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

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Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary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.

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.

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.

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.