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Pehlivanturk Kizilkan M, Akgül S, Kanbur N, Derman O. Reply to the commenting letter by Panda PK, et al. Eur J Pediatr 2024; 183:1471-1472. [PMID: 38300365 DOI: 10.1007/s00431-024-05453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
| | - Sinem Akgül
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Türkiye
| | - Nuray Kanbur
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Türkiye
| | - Orhan Derman
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Türkiye
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Morin CR, Baeva ME, Hollenberg MD, Brain MC. Milk and multiple sclerosis: A possible link? Mult Scler Relat Disord 2024; 83:105477. [PMID: 38308914 DOI: 10.1016/j.msard.2024.105477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/07/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Abstract
Despite having been formally defined over 150 years ago, the etiology of multiple sclerosis (MS) is still relatively unknown. However, it is now recognized as a multifactorial disease in which genetics, infection, immune function, and environment play a role. We propose an additional piece to the puzzle: milk. In this review, milk is highlighted as a potential risk factor for MS. We examine the overall correlation between bovine milk consumption and the incidence of MS. We then discuss possible mechanisms that may explain the positive association between milk consumption and the development of MS. For instance, butyrophilin (BTN), a milk glycoprotein, can provide molecular mimicry of myelin oligodendrocyte glycoprotein and induce an autoinflammatory response against myelin. Other milk components such as casein, gangliosides, xanthine oxidase, and saturated fats are also analyzed for their potential involvement in the pathophysiology of MS. Finally, we fit milk alongside other well known risk factors of MS: vitamin D levels, Epstein Barr virus infection, and gut dysbiosis. In conclusion, this review summarizes potential mechanisms linking milk as an underappreciated potential risk factor for the development of MS.
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Affiliation(s)
- Caleb R Morin
- University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
| | | | - Morley D Hollenberg
- Department of Physiology & Pharmacology, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
| | - Michael C Brain
- Department of Biochemistry and Molecular Biology, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada
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Muacevic A, Adