters were collected.

Results

There were 119 critically ill children (47 females and 72 males) admitted to our PICU. A total of 56 children were in the vitamin-D-deficient group, giving a prevalence of 47.05%. Sixty-three children had either insufficient or normal levels of 25(OH)D. Mean serum 25-OH cholecalciferol was 22.82 ± 16.48 nmol/L. There were no significant differences in O2 utilization, ventilation requirement, length of PICU stay, or the frequencies of use of antibiotics and steroids between the groups. The overall mortality rate in this study was 5.8% (three children died in the deficient group as compared with four in the insufficient/normal group).

Conclusion

Even though vitamin-D deficiency was highly prevalent in the PICU, there were no statistically significant differences in O2 utilization, length of PICU stay, duration of mechanical ventilation, the use of antibiotics/steroids, and mortality outcome for both deficient and insufficient/normal groups.

How to cite this article

Loni R, Zameer S, Hasan FA, Abbas I, Mesrati H, George J, et al. Vitamin-D Status and Clinical Outcomes in Critically Ill Children. Indian J Crit Care Med 2023;27(7):503-509.

Vitamin D Deficiency: An Underestimated Factor in Sepsis?

Vitamin D is an important immune modulator that is linked to infection susceptibility. It has been suggested that vitamin D deficiency plays a role in sepsis and septic shock because vitamin-D-related pathways are associated with various immunological, endocrine, and endothelial functions. Previous research has yielded inconclusive results regarding the link between mortality and vitamin D deficiency in sepsis patients. In patients with sepsis and severe vitamin D deficiency, an adequate vitamin D concentration may reduce mortality. Randomized controlled trials to assess the influence of vitamin D supplementation on clinical outcomes in sepsis patients with vitamin D deficiency are uncommon. We will provide an overview of the current knowledge about the relationship between vitamin D and sepsis in this review, as well as consider the potential value of vitamin D supplementation in this situation.

Vitamin therapy in sepsis

Vitamins are essential micronutrients with key roles in many biological pathways relevant to sepsis. Some of these relevant biological mechanisms include antioxidant and anti-inflammatory effects, protein and hormone synthesis, energy generation, and regulation of gene transcription. Moreover, relative vitamin deficiencies in plasma are common during sepsis and vitamin therapy has been associated with improved outcomes in some adult and pediatric studies. High-dose intravenous vitamin C has been the vitamin therapy most extensively studied in adult patients with sepsis and septic shock. This includes three randomized control trials (RCTs) as monotherapy with a total of 219 patients showing significant reduction in organ dysfunction and lower mortality when compared to placebo, and five RCTs as a combination therapy with thiamine and hydrocortisone with a total of 1134 patients showing no difference in clinical outcomes. Likewise, the evidence for the role of other vitamins in sepsis remains mixed. In this narrative review, we present the preclinical, clinical, and safety evidence of the most studied vitamins in sepsis, including vitamin C, thiamine (i.e., vitamin B₁), and vitamin D. We also present the relevant evidence of the other vitamins that have been studied in sepsis and critical illness in both children and adults, including vitamins A, B₂, B₆, B₁₂, and E. IMPACT: Vitamins are key effectors in many biological processes relevant to sepsis. We present the preclinical, clinical, and safety evidence of the most studied vitamins in pediatric sepsis. Designing response-adaptive platform trials may help fill in knowledge gaps regarding vitamin use for critical illness and association with clinical outcomes.

Association Between the Circulating Level of 25-Hydroxyvitamin D and Clinical Results After Cardiac Surgery: A Meta-Analysis and Systematic Review

Background: Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D (25-(OH)-VitD), in patients after cardiac surgery and the relationship between VitD deficiency and adverse outcomes, but the results have been inconsistent. We carried out a meta-analysis to evaluate differences in the 25-(OH)-VitD level before and after cardiac surgery, and evaluated the predictive value of 25-(OH)-VitD level in the clinical outcomes of patients undergoing cardiac surgery.

Methods: Studies related to VitD level and cardiac surgery were searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from inception to October 2020. We applied the Newcastle–Ottawa Scale to assess the risk of a bias in individual studies. We examined the heterogeneity and publication bias and performed subgroup analyses and sensitivity analyses.

Results: Fifteen studies were included in our analysis. The 25-(OH)-VitD level was significantly lower immediately after surgery [stand mean difference (SMD), 0.69; 95%CI (0.1, 1.28), P = 0.023] and 24-h after surgery [0.84; (0.47, 1.21), 0.000] compared with that before surgery. A higher prevalence of 25-(OH)-VitD deficiency was recorded 24 h after surgery [RR, 0.59; 95%CI (0.47, 0.73), P = 0.00]. Pooled results demonstrated a significant relationship between the preoperative 25-(OH)-VitD level and vasoactive-inotropic score (VIS) [SMD, −3.71; 95%CI (−6.32, −1.10); P = 0.005], and patients with 25-(OH)-VitD deficiency revealed a comparatively poor prognosis and severe condition after cardiac surgery [−0.80; (−1.41, −0.19), 0.01]. However, 25-(OH)-VitD deficiency was not associated with the duration of stay in the intensive care unit.

Conclusions: Cardiac surgery would leads to deficiency of 25-(OH)-VitD. And the preoperative and postoperative levels of 25-(OH)-VitD are associated with adverse events, which is eligible to work as an indicator to demonstrate clinical outcomes.

Serum Vitamin D Deficiency in NICU Hospitalized Neonates and Its Association With Neonatal Outcomes

Objective: Vitamin D deficiency is a major health problem in all age groups. In the present study, we aimed to determine the prevalence of vitamin D deficiency in neonates hospitalized in an intensive care unit (NICU) and its association with clinical neonatal outcomes.

Materials and methods: A prospective cross-sectional study was carried out on all neonates hospitalized in the NICU of Children's Medical Center over a period of one year (January–December 2018). Immediately on admission, a serum sample for vitamin D measurement was obtained with another routine blood sampling. Demographic and clinical data including sex, gestational age, the season of birth, serum levels of vitamin D and calcium, the causes of hospitalization, age at admission and neonatal outcomes including length of hospital stay and mortality during hospitalization were assessed.

Results: One hundred neonates entered the study. Vitamin D deficiency and insufficiency were present in 95% of neonates. There was a significant association between vitamin D status and birth during winter (p=0.014); hypocalcemia (p=0.025) and older age at NICU admission (p<0.001). The mean value of vitamin D in term neonates was significantly lower than in preterm neonates (p=0.031). There were no correlations between length of hospital stay and neonatal mortality rate with vitamin D status (p=0.876).

Conclusion: Vitamin D deficiency and insufficiency were highly prevalent among NICU patients. Maternal vitamin D supplementation during pregnancy may prevent or reduce the risk of low levels of vitamin D in neonates.

Vitamin D deficiency relation to sepsis, paediatric risk of mortality III score, need for ventilation support, length of hospital stay, and duration of mechanical ventilation in critically ill children: A meta-analysis

INTRODUCTION

Vitamin D deficiency in children is related to the augmented risk of bone illnesses, but its effect on critically ill children is still conflicting. This meta-analysis study was performed to assess the relationship between vitamin D deficiency in children and sepsis, paediatric risk of mortality III score, need for ventilation support, length of hospital stay, and duration of mechanical ventilation in critically ill children.

METHODS

Through a systematic literature search up to June 2020, 16 studies with 2382 children, 1229 children of them with vitamin D deficiency, were found recording relationships between vitamin D deficiency and sepsis, paediatric risk of mortality III score, need for ventilation support, length of hospital stay, and/or duration of mechanical ventilation. Odds ratio (OR) with 95% confidence intervals (CIs) was calculated between vitamin D deficiency children to non-vitamin D deficiency children on the different outcomes in critically ill children using the dichotomous or continuous methods with a random or fixed-effect model.

RESULTS

The vitamin D deficiency children category had significantly higher sepsis (OR, 2.35; 95% CI, 1.19-4.63, P = .01); paediatric risk of mortality III score (OR, 2.19; 95% CI, 1.13-4.25, P = .02); higher length of hospital stay (OR, 4.26; 95% CI, 0.81-7.70, P = .02); higher duration of mechanical ventilation (OR, 1.89; 95% CI, 0.22-3.56, P = .03) compared with that in the non-vitamin D deficiency children. However, the need for ventilation support in vitamin D deficiency children did not significantly differ from non-vitamin D deficiency children (OR, 2.00; 95% CI, 0.98-4.07, P = .06) with relatively higher results in vitamin D deficiency children.

CONCLUSIONS

Vitamin D deficiency in children might have an independent relationship with higher sepsis, paediatric risk of mortality III score, length of hospital stay, and duration of mechanical ventilation. The relation was relative with a higher risk in need for ventilation support with vitamin D deficiency children. This relationship encouraged us to recommend testing vitamin D levels in all critically ill children and providing them with supplemental vitamin D as prophylaxis.

Vitamin D status was associated with sepsis in critically ill children: A PRISMA compliant systematic review and meta-analysis

BACKGROUND

Sepsis leads to the high mortality in critically ill infants and children. It is still controversial whether vitamin D deficiency was associated with the incidence of sepsis. Thus we designed the systematic review and meta-analysis.

METHODS

The Ovid Medline, Embase, PubMed, and Cochrane library were systematically searched until April 5, 2020. The 25 hydroxyvitamin D (25-OHD) level was recorded and set 20 ng/mL as cut-off in cohort study to divide the lower and higher 25-OHD group. The odds ratio (OR) and 95% confidence intervals (CIs) were calculated for comparing the impact of vitamin D deficiency on the incidence of sepsis in critically ill children.

RESULTS

A total of 27 studies were included with 17 case-control studies and 10 cohort studies. In those case-control studies, the maternal 25-OHD level and neonatal 25-OHD level in sepsis group was significant lower than non-sepsis group (P < .001). The percentage of severe vitamin D deficiency was significant higher in sepsis group comparing to non-sepsis group (odds ratio [OR] = 2.66, 95% CI = 1.13-6.25, P < .001). In those cohort studies, the incidence of sepsis in lower 25-OHD group was 30.4% comparing with 18.2% in higher 25-OHD level group. However, no statistical significant difference in terms of mechanical ventilation rate and 30-day mortality.

CONCLUSION

We demonstrated that critically ill infants and children with sepsis could have a lower 25-OHD level and severe vitamin D deficiency comparing to those without sepsis. Future studies should focus on the association of vitamin D supplement and the occurrence of sepsis in critically ill children.

Correlation of Vitamin D Deficiency with Predictors of Mortality in Critically Ill Children at a Tertiary Care Centre in North India-A Prospective, Observational Study

This study was conducted to assess the relationship of vitamin D deficiency (VDD) with various demographic characteristics, laboratory parameters, and predictors of mortality. This prospective observational study was performed at pediatric intensive care unit (PICU) of a tertiary care hospital situated in north India. A total of 125 children admitted in PICU with age from 2 months to 14 years were analyzed. The subjects were classified as Vitamin D deficient (≤20 ng/mL) and nondeficient (>20 ng/mL). The relationship between VDD and predictors of mortality were analyzed using correlation and multivariate analysis. Respiratory system (40%) was most commonly involved. VDD was seen in 72% of the patients. There was statistically significant correlation of VDD with age ( p  = 0.019), season ( p  = 0.018), height ( p  = 0.005), and weight ( p  = 0.003). On multivariate analysis factors associated with VDD were age (odds ratio [OR] = 1.01, 95% confidence interval [CI] 1.00-1.03, p  = 0.006), season (OR = 3.98, 95% CI 1.09-14.50, p  = 0.036). VDD was also correlated to bacteriuria ( p  = 0.033), cardiovascular sequential sepsis-related organ failure assessment score (CV-SOFA score) ( p  = 0.001), and mechanical ventilation ( p  = 0.043). On multivariate analysis, factors associated with VDD were bacteriuria (OR = 4.88, 95% CI 1.04-22.89, p  = 0.04), mechanical ventilation requirement (OR = 2.95, 95% CI 1.12-7.85, p  = 0.029), and CV-SOFA score (OR = 2.33, 95% CI 1.14-4.76, p  = 0.021). Median (interquartile range) duration of PICU stay in VDD patients was (3-7) days while in nondeficient patients it was (2-6) days ( p  = 0.107). VDD was a significant risk factor for the need of mechanical ventilation, bacteriuria, and mortality among patients in our cohort.

The Association Between Low Levels of Vitamin D and Clinical Outcomes in Critically-Ill Children: A Systematic Review and Meta-Analysis

Background: We conducted a meta-analysis to investigate the possible effects of vitamin D deficiency on clinical outcomes of critically-ill children.Methods: We searched Scopus-Embase and PubMed-Medline databases to find eligible observational articles. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to estimate the strength of associations.Results: Seventeen articles (eighteen studies) involving 2987 critically ill patients met our inclusion criteria. Vitamin D deficiency was not associated with increased mortality. A significant association was only observed in very high developed countries between vitamin D deficiency and risk of sepsis [OR (95%CIs): 2.65 (1.30, 5.41)] and ventilation support requirement [OR (95%CIs): 1.35 (1.03, 1.77)].Conclusion: Our findings suggest that vitamin D deficiency is not associated with higher mortality among critically ill children but increases susceptibility to sepsis and the need for ventilator support in critical care settings.

Association Between Vitamin D Deficiency and Duration of Hospital Stay, Pediatric Intensive Care Unit Stay, and Ventilation; Pediatric Risk of Mortality Score; and Rate of Readmission: A Prospective Observational Study

Introduction The study aims to evaluate the association between a deficiency of Vitamin D level with the duration of hospital stay, pediatric intensive care unit (PICU) stay, and ventilation; the pediatric risk of mortality (PRISM) score, and the rate of readmission. Materials and methods This prospective observational study was conducted from November 2014 to October 2015, and the study population consisted of children admitted to the pediatric intensive care unit (PICU) in a tertiary care hospital of Puducherry. After measuring vitamin D levels, children were allotted into three categories depending on their serum 25(OH)D levels as the sufficient group (25[OH]D level ≥ 30 ng/mL), insufficient group (25[OH]D level = 20 - 29.9 ng/mL), and deficient group (25[OH]D level < 20 ng/mL). Among these three groups, the duration of hospital stay, PICU stay, and ventilation; the PRISM score, and the rate of readmission were compared. Results A total of 522 patients were included in the study. Based on their 25(OH)D level, 222 patients (42.5%) were in the sufficient category, 153 patients (29.3%) were in the deficient category, and 147 patients (28.2%) were in the insufficient category. Vitamin D deficiency state is not statistically significantly associated with the duration of hospital stay (P = .84), duration of PICU stay (P = .69), duration of ventilation (P = .48), PRISM score (P = .63), and rate of readmission (P = .91). Conclusions Longer hospital stay, prolonged PICU stay, longer duration of ventilation, and higher PRISM III score were independent risk factors for higher mortality in the PICU. However, lower vitamin D levels are not statistically significant to predict mortality among the study population.

Vitamin D in Acute and Critically Sick Children with a Subgroup of Sepsis and Mortality: A Meta-Analysis

A meta-analysis study was performed to evaluate the relationship between vitamin D deficiency children and sepsis and acute and critically mortality. Through a systematic literature search up to December 2019, 23 studies with 4451 children, 2500 children with vitamin D deficiency were identified reporting relationships between vitamin D deficiency and sepsis and/or acute and critical care unit mortality (six sepsis only, four acute and critically mortality only and 13 both sepsis and acute and critically mortality). Odd ratio (OR) with 95% confidence intervals (CIs) was calculated comparing vitamin D deficiency children to normal vitamin D children on the bases of sepsis and mortality in acute and critical care units using the dichotomous method with a random effect model. No significant difference was found between males and females in pooled studies all together (OR, 0.72; 95% CI, 0.43-1.22). Vitamin D deficiency children (OR, 2.24; 95% CI, 1.42-3.53) had higher sepsis compared to normal vitamin D children. Also, vitamin D deficiency children (OR, 1.77; 95% CI, 1.26-2.49) had higher acute and critically mortality compared to normal vitamin D children but not as much as that in sepsis. The extent of increased sepsis was higher than that in acute and critically mortality. The impact of vitamin D deficiency in children was observed in all populations. Based on this meta-analysis, vitamin D deficiency in children may have an independent-relationship with up to 2.24 fold risk of sepsis and acute and critical care unit mortality. This relationship forces us to recommend checking vitamin D concentration in all critically ill children.

Serum vitamin D status following pediatric cardiac surgery and association with clinical outcome

Our aim is to determine the prevalence of vitamin D deficiency in children with congenital heart disease (CHD). In addition, we demonstrated the effect of cardiopulmonary bypass (CPB) on vitamin D, parathyroid hormone (PTH), and calcium levels. The association between perioperative vitamin D levels and postoperative clinical outcomes has been explored. A prospective observational study was conducted from February 2018 to June 2019 on 69 children undergoing elective surgery for CHD under CPB. Blood samples were collected preoperatively, immediate postoperatively, and 24 h postoperatively. Vitamin D deficiency was present in 34 (49.3%) patients preoperatively and 63 (91.3%) patients immediately postoperative. We identified 42.03% decline of 25(OH)D immediately postoperative. Changes in ionized calcium (iCa) concentrations were accompanied by reciprocal alterations in PTH concentrations. Lower postoperative 25(OH)D was associated with higher maximum vasoactive inotropic score (VIS) in the first 24 h postoperative (r = - 0.259, p = 0.03).Conclusion: Vitamin D deficiency is common in children with CHD and the majority are vitamin D deficient following cardiac surgery with acute decline of serum 25(OH)D after CPB. Lower postoperative vitamin D levels in children undergoing cardiac surgery are associated with the need for increasing the inotropic support.What is Known:• Vitamin D is a pleiotropic hormone, important for calcium homeostasis.• Vitamin D deficiency might affect the outcome in critically ill patients.What is New:• Cardiopulmonary bypass causes acute decline of vitamin D in children.• Lower postoperative vitamin D is associated with higher inotropic support.

Association of vitamin D deficiency with clinical outcomes in critically ill Korean children

BACKGROUND/OBJECTIVES

Vitamin D is a pleiotropic hormone that affects various body organ systems. We evaluated the prevalence of a vitamin D deficiency (VDD) and its potential role in the clinical condition of critically ill Korean children.

SUBJECTS/METHODS

Patients under 18 years old with a 25(OH) vitamin D measurement on the first day of PICU admission were included from among the children admitted to the pediatric intensive care unit (PICU) of our tertiary children's hospital between October 2017 and January 2019.

RESULTS

A total of 172 pediatric patients were enrolled. The mean 25(OH) vitamin D level was 17.5 ± 12.8 ng/mL. There was a 65.1% prevalence of VDD (25(OH) vitamin D level < 20 ng/mL). VDD was associated with age at PICU admission, gastrointestinal/hepatobiliary disorders, International Society of Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH DIC) score, pediatric multiple organ dysfunction syndrome (pMODS) score and with several laboratory test findings including hemoglobin, platelet, C-reactive protein, serum albumin, total bilirubin, prothrombin time, and anti-thrombin III levels. Most of these parameters also showed significant linear correlations with the 25(OH) vitamin D level (P < 0.05). However, no statistically meaningful association was found between VDD and other clinical conditions such as the need for a mechanical ventilator, requirement for vasoactive drugs, duration of the PICU and hospital stays, or PICU mortality.

CONCLUSION

There is a high prevalence of VDD in critically ill Korean children. There were significant associations between the 25(OH) vitamin D level and gastrointestinal/hepatobiliary disorders, the pMODS score and with coagulation related factors. Further large-scale studies with more specific subgroup analyses are required to more precisely assess the clinical implications of VDD in critically ill pediatric patients.

Importance of vitamin D in acute and critically ill children with subgroup analyses of sepsis and respiratory tract infections: a systematic review and meta-analysis

OBJECTIVES

To estimate the prevalence of 25-hydroxyvitamin D (25(OH)D) deficiency and investigate its association with mortality in children with acute or critical conditions.

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

PubMed, OVID, Google Scholar and the Cochrane Library searched until 21 December 2018.

ELIGIBILITY CRITERIA

Studies of children hospitalised with acute or critical conditions who had blood 25(OH)D levels measured.

DATA EXTRACTION AND SYNTHESIS

We obtained pooled prevalence estimates of 25(OH)D deficiency and ORs for mortality. We calculated 95% CI and prediction intervals and investigated heterogeneity and evidence of small-study effects.

RESULTS

Fifty-two studies were included. Of 7434 children, 3473 (47.0%) were 25(OH)D deficient (<50 nmol/L). The pooled prevalence estimate of 25(OH)D deficiency was 54.6% (95% CI 48.5% to 60.6%, I²=95.3%, p<0.0001). Prevalence was similar after excluding smaller studies (51.5%). In children with sepsis (18 studies, 889 total individuals) prevalence was 64.0% (95% CI 52.0% to 74.4%, I²=89.3%, p<0.0001) and 48.7% (95% CI 38.2% to 59.3%; I²=94.3%, p<0.0001) in those with respiratory tract infections (RTI) (25 studies, 2699 total individuals). Overall, meta-analysis of mortality (18 cohort studies, 2463 total individuals) showed increased risk of death in 25(OH)D deficient children (OR 1.81, 95% CI 1.24 to 2.64, p=0.002, I²=25.7%, p=0.153). Four (22.0%) of the 18 studies statistically adjusted for confounders. There were insufficient studies to meta-analyse sepsis and RTI-related mortality.

CONCLUSIONS

Our results suggest that 25(OH)D deficiency in acute and critically ill children is high and associated with increased mortality. Small-study effects, reverse causation and other biases may have confounded results. Larger, carefully designed studies in homogeneous populations with confounder adjustment are needed to clarify the association between 25(OH)D levels with mortality and other outcomes.

PROSPERO REGISTRATION NUMBER

CRD42016050638.

Effect of Severe Vitamin D Deficiency at Admission on Shock Reversal in Children With Septic Shock: A Prospective Observational Study

OBJECTIVES:

To evaluate the association of severe vitamin D deficiency with clinically important outcomes in children with septic shock.

METHODS:

We enrolled children ≤17 years with septic shock prospectively over a period of 6 months. We estimated 25-hydroxyvitamin D [25 (OH) D] levels at admission and 72 hours. Severe deficiency was defined as serum 25 (OH) <10 ng/mL. We performed univariate and multivariate analysis to evaluate association with clinically important outcomes.

RESULTS:

Forty-three children were enrolled in the study. The prevalence of severe vitamin D deficiency was 72% and 69% at admission and 72 hours, respectively. On univariate analysis, severe vitamin D deficiency at admission was associated with lower rates of shock reversal, 74% (23) versus 25% (3); relative risk (95% confidence interval [CI]): 2.9 (1.09-8.08), at 24 hours and greater need for fluid boluses (75 vs 59 mL/kg). On multivariate analysis, nonresolution of shock at 24 hours was significantly associated with severe vitamin D deficiency after adjusting for other key baseline and clinical variables, adjusted odds ratio (95% CI): 12 (2.01-87.01); 0.01.

CONCLUSION:

The prevalence of severe vitamin D deficiency is high in children with septic shock admitted to pediatric intensive care unit. Severe vitamin D deficiency at admission seems to be associated with lower rates of shock reversal at 24 hours of ICU stay. Our study provides preliminary data for planning interventional studies in children with septic shock and severe vitamin D deficiency.

Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa

The prevalence of vitamin D deficiency in intensive care units ranges typically between 40 and 70%. There are many reasons for being or becoming deficient in the ICU. Hepatic, parathyroid and renal dysfunction additionally increases the risk for developing vitamin D deficiency. Moreover, therapeutic interventions like fluid resuscitation, dialysis, surgery, extracorporeal membrane oxygenation, cardiopulmonary bypass and plasma exchange may significantly reduce vitamin D levels. Many observational studies have consistently shown an association between low vitamin D levels and poor clinical outcomes in critically ill adults and children, including excess mortality and morbidity such as acute kidney injury, acute respiratory failure, duration of mechanical ventilation and sepsis. It is biologically plausible that vitamin D deficiency is an important and modifiable contributor to poor prognosis during and after critical illness. Although vitamin D supplementation is inexpensive, simple and has an excellent safety profile, testing for and treating vitamin D deficiency is currently not routinely performed. Overall, less than 800 patients have been included in RCTs worldwide, but the available data suggest that high-dose vitamin D supplementation could be beneficial. Two large RCTs in Europe and the United States, together aiming to recruit >5000 patients, have started in 2017, and will greatly improve our knowledge in this field. This review aims to summarize current knowledge in this interdisciplinary topic and give an outlook on its highly dynamic future.

Vitamin D deficiency and clinical outcomes related to septic shock in children with critical illness: a systematic review

PURPOSE

Low vitamin D blood levels are related to many clinical outcomes in children with critically illness. However, the relationship of it and septic shock has not been systematically analyzed. The objective of this review was to evaluate the effect of vitamin D on septic shock and predict if vitamin D administration can improve prognosis of it.

MATERIALS AND METHODS

Online databases were searched up to June 1st, 2017 for studies on the relation of vitamin D deficiency (VDD) and clinical outcomes on septic shock in children with critical illness. The primary end point was the effect of VDD on occurrence of septic shock. The secondary endpoints were the association of VDD and clinical outcomes related to septic shock. We summarized the strength of association between VDD and each factor on septic shock. Individual factors were defined as strong, moderate, weak, or inconclusive according to the numbers of the article supporting the relation between them.

RESULTS

Eight studies published between 2012 and 2017, for a total of 1367 patients, were included in the final analysis. We extracted eight patient-level factors and among them one showed strong association of VDD and septic shock. Four factors demonstrated moderate or weak strength of evidence for it: nonresolution of shock, catecholamine refractory shock, fluid boluses, vasopressor use. But evidence for the association between VDD and severity of illness, stay of pediatric intensive care unit (PICU), are weak. Most of the articles showed no significant association between VDD and mortality.

CONCLUSIONS

Among critically ill children, VDD might be associated with the occurrence and resolution of septic shock. A larger multicenter trial could conclusively confirm these findings. Further research is also needed to identify vitamin D administration for better outcomes in pediatric patients.

Study protocol for a phase II dose evaluation randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study)

BACKGROUND

Clinical research has recently demonstrated that vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (PICU) and associated with worse clinical course. Multiple adult ICU trials have suggested that optimization of vitamin D status through high-dose supplementation may reduce mortality and improve other clinically relevant outcomes; however, there have been no trials of rapid normalization in the PICU setting. The objective of this study is to evaluate the safety and efficacy of an enteral weight-based cholecalciferol loading dose regimen in critically ill children with VDD.

METHODS/DESIGN

The VITdAL-PICU pilot study is designed as a multicenter placebo-controlled phase II dose evaluation pilot randomized controlled trial. We aim to randomize 67 VDD critically ill children using a 2:1 randomization schema to receive loading dose enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or a placebo solution. Participants, caregivers and outcome assessors will be blinded to allocation. Eligibility criteria include ICU patient, aged 37 weeks to 18 years, expected ICU length of stay more than 48 h, anticipated access to bloodwork at 7 days, and VDD (blood total 25 hydroxyvitamin D < 50 nmol/L). The primary objective is to determine whether the dosing protocol normalizes vitamin D status, defined as a blood total 25(OH)D concentration above 75 nmol/L. Secondary objectives include an examination of the safety of the dosing regimen (e.g. hypercalcemia, hypercalciuria, nephrocalcinosis), measures of vitamin D axis function (e.g. calcitriol levels, immune function), and protocol feasibility (eligibility criteria, protocol deviations, blinding).

DISCUSSION

Despite significant observational literature suggesting VDD to be a modifiable risk factor in the PICU setting, there is no robust clinical trial evidence evaluating the benefits of rapid normalization. This phase II clinical trial will evaluate an innovative weight-based dosing regimen intended to rapidly and safely normalize vitamin D levels in critically ill children. Study findings will be used to inform the design of a multicenter phase III trial evaluating the clinical and economic benefits to rapid normalization. Recruitment for this trial was initiated in January 2016 and is expected to continue until November 30, 2017.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02452762.

Vitamin D deficiency in critically ill children: a systematic review and meta-analysis

BACKGROUND

Vitamin D deficiency (VDD) has been hypothesized not only to be common but also to represent a potentially modifiable risk factor for greater illness severity and clinical outcome during critical illness. The objective of this systematic review was to determine the frequency of VDD in pediatric critical illness and its association with clinical outcomes.

METHODS

MEDLINE, Embase, and CENTRAL were searched through December 12, 2016, with no date or language restrictions. The primary objective was to estimate the prevalence of VDD in the pediatric intensive care unit (PICU) and compare vitamin D status with healthy control populations. Secondary objectives were to evaluate whether VDD is associated with mortality, increased illness severity, PICU interventions, and patient clinical course. Random effects meta-analysis was used to calculate pooled VDD event rate, compare levels with those of control subjects, and evaluate for associations between VDD and clinical outcome.

RESULTS

Among 2700 citations, 17 studies meeting study eligibility were identified. The studies reported a total of 2783 critically ill children and had a median sample size of 120 (range 12-511). The majority of studies used a 25-hydroxyvitamin D [25(OH)D] level less than 50 nmol/L to define VDD, and the pooled VDD prevalence was 54.8 (95% CI 45.4-63.9). Average 25(OH)D levels were significantly lower in PICU patients than in healthy control subjects (pooled difference -17.3 nmol/L, 95% CI -14.0 to -20.6). In a meta-analysis calculation, we found that VDD was associated with increased mortality (OR 1.62, 95% CI 1.11-2.36), illness severity, and need for PICU interventions.

CONCLUSIONS

Approximately 50% of critically ill children have VDD at the time of PICU admission, defined as a blood total 25(OH)D concentration under 50 nmol/L. VDD was further determined to be associated with greater illness severity, multiple organ dysfunction, and mortality in the PICU setting. Clinical trials are required to determine if optimization of vitamin D status improves patient outcome.

TRIAL REGISTRATION

PROSPERO, CRD42016026617 . Registered on 11 January 2016.

Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities

Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.

Vitamin D Deficiency and Parathyroid Response in Critically-ill Children: Association with Illness Severity and Clinical Outcomes

OBJECTIVE

To determine the prevalence of vitamin D deficiency in critically ill children, and to study its association with parathyroid response, severity of illness and clinical outcomes.

DESIGN

Prospective observational study.

SETTING

Medical Pediatric Intensive Care Unit of a tertiary care centre of Northern India.

PARTICIPANTS

154 children in-patients: August 2011-January 2013.

MAIN OUTCOME MEASURES

Vitamin D deficient children were (serum 25-hydroxy vitamin D <20 ug/mL) divided into parathyroid-responder [serum parathyroid hormone >65 pg/mL with 25(OH)D<20 ug/mL and/or calcium corrected for albumin <8.5 mg/dL] and non parathyroid-responder. Illness severity was assessed by Pediatric Index of Mortality-2 (PIM-2) score at admission. Biochemical parameters, illness severity scores and clinical outcomes were compared between parathyroid-responders and non-parathyroid-responders.

RESULTS

Vitamin D deficiency and hypocalcemia were observed in 125 (83.1%) and 91 (59%) children, respectively at admission. There were no differences in illness severity score at admission, mortality rate and length of stay between vitamin D-deficient children and 19.8% of non-vitamin D-deficient children. Among Vitamin D-deficient children, parathyroid-responders had higher PIM-2 score at admission compared to non-parathyroid-responder [12.8 (7.4,20.6) vs. 6.5 (2.5,12.2), P=0.01]. However, there were no differences in other clinical outcomes between two groups.

CONCLUSION

Critically ill children have high prevalence of vitamin D deficiency. Parathyroid gland response secondary to hypocalcemia or vitamin D defiency is impaired in critical illness.

Serum Vitamin D Status and Outcome in Critically Ill Children

Background

Vitamin D is a pleiotropic hormone essential for optimal health. Critical illness in children is a major cause of significant health-care utilization and mortality around the world. The association of Vitamin D deficiency (VDD) in critically ill adults has been well-studied, in comparison, the importance of Vitamin D in pediatric critical illness has been much less studied.

Aim and Objectives

This study aimed to assess Vitamin D status and its determinants in patients admitted to a pediatric intensive care unit (PICU) in North of Turkey. We also investigated the association between Vitamin D status and clinical outcomes.

Materials and Methods

All patients aged 1 month to 18 years admitted to the PICU of a tertiary care hospital who had levels of 25-hydroxy Vitamin D available within 24 h of admission were included in this retrospective study. VDD was defined as <20 ng/mL levels.

Results

VDD was observed in 120 (58.5*) children. In multivariable linear regression model, only identified patient age and winter season as statistically associated with VDD. Vitamin D deficient patients were older and heavier and were more likely to receive catecholamine. There was no association between Vitamin D deficiency and other illness severity factors including mortality.

Conclusions

Hypovitaminosis D occurrence was high in critically ill children and was associated with higher vasopressor requirement but not with other markers of illness severity including mortality.

Vitamin D deficiency and length of pediatric intensive care unit stay: a prospective observational study

BACKGROUND

Due to the limited data available in the pediatric population and lack of interventional studies to show that administration of vitamin D indeed improves clinical outcomes, opinion is still divided as to whether it is just an innocent bystander or a marker of severe disease. Our objective was therefore to estimate the prevalence of vitamin D deficiency in children admitted to intensive care unit (ICU) and to examine its association with duration of ICU stay and other key clinical outcomes.

METHODS

We prospectively enrolled children aged 1 month-17 years admitted to the ICU over a period of 8 months (n = 101). The primary objectives were to estimate the prevalence of vitamin D deficiency (serum 25 (OH) <20 ng/mL) at 'admission' and to examine its association with length of ICU stay.

RESULTS

The prevalence of vitamin D deficiency was 74 % (95 % CI: 65-88). The median (IQR) duration of ICU stay was significantly longer in 'vitamin D deficient' children (7 days; 2-12) than in those with 'no vitamin D deficiency' (3 days; 2-5; p = 0.006). On multivariable analysis, the association between length of ICU stay and vitamin D deficiency remained significant, even after adjusting for key baseline variables, diagnosis, illness severity (PIM-2), PELOD, and need for fluid boluses, ventilation, inotropes and mortality [adjusted mean difference (95 % CI): 3.5 days (0.50-6.53); p = 0.024].

CONCLUSIONS

We observed a high prevalence of vitamin D deficiency in critically ill children in our study population. Vitamin D deficient children had a longer duration of ICU stay as compared to others.

[Vitamin D deficiency and morbimortality in critically ill paediatric patients]

OBJECTIVES

To determine the prevalence and risks factors of vitamin D deficiency, as well as its relationship with morbidity and mortality in a PICU.

MATERIAL AND METHODS

An observational prospective study in a tertiary children's University Hospital PICU conducted in two phases: i: cohorts study, and ii: prevalence study. The study included 340 critically ill children with ages comprising 6 months to 16 years old.

EXCLUSION CRITERIA

Chronic kidney disease, known parathyroid disorders, and vitamin D supplementation. Total 25-hydroxyvitamin D [25(OH)D] was measured in the first 48hours of admission to a PICU. Parathormone, calcium, phosphate, blood gases, blood count, C-reactive protein, and procalcitonin were also analysed. A record was also made of demographic features, characteristics of the episode, and complications during the PICU stay.

RESULTS

The overall prevalence rate of vitamin D deficiency was 43.8%, with a mean of 22.28 (95% CI 21.15-23.41) ng/ml. Patients with vitamin D deficiency were older (61 vs 47 months, P=.039), had parents with a higher level of academic studies (36.5% vs 20%, P=.016), were admitted more often in winter and spring, had a higher PRISM-III (6.8 vs 5.1, P=.037), a longer PICU stay (3 vs 2 days, P=.001), and higher morbidity (61.1% vs 30.4%, P<001) than the patients with sufficient levels of 25(OH)D. Patients who died had lower levels of 25(OH)D (14±8.81ng/ml versus 22.53±10.53ng/ml, P=.012). Adjusted OR for morbidity was 5.44 (95%CI; 2.5-11.6).

CONCLUSIONS

Vitamin D deficiency is frequent in critically ill children, and it is related to both morbidity and mortality, although it remains unclear whether it is a causal relationship or it is simply a marker of severity in different clinical situations.

Critically Ill Children Have Low Vitamin D-Binding Protein, Influencing Bioavailability of Vitamin D

RATIONALE

Vitamin D deficiency, often defined by total serum 25-hydroxyvitamin D (25[OH]D) <20 ng/ml, is common in critically ill patients, with associations with increased mortality and morbidity in the intensive care unit. Correction of vitamin D deficiency in critical illness has been recommended, and ongoing clinical trials are investigating the effect of repletion on patient outcome. The biologically active amount of 25(OH)D depends on the concentration and protein isoform of vitamin D-binding protein (VDBP), which is also an acute-phase reactant affected by inflammation and injury.

OBJECTIVES

We performed a secondary analysis of a cohort of critically ill children in which we reported a high rate of vitamin D deficiency, to examine how VDBP level and genotype would impact vitamin D status.

METHODS

We prospectively enrolled 511 children admitted to the pediatric intensive care unit over a 12-month period.

MEASUREMENTS AND MAIN RESULTS

We measured serum VDBP in 479 children. We genotyped single nucleotide polymorphisms rs7041 and rs4588 in the VDBP gene (GC) to determine haplotypes GC1F, GC1S, and GC2 in 178 subjects who consented, then calculated bioavailable 25(OH)D from serum 25(OH)D, VDBP, albumin, and GC haplotype. The median serum VDBP level was 159 μg/ml (interquartile range, 108-221), lower than has been reported in healthy children. Factors predicting lower levels in multivariate analysis included age <1 year, nonwhite race, being previously healthy, 25(OH)D <20 ng/ml and greater illness severity. In the subgroup that was genotyped, GC haplotype had the strongest association with VDBP level; carriage of one additional copy of GC1S was associated with a 37.5% higher level (95% confidence interval, 31.9-44.8; P < 0.001). Bioavailable 25(OH)D was also inversely associated with illness severity (r = -0.24, P < 0.001), and ratio to measured total 25(OH)D was variable and related to haplotype.

CONCLUSIONS

Physiologic deficiency of 25(OH)D in critical illness may be more difficult to diagnose, given that lower VDBP levels increase bioavailability. Treatment studies conducted on the basis of total 25(OH)D level, without consideration of VDBP concentration and genotype, may increase the risk of falsely negative results.

[Vitamin D deficiency in children admitted to the paediatric intensive care unit]

INTRODUCTION

Vitamin D is essential for bone health, as well as for cardiovascular and immune function. In critically ill adults vitamin D deficiency (VDD) is common, and is associated with sepsis and higher critical illness severity.

OBJECTIVES

To establish the prevalence of VDD and its association with clinically relevant outcomes in children admitted to a Paediatric Intensive Care Unit (PICU) in Concepcion, Chile.

PATIENTS AND METHOD

Prospective observational cohort study in 90 consecutive children admitted to the PICU in a university general hospital. Blood was collected on admission to PICU and analysed for 25-OH-D levels. Severity of illness and vasopressor use were assessed using PRISM, PELOD, and vasoactive-inotropic score (VIS) score. VDD was defined as a serum 25-OH-D level<20ng/ml. Relative risks (RR) were calculated to determine the association between VDD and relevant clinical outcomes.

RESULTS

Mean (SD) serum vitamin D (25-OH-D) level in the cohort was 22.8 (1.0)ng/ml. The prevalence of VDD was 43.3%. VDD was associated with vasopressors use (RR1.6; 95%CI: 1.2-2.3; P<.01), mechanical ventilation (RR2.2; 95%CI: 1.2-3.9, P<.01), septic shock (RR1.9; 95%CI: 1.3-2.9, P<.001), and fluid bolus>40ml/kg in the first 24h of admission (RR 1.5; 95%CI: 1.1-2.1, P<.05).

CONCLUSIONS

In this study, VDD at PICU admission was prevalent in critically ill children and was associated with adverse clinical outcomes. Further studies are needed to assess the potential benefit of optimizing vitamin D status in the PICU.

Vitamin D Status After Cardiopulmonary Bypass in Children With Congenital Heart Disease

Deficiency in 25-hydroxyvitamin D (25OHD) is associated with increased morbidity and mortality in the critically ill. Children who underwent surgery for congenital heart disease under cardiopulmonary bypass (CPB) are typically deficient in 25OHD. It is unclear whether this deficiency is due to CPB. We hypothesized that CPB reduces the levels of 25OHD in children with congenital heart disease. We conducted a prospective observational study on children aged 2 months to 17 years who underwent CPB. Serum was collected at 3 time points: immediately before, immediately after surgery, and 24 hours after surgery. 25-Hydroxyvitamin D, 1,25-dihydroxyvitamin D, 1,25(OH)₂D, vitamin D binding protein, and albumin levels were measured. Levels were compared using repeated measures analysis of variance. We enrolled 20 patients, 40% were deficient in 25OHD with levels <20 ng/mL prior to surgery. Mean (±standard deviation) of 25OHD at the 3 time points was 21.3 ± 8 ng/mL, 19 ± 5.8 ng/mL, and 19.5 ± 6.6 ng/mL, respectively ( P = .02). The decrease in 25OHD was observed primarily in children with sufficient levels of 25OHD, with mean levels at the 3 time points: 26.8 ± 4.2 ng/mL, 21.5 ± 5.7 ng/mL, and 23.0 ± 4.9 ng/mL, respectively ( P < .001). Calculated means of free fraction of 25OHD at the 3 time points were 6.2 ± 2.8 pg/mL, 5.8 ± 2.2 pg/mL, and 5.5 ± 2.4 pg/mL, respectively, ( P = .04). Mean levels of 1,25(OH)₂D were 63.7 ± 34.9 ng/mL, 53.2 ± 30.6 ng/mL, and 67.7 ± 23.5 ng/mL ( P = .04). Vitamin D binding protein and albumin levels did not significantly change. Cardiopulmonary bypass decreases 25OHD by reducing the free fraction. Current investigations are geared to establish whether vitamin D deficiency is associated with outcomes and if treatment is appropriate.

Vitamin D Deficiency in Pediatric Critical Care

Vitamin D deficiency (VDD) is a well-established cause of pediatric bone and muscle disease. In addition, a role has been recognized for vitamin D in the health and stress response of other organs, including the cardiovascular, immune, and respiratory systems. As these organs are central to the development of and recovery from critical illness, VDD has been hypothesized to be a modifiable risk factor for ICU outcome. Over the past 5 years, a growing number of adult and pediatric critical care studies have investigated the prevalence of VDD and its association with illness severity and outcome. The adult studies have recently been synthesized in systematic reviews, with results that convincingly suggest the need for trials to determine whether optimization of vitamin D status improves outcome. In contrast, the pediatric ICU and related literature has not been similarly synthesized. The goal of this review is to describe vitamin D metabolism, known biological mechanisms, potential role in pathophysiology, and summarize the available pediatric intensive care unit (PICU) studies reporting on prevalence of VDD deficiency and its association with outcome. The problems with currently approved supplementation approaches and alternative strategies are discussed, including evidence from available RCTs in adult ICU. Altogether the results suggest that critically ill children are at risk for VDD, and that VDD appears to be associated with a worse clinical course. Clinical trials evaluating novel approaches to testing for and supplementing vitamin D require exploration.

Is there a relationship between low vitamin D and rotaviral diarrhea?

BACKGROUND

For children under 5 years of age, 1700 000 000 episodes of diarrhea are seen worldwide, and death occurs in 700 000 of these cases due to diarrhea. Rotavirus is an important cause of diarrhea in this age group, and many studies have shown that vitamin D plays a pivotal role in the immune system, as well as in antimicrobial peptide gene expression. In addition, lower vitamin D has been correlated with higher rates of infectious diseases such as respiratory tract infection, tuberculosis, and viral infection.

METHODS

Seventy patients with rotaviral diarrhea and 67 healthy patients were enrolled in this study. Serum 25-hydroxy vitamin D(3) (25(OH)D(3)), parathormone, calcium, phosphate, alkaline phosphatase, complete blood count parameters, and C-reactive protein were compared between pre-school children hospitalized due to rotaviral diarrhea and healthy children. Additionally, birthweight, feeding habits in the first 6 months of life, vitamin D and multivitamin supplements, and rotaviral vaccinations were also evaluated in each group.

RESULTS

There were no differences between the groups with regard to gender and age, but 25(OH)D(3) was significantly different: 14.6 ± 8.7 ng/mL in the rotaviral diarrhea patients versus 29.06 ± 6.51 ng/mL in the health controls (P < 0.001), and serum 25(OH)D(3) <20 ng/mL (OR, 6.3; 95%CI: 3.638-10.909; P < 0.001) was associated with rotaviral diarrhea.

CONCLUSIONS

Low vitamin D is associated with rotaviral diarrhea. This is the first study in the literature to show this, and this result needs to be repeated in larger controlled clinical studies.

Factors associated with not meeting the recommendations for micronutrient intake in critically ill children

OBJECTIVE

Children admitted to the intensive care unit (ICU) are at risk of not meeting their nutritional requirements. This study aimed to identify factors associated with failure to meet the dietary recommended intake (DRI) of zinc, selenium, cholecalciferol, and thiamine in critically ill children receiving enteral tube feeding during their stay in the ICU.

METHODS

We analyzed prospectively 260 cases, corresponding to 206 patients who received enteral tube feeding for a minimum of 3 days up to 10 days during the first 10 d of ICU stay. Individual intake was compared to estimated average requirement (EAR) and adequate intake (AI) values during the first 10 d of ICU stay. The outcome variable was defined as not meeting the recommended intake of the micronutrients studied. Potential explanatory variables for the outcome were age <1 year, malnutrition (WHO), clinical severity scores, heart disease, severe sepsis or septic shock, use of alpha-adrenergic drugs, and renal replacement therapy (RRT). The effect of the explanatory variables on the outcome was analyzed by logistic regression analysis.

RESULTS

The majority of patients did not meet the recommendations for micronutrients. After adjusting for covariates, age <1 year, malnutrition, heart disease, use of alpha-adrenergic drugs, and renal replacement therapy were associated with failure to meet the recommendations for at least one of the micronutrients studied.

CONCLUSIONS

Factors associated with failure to meet the recommendations for micronutrient intake in children receiving enteral tube feeding during their ICU stay are linked to patients' low weight, restriction in fluid intake, and clinical severity of the disease.

Serum Vitamin D Status and Outcome among Critically Ill Children Admitted to the Pediatric Intensive Care Unit in South India

OBJECTIVES

To determine the vitamin D status and the association between vitamin D status and the clinical outcome of critically ill children admitted to pediatric intensive care unit (PICU) in South India.

METHODS

Fifty-four consecutive children with medical and surgical diagnoses were included with parental consent. Severity of illness was assessed using PIM-2 score; Sequential Organ Failure Assessment Cardiovascular Score (CV-SOFA) was used to describe vasopressor use. Serum for 25(OH) D levels was obtained as close as possible to the ICU admission. Vitamin D deficiency was defined as serum 25(OH) D level < 20 ng/ml (50 nmol/L). Primary outcome measures were serum 25(OH) D level and in-hospital all cause mortality. Secondary outcomes were illness severity, vasopressor requirement, use of mechanical ventilation and duration of ICU stay.

RESULTS

Of the 54 children, two were excluded due to insufficient serum for vitamin D analysis. Median age was 17.5 mo (IQR = 4.5-78); 38.5 % were infants. Higher age was associated with low vitamin D levels (r s  = -0.34; p 0.01). Median serum 25(OH) D level was 25.1 ng/ml (IQR = 16.2-34.2). Shock (30.8 %), CNS conditions (23.1 %) and respiratory illnesses (21.2 %) were the three most common reasons for admission to the PICU. Vitamin D deficiency was seen in 40.3 % of the critically ill children. Higher PIM score or SOFA score were associated with low vitamin levels (r s  = -0.29, p 0.04 and r s  = -0.29, p 0.05 respectively). Children who were mechanically ventilated had a significantly lower median serum 25(OH) D level than those who were not on ventilation [19.5 ng/ml (IQR = 14.6-27.7)] vs. 32.1 ng/ml[(IQR = 16.5-50.9), p 0.01]. Serum 25(OH) D level was also positively associated with serum calcium levels (r s = 0.32, p 0.03). The proportion of children who died or were discharged terminally at parental request was 23.8 % among those with serum 25(OH) D level < 20 ng/ml as compared to 16.1 % among those with serum 25(OH) D level > 20 ng/ml (p 0.49).

CONCLUSIONS

Vitamin D deficiency is common among pediatric patients admitted to PICU in South India. Low serum 25(OH) D level was associated with higher severity of illness, need for mechanical ventilation, more vasopressor use and lower serum calcium levels. No association between vitamin D status and mortality was demonstrated.

Vitamin D deficiency in critically ill children with sepsis

BACKGROUND

Data on the prevalence of vitamin D deficiency (VDD) in critically ill children with sepsis and its association with illness severity and outcome are limited.

AIM

To investigate the prevalence of VDD in critically ill children with sepsis.

METHODS

One hundred and twenty-four critically ill children with sepsis aged 1-12 years were prospectively enrolled in a paediatric intensive care unit (PICU) in North India over a 1-year period. Demographic data, clinical signs and risk factors for VDD, Paediatric Index of Mortality III (PRISM III) score, and sequential organ failure assessment (SOFA) score were recorded. Plasma 25-hydroxy vitamin D [25(OH)D] levels were measured by ELISA within 24 hours of admission. The occurrence of septic shock, multiple organ dysfunction syndrome (MODS) and healthcare-associated infection (HCAI), need for mechanical ventilation and catecholamines, length of PICU stay and mortality were also recorded. Cases were compared with 338 apparently healthy children for baseline variables and vitamin D status.

RESULTS

Prevalence of VDD [25(OH)D level < 50 nmol/L] was higher among critically ill children with sepsis compared to healthy controls (50.8% vs 40.2%, P = 0.04). VDD was not associated with any significant difference in baseline demographic variables or risk factors for VDD. Although there was a trend toward increased PRISM III score, septic shock, MODS, HCAI, need for mechanical ventilation and catecholamines, length of PICU stay, and mortality, the difference was not statistically significant.

CONCLUSION

A high prevalence of VDD in critically ill children with sepsis was found but it was not associated with greater severity of illness or other clinical outcomes.

Vitamin D/VDR signaling attenuates lipopolysaccharide‑induced acute lung injury by maintaining the integrity of the pulmonary epithelial barrier

Vitamin D and its receptor have a protective effect on epithelial barriers in various tissues. Low levels of vitamin D are associated with numerous pulmonary diseases, including acute lung injury (ALI) and acute respiratory distress syndrome. The present study investigated whether the vitamin D/vitamin D receptor (VDR) pathway may ameliorate lipopolysaccharide (LPS)-induced ALI through maintaining the integrity of the alveolar epithelial barrier. This was investigated by exposing wild-type (WT) and VDR knockout C57BL/6J mice to LPS, then comparing the healthy and LPS-treated mice lungs and bronchoalveolar lavage fluid (BALF). More specifically, lung histology, mRNA levels of proinflammatory cytokines and chemokines, and protein expression levels of tight junction proteins were determined. In addition, a vitamin D analog (paricalcitol) was administered to WT mice in order to investigate the effect of vitamin D on the alveolar epithelial barrier following exposure to LPS. VDR knockout mice exhibited severe lung injuries (P<0.001), increased alveolar permeability [demonstrated by a higher wet-dry ratio of lung weight (P<0.05), greater expression levels of BALF protein (P<0.001) and fluorescein isothiocyanate-conjugated 4 kDa dextran (P<0.001) leakage into the alveolar space], elevated proinflammatory cytokine and chemokine mRNA levels, as demonstrated by reverse transcription-quantitative polymerase chain reaction (P<0.05), and decreased protein and mRNA expression levels of occludin (P<0.01) and zonula occludens-1 (ZO-1; P<0.01) compared with WT mice. Paricalcitol treatment partially inhibited these pathological changes in WT mice by maintaining the mRNA and protein expression levels of occludin (P<0.01) and ZO-1 (P<0.05). A lack of VDRs in the pulmonary epithelial barrier appeared to compromise its defense, leading to more severe LPS-induced lung injury. Furthermore, vitamin D treatment alleviated LPS-induced lung injury and preserved alveolar barrier function. Therefore vitamin D treatment may present as a potential therapeutic strategy in ALI and acute respiratory distress syndrome.

Vitamin D Deficiency and Critical Illness

OBJECTIVE

To determine the prevalence of vitamin D deficiency in critically ill children and assess its association with severity of illness and other outcomes associated with critical illness.

METHODS

Eighty children aged 2 mo to 12 y, admitted with medical conditions to the pediatric intensive care unit of a tertiary care hospital were enrolled in this prospective observational study. Vitamin D levels were obtained during the first hour of stay. Severity score was assessed using the Pediatric Risk of Mortality III (PRISM III) within first 12 h of admission.

RESULTS

Vitamin D deficiency {25-hydroxy vitamin D [25(OH)D] levels < 20 ng/ml} was observed in 67 (83.8%) children. Vitamin D deficient children had significantly higher PRISM III score compared to vitamin D sufficient children [10 (IQR:5-15) vs. 6 (IQR:3-7); p 0.0099]. 25(OH)D levels had a significant negative correlation with PRISM III score (ρ -0.3747; p 0.0006).

CONCLUSIONS

Vitamin D appears to be of utmost importance in critically ill children.

[Vitamin D deficiency in childhood: an opportunity for prevention]

The prevalence of vitamin D deficiency in the pediatric population has increased in recent years and continues to be underdiagnosed and undertreated. According to data from the "ENSANUT 2006" (National Health and Nutrition Survey), the prevalence of vitamin D deficiency in Mexico was 16% in children aged 2-12 years. Vitamin D plays a critical role in the formation and bone homeostasis and consequently on growth. Its deficiency is clearly associated with diseases such as rickets and osteomalacia, and it has been linked to other diseases such as obesity, metabolic syndrome, diabetes, cancer, respiratory infections and immune system disease. Specific risk groups have been described in the medical literature for vitamin D deficiency in which supplementation may offer a benefit. Currently, there is still controversy in defining the serum levels of proficiency and dose supplementation. In Mexico, the daily suggested intake of vitamin D is 5.6μg (224 IU), which is significantly lower than the recommendations in the U.S. and Europe (i.e., between 400 and 1000 IU/day). An increase in vitamin D deficiency has been reported in recent years. There is no consensus regarding the sufficiency levels of vitamin D. Cut-off values vary from 20 to 30ng/ml. Therefore, the objective of this review was to provide an overview of the problem in the pediatric population and to describe the groups at risk, as well as to analyze the current recommendations for vitamin D supplementation. Vitamin D deficiency was considered rare in Mexico according to the National Institute of Medical Science and Nutrition Salvador Zubirán. Lack of evidence did not help to establish the international recommended daily intake. Currently, vitamin D deficiency must be recognized as a health problem, worthy of attention and action. We suggest that prospective studies are carried out in our country where the relationship between serum vitamin D deficiency and poor bone mineralization will be established.

Inadequate vitamin D levels are associated with culture positive sepsis and poor outcomes in paediatric intensive care

AIM

This study aimed to assess vitamin D status, and its determinants, in paediatric patients with suspected sepsis who were admitted to a paediatric intensive care unit (PICU). We also investigated the association between vitamin D status and clinical outcomes.

METHODS

Serum 25-hydroxy vitamin D (25OHD) and clinical determinants were prospectively assessed in children with suspected sepsis (<12 years old) admitted to the PICU. The relationship between 25OHD and clinical outcomes was evaluated. Vitamin D status was also assessed in control children of a similar age.

RESULTS

We enrolled 120 children with suspected sepsis admitted to the PICU and 30 paediatric controls. 25OHD was <50 nmol/L in 59% of the children admitted to the PICU and 25OHD was lower than in the controls (47 ± 29 vs 66 ± 26 nmol/L, p < 0.001). After adjusting for potential confounders, 25OHD was strongly associated with culture positive sepsis (p < 0.001), the paediatric index of mortality (p = 0.026) and the duration of mechanical ventilation (p = 0.008). There was a negative correlation between 25OHD and C-reactive protein (CRP): each 0.1% decrease in 25OHD increased CRP (p = 0.04).

CONCLUSION

Children admitted to the PICU with suspected sepsis had lower 25OHD than controls and inadequate 25OHD status was associated with confirmed sepsis and poor outcomes.

Vitamin D Metabolites and Their Association with Calcium, Phosphorus, and PTH Concentrations, Severity of Illness, and Mortality in Hospitalized Equine Neonates

Background

Hypocalcemia is a frequent abnormality that has been associated with disease severity and outcome in hospitalized foals. However, the pathogenesis of equine neonatal hypocalcemia is poorly understood. Hypovitaminosis D in critically ill people has been linked to hypocalcemia and mortality; however, information on vitamin D metabolites and their association with clinical findings and outcome in critically ill foals is lacking. The goal of this study was to determine the prevalence of vitamin D deficiency (hypovitaminosis D) and its association with serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations, disease severity, and mortality in hospitalized newborn foals.

Methods and Results

One hundred newborn foals ≤72 hours old divided into hospitalized (n = 83; 59 septic, 24 sick non-septic [SNS]) and healthy (n = 17) groups were included. Blood samples were collected on admission to measure serum 25-hydroxyvitamin D₃ [25(OH)D₃], 1,25-dihydroxyvitamin D₃ [1,25(OH) ₂D₃], and PTH concentrations. Data were analyzed by nonparametric methods and univariate logistic regression. The prevalence of hypovitaminosis D [defined as 25(OH)D₃ <9.51 ng/mL] was 63% for hospitalized, 64% for septic, and 63% for SNS foals. Serum 25(OH)D₃ and 1,25(OH) ₂D₃ concentrations were significantly lower in septic and SNS compared to healthy foals (P<0.0001; P = 0.037). Septic foals had significantly lower calcium and higher phosphorus and PTH concentrations than healthy and SNS foals (P<0.05). In hospitalized and septic foals, low 1,25(OH)₂D₃ concentrations were associated with increased PTH but not with calcium or phosphorus concentrations. Septic foals with 25(OH)D₃ <9.51 ng/mL and 1,25(OH) ₂D₃ <7.09 pmol/L were more likely to die (OR=3.62; 95% CI = 1.1-12.40; OR = 5.41; 95% CI = 1.19-24.52, respectively).

Conclusions

Low 25(OH)D₃ and 1,25(OH)₂D₃ concentrations are associated with disease severity and mortality in hospitalized foals. Vitamin D deficiency may contribute to a pro-inflammatory state in equine perinatal diseases. Hypocalcemia and hyperphosphatemia together with decreased 1,25(OH)₂D₃ but increased PTH concentrations in septic foals indicates that PTH resistance may be associated with the development of these abnormalities.

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE

Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients.

METHOD

In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity.

RESULTS

Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity.

CONCLUSIONS

This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

A pediatric critical care perspective on vitamin D

The mechanisms of action of vitamin D are the subject of intense investigation. Evidence now suggests vitamin D affects immune function and cell proliferation, prompting interest in its role in critical illness and cardiac disease. Multiple studies demonstrate strong associations between vitamin D deficiency and severity of illness including need for higher inotrope support, more fluid resuscitation, and longer intensive care unit stay. The pediatric cardiac population may be at even more risk and nearly twice as likely to be deficient compared to the noncardiac population. Low vitamin D levels have been found in postoperative cardiac patients, where investigators speculate cardiopulmonary bypass alters levels directly or indirectly. Patients with congestive heart failure who are deficient also seem to benefit from vitamin D supplementation. This review summarizes recent studies in children that investigate the relation between vitamin D status and clinical outcomes in the critically ill including those with cardiac disease.

Rapid normalization of vitamin D levels: a meta-analysis

BACKGROUND

Vitamin D deficiency may represent a modifiable risk factor to improve outcome in severe illness. The efficacy of high-dose regimens in rapid normalization of vitamin D levels is uncertain.

METHODS

We conducted a systematic review of pediatric clinical trials administering high-dose vitamin D to evaluate 25-hydroxyvitamin D (25[OH]D) response and characteristics associated with final 25(OH)D levels by using Medline, Embase, and the Cochrane Central Register of Controlled Trials, including reference lists of systematic reviews and eligible publications. Uncontrolled and controlled trials reporting 25(OH)D levels after high-dose (≥1000 IU) ergocalciferol or cholecalciferol were selected. Two reviewers independently extracted and verified predefined data fields.

RESULTS

We identified 88 eligible full-text articles. Two of 6 studies that administered daily doses approximating the Institute of Medicine's Tolerable Upper Intake Level (1000-4000 IU) to vitamin D-deficient populations achieved group 25(OH)D levels >75 nmol/L within 1 month. Nine of 10 studies evaluating loading therapy (>50 000 IU) achieved group 25(OH)D levels >75 nmol/L. In meta-regression, baseline 25(OH)D, regimen type, dose, age, and time factors were associated with final 25(OH)D levels. Adverse event analysis identified increased hypercalcemia risk with doses >400 000 IU, but no increased hypercalcemia or hypercalciuria with loading doses <400 000 IU (or 10 000 IU/kg). Few studies in adolescents evaluated loading dose regimens >300 000 IU.

CONCLUSIONS

Rapid normalization of vitamin D levels is best achieved by using loading therapy that considers disease status, baseline 25(OH)D, and age (or weight). Loading doses >300 000 IU should be avoided until trials are conducted to better evaluate risk and benefit.