Supplementation with Three Different Daily Doses of Vitamin D3 in Healthy Pre-pubertal School Girls: A Cluster Randomized Trial

The Relationship Between Vitamin D Intake and Serum 25-hydroxyvitamin D in Young Children: A Meta-Regression to Inform WHO/FAO Vitamin D Intake Recommendations

BACKGROUND

This work was commissioned by the World Health Organization and Food and Agriculture Organization to inform their update on the vitamin D requirements for children aged <4 y.

OBJECTIVES

The objective of this work was to undertake multilevel and multivariable dose-response modeling of serum 25-hydroxyvitamin D (25OHD) to total vitamin D intake in children aged <4 y with the goal of deriving updated vitamin D requirements for young children.

METHODS

Systematically identified randomized controlled trials among healthy children from 2 wk up to 3.9 y of age provided with daily vitamin D supplements or vitamin D-fortified foods were included. Linear and nonlinear random effects multilevel meta-regression models with and without covariates were fitted and compared. Interindividual variability was included by simulating the individual serum 25OHD responses. The percentage of individuals reaching set minimal and maximal serum 25OHD thresholds was calculated and used to derive vitamin D requirements.

RESULTS

A total of 31 trials with 186 data points from North America, Europe, Asia, and Australasia/Oceania, with latitudes ranging from 61°N to 38°S, and with participants of likely mostly light or medium skin pigmentation, were included. In 29 studies the children received vitamin D supplements and in 2 studies the children received vitamin D-fortified milk with or without supplements. The dose-response relationship between vitamin D intake and serum 25OHD was best fitted with the unadjusted quadratic model. Adding additional covariates, such as age, did not significantly improve the model. At a vitamin D intake of 10 μg/d, 97.3% of the individuals were predicted to achieve a minimal serum 25OHD threshold of 28 nmol/L. At a vitamin D intake of 35 μg/d, 1.4% of the individuals predicted to reach a maximal serum 25OHD threshold of 200 nmol/L.

CONCLUSIONS

In conclusion, this paper details the methodological steps taken to derive vitamin D requirements in children aged <4 y, including the addition of an interindividual variability component.

Effect of Vitamin D Supplementation on (25(OH)D) Status in Children 12-30 Months of Age: A Randomized Clinical Trial

Vitamin D (VD) deficiency (serum 25(OH)D < 50 nmol/L) affects 27.3% of preschool children in Mexico. The purpose of this study was to assess the effect of vitamin D supplementation at different doses on serum 25(OH)D concentrations in preschool children. In a randomized control trial, 222 children 12-30 months old were randomly assigned to one of four treatment groups: (1) Vitamin D2 (Ergocalciferol) 400 IU/day (n = 56); (2) Vitamin D2 (Ergocalciferol) 800 IU/day (n = 55); (3) Vitamin D3 (Cholecalciferol) 1000 IU/day (n = 56); or (4) multiple micronutrients (MM) non-VD (n = 55). Supplements were given five days/wk for three months. Serum 25(OH)D was measured at baseline and after three months. At baseline, mean serum 25(OH)D was 58.9 ± 12.6 nmol/L and 23.4% were VD-deficient. There was a statistically significant increase in serum concentrations of 25(OH)D (range across groups: +8.2 to +17.3 nmol/L). Additionally, the prevalence of vitamin D deficiency decreased after three months: for D2 400 IU, -9.0%; for D2 800 IU, -11.0%; for D3 1000 IU, -18.0%; and for MM non-VD, -2.8% (p < 0.05). No adverse effects were observed. VD supplementation for three months was effective for increasing serum 25(OH)D concentrations and for reducing VD deficiency in preschool children. The highest efficacy was observed by giving 1000 IU D3/d.

Micronutrient interventions among vulnerable population over a decade: A systematic review on Indian perspective

Background: Micronutrient deficiency has long been recognized as a public health problem, particularly among vulnerable groups such as children, adolescents, pregnant and lactating women. Micronutrient deficiency could not be ruled out in spite of the implementation of various intervention strategies. Different interventions are being used to prevent and treat micronutrient deficiencies at the national and global level. The aim of this study is to systematically review the intervention strategies among different vulnerable age groups in India.

Methods: The review was focused on identifying various interventions published based on the internet databases and the peer-reviewed papers from 2011 to 2021, on the predefined inclusive/exclusive criteria. The major intervention strategies implemented in India were recognized and evaluated based on dietary supplementation, micronutrient supplementation, knowledge interventions and food fortification among various age groups.

Results: The results show that there are still considerable gaps in identifying the effective intervention strategies, research initiatives, programs and policies addressing to tackle micronutrient deficiencies in India. Multiple interventions are effective that could lead the road to innovations in approaches with diverse dietary intake, developing multiple micronutrient supplements, fortifying foods and nutrition interventions to address calcium, zinc, iodine, vitamin D and vitamin A deficiencies among the vulnerable population.

Conclusion: Evidence-based multiple intervention studies covering a large population, in the long term cross-sectional, is the need for the hour to design policies and programs for improving the micronutrient status of vulnerable population in the community.

Daily v. weekly oral vitamin D3 therapy for nutritional rickets in Indian children: a randomised controlled open-label trial

The aim of the study was to compare the efficacy of daily v. weekly oral vitamin D3 therapy in radiological healing of nutritional rickets. Children 6 months to 12 years (n 132) diagnosed with nutritional rickets were randomised into three groups (n 44): group A - 2000 IU daily vitamin D3 for 12 weeks, B - 60 000 IU weekly for 3 weeks, C - 60 000 IU weekly for 6 weeks. Serum calcium, phosphorus, 25-hydroxyvitamin D (25(OH)D), parathyroid hormone and X-ray score were estimated at baseline and 12 weeks (endline). The proportion of children who achieved complete radiological healing at endline was compared between three groups by χ2 and delta change in laboratory parameters by ANOVA (parametric data) or Kruskal Wallis test (non-parametric data), respectively. Baseline 25(OH)D ≤ 20 ng/ml was seen in 119 (90·2 %), hyperparathyroidism in 90 (68·8 %) and hypocalcaemia in 96 (72·7 %). A total of 120/132 children completed the study. Complete radiological healing seen in 30 (75 %) in group A, 23 (60·5 %) in group B and 26 (61·9 %) in group C; P = 0·15, with comparable endline X-ray scores; P = 0·31. The median (interquartile range (IQR)) delta X-ray score (baseline-endline) was 7 (4,9), 5 (2·25, 6) and 6 (4,7) in groups A, B and C, respectively; P = 0·019. Median (IQR) 25(OH)D endline levels in groups A, B and C were 50·0 (26·5, 66·5), 42·1 (28·4, 54·4) and 53·5 (33·7, 71·2) ng/ml, respectively; P = 0·045. Radiological scores were comparable at endline among daily and weekly vitamin D groups with greater change from baseline in daily supplemented group.

Vitamin D and calcium intakes in general pediatric populations: A French expert consensus paper

OBJECTIVES

Nutritional vitamin D supplements are often used in general pediatrics. Here, the aim is to address vitamin D supplementation and calcium nutritional intakes in newborns, infants, children, and adolescents to prevent vitamin D deficiency and rickets in general populations.

STUDY DESIGN

We formulated clinical questions relating to the following categories: the Patient (or Population) to whom the recommendation will apply; the Intervention being considered; the Comparison (which may be "no action," placebo, or an alternative intervention); and the Outcomes affected by the intervention (PICO). These PICO elements were arranged into the questions to be addressed in the literature searches. Each PICO question then formed the basis for a statement. The population covered consisted of children aged between 0 and 18 years and premature babies hospitalized in neonatology. Two groups were assembled: a core working group and a voting panel from different scientific pediatric committees from the French Society of Pediatrics and national scientific societies.

RESULTS

We present here 35 clinical practice points (CPPs) for the use of native vitamin D therapy (ergocalciferol, vitamin D2 and cholecalciferol, vitamin D3) and calcium nutritional intakes in general pediatric populations.

CONCLUSION

This consensus document was developed to provide guidance to health care professionals on the use of nutritional vitamin D and dietary modalities to achieve the recommended calcium intakes in general pediatric populations. These CPPs will be revised periodically. Research recommendations to study key vitamin D outcome measures in children are also suggested.

Vitamin D biomarkers for Dietary Reference Intake development in children: a systematic review and meta-analysis

BACKGROUND

Circulating 25-hydroxyvitamin D [25(OH)D] has been the accepted vitamin D exposure/intake biomarker of choice within recent DRI exercises, but use of other vitamin D-related biomarkers as well as functional markers has been suggested. These may be of value in future vitamin D DRI exercises, such as the FAO/WHO's one for young children.

OBJECTIVES

To systematically review the usefulness of circulating 25(OH)D, parathyroid hormone (PTH), free and bioavailable 25(OH)D, C3-epimer of 25(OH)D, vitamin D3, 24,25-dihydroxyvitamin D [24,25(OH)2D], and bone turnover markers and calcium absorption as vitamin D biomarkers for DRI development in children.

METHODS

Methods included structured searches of published articles, full-text reviews, data extraction, quality assessment, meta-analysis, and random-effects meta-regression.

RESULTS

Fifty-nine vitamin D supplementation randomized controlled trials (RCTs) were included (39 in infants/children as the priority group and the remainder in adults since pediatric studies were absent/limited). Vitamin D supplementation significantly raised circulating 25(OH)D in infants and children, but the response was highly heterogeneous [weighted mean difference (WMD): 27.7 nmol/L; 95% CI: 22.9, 32.5; 27 RCTs; I2 = 93%]. Meta-regression suggested an increase by 1.7 nmol/L (95% CI: 0.7, 2.6) in serum 25(OH)D per each 100-IU increment in vitamin D intake (P = 0.0005). Vitamin D supplementation had a significant effect on circulating 24,25(OH)2D (WMD: 3.4 nmol/L; 95% CI: 2.4, 4.5; 13 RCTs; I2 = 95%), with a dose-response relation (+0.15 nmol/L per 100 IU; 95% CI: -0.01, 0.29). With circulating PTH, although there was a significant effect of vitamin D on WMD (P = 0.05), there was no significant dose-response relation (P = 0.32). Pediatric data were too limited in relation to the usefulness of the other biomarkers.

CONCLUSIONS

Circulating 25(OH)D may be a useful biomarker of vitamin D exposure/intake for DRI development in infants and children. Circulating 24,25(OH)2D also showed some promise, but further data are needed, especially in infants and children.

Vitamin D Status of School-Age Children in North India

Information on vitamin D deficiency in prepubertal children is scarce. The authors studied calcium intake, sunlight exposure, serum calcium, alkaline phosphatase, 25-hydroxyvitamin (25OHD), and intact parathormone (iPTH) in the children (N = 135) attending the pediatric endocrinology clinic (declared normal after evaluation) and their healthy siblings. Serum 25OHD < 12 ng/mL was frequent (55.6%) and median (IQR) 25OHD lower [10.1 (11.4) ng/mL] in pubertal (n = 36) versus prepubertal (n = 99) children [36.4% (p < 0.05), 15.5 (13.2) ng/mL (p < 0.001)]. Girls had lower 25OHD [12.33 (10.32)] vs. [15.83 (13.37) ng/mL, p < 0.05], calcium intake [517.20 (405.5) vs. 623.6 (430.5) mg, p < 0.05], and minutes of sunlight exposure [MSE, 38.55 (42.86) vs. 63.4 (66.8) min, p < 0.01] than boys. MSE and body surface area (BSA) exposed were significant associations of 25OHD in a multivariate model. Vitamin D deficiency in children, both pubertal and prepubertal, assumes public health importance in the authors' region. Girls are at higher risk. Duration of sunlight exposure and BSA are modifiable factors.

Maternal vitamin D deficiency and GDM risk: evidence for the case of investing more attention in antenatal clinics

Gestational diabetes mellitus (GDM) is a global public health problem, and in India, it affects about 20% of pregnancies. India, despite being a tropical country with abundant sunshine has a high prevalence (80%) of vitamin D deficiency (VDD) among reproductive-aged women. Global and Indian evidence links VDD with a higher risk of hyperglycaemia in pregnancy and GDM. VDD has also been implicated in gestational hypertension, preterm birth and poorer offspring health. Global scientific consensus acknowledges the need for maternal vitamin D screening and supplementation, but knowledge gaps exist about optimal blood levels (50-100 nmol/l), and the required vitamin D dosage (400-4000 IU). Diet can provide <10% of the vitamin D requirements, food fortification can deliver limited amounts, and hence optimal antenatal supplementation is key. Prenatal calcium supplements containing 400 IU of vitamin D may be sufficient for calcium absorption and bone health, but may not provide immunomodulatory benefits, including GDM prevention. Increasing evidence calls for higher maternal vitamin D requirements (2000-4000 IU) for skeletal, metabolic and immune health benefits. Current screening and supplementation for maternal VDD in India is low. We need to invest in future studies to determine optimal maternal vitamin D requirements and formulate policies for vitamin D supplementation to prevent GDM. Improving the maternal vitamin D status is an important nutritional priority for policymakers to reduce the large economic burden of non-communicable diseases (10% of India's gross domestic product), and eventually achieve the 2030 UN sustainable development goals.

Association of serum 25-Hydroxyvitamin D with Vitamin D intervention and outdoor activity among children in North China: an observational study

Background

Living at high latitudes is one of the risk factors for vitamin D deficiency in children. However, evidence on vitamin D improvement for this pediatric population to date is limited. This study aims at evaluating the association of different vitamin D intervention methods and outdoor activity on the vitamin D status of children in North China.

Methods

In this observational study, a total of 55,925 children aged 1 month to 18 years old were recruited from pediatric outpatient departments from July 2016 to June 2017. Data on demographics, anthropometric measurements, vitamin D intervention (either prescribed by physicians or given by parents) and outdoor activity were recorded. The serum levels of 25-hydroxycholecalciferol (25(OH)D) were determined by high performance liquid chromatography tandem–mass spectrometry. Logistic regression analysis was performed to assess the association of vitamin D intervention or outdoor activity with blood vitamin D status, adjusted for age, gender, BMI for age, and seasons.

Results

The overall rate of hypovitaminosis D was 65.60%. Of the children’s outdoor activity, 35.63, 31.95, and 32.42% were below 30 min/d, 30–60 min/d and over 60 min/d, respectively. Furthermore, the proportion of therapeutic intervention, supplementation intervention and no vitamin D intervention among the children was 16.48, 32.87, and 50.65%, respectively. After adjusted for confounding factors, vitamin D intervention was associated with a lower risk of hypovitaminosis D, with OR (95% CI) of 0.191 (0.180, 0.202) in children with therapeutic doses and 0.423 (0.404, 0.443) in those with supplementation doses, compared with children without vitamin D intervention. In addition, longer outdoor time was associated with a lower risk of hypovitaminosis D [0.479 (0.456, 0.504) for 60 min/d, 0.737 (0.701, 0.776) for 30–60 min/d], independent of vitamin D intervention.

Conclusions

High prevalence of vitamin D deficiency was found in children living at high latitudes. Vitamin D intervention and outdoor activity are all negatively associated with children’s vitamin D deficiency. Routine vitamin D intervention combined with increased outdoor time might be an effective approach to prevent hypovitaminosis D among children, especially those at school, living at high latitudes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02435-9.

Interventions for Prevention and Control of Epidemic of Vitamin D Deficiency

Vitamin D deficiency (VDD) remains a significant health challenge globally with its overwhelming effects on skeletal growth and varied associations with extra-skeletal diseases. The last decade has reported a high prevalence of VDD in all age-groups across all zones of India. Children and adolescents are most vulnerable to ill-effects of VDD as peak linear growth and bone mass accrual occurs during these years. Vitamin D deficiency in mothers predisposes their infants to have low serum vitamin D levels. Indians have increased susceptibility to develop VDD due to predominant vegetarian dietary habits, high melanin skin content, atmospheric pollution, modest tradition of clothing and limited availability of fortified foods. Vitamin D supplementation during infancy and childhood has emerged as an effective strategy to combat VDD. However, effects of vitamin D supplementation are transient and are not cost-effective as a maintenance strategy. Fortification of foodstuffs has been adopted by many developed countries globally which has emerged as a safe, efficacious and cost-effective strategy to control VDD. A strong political will and support is required to sustain food fortification in India. The current review focuses on strategies to prevent and control the epidemic of VDD in children.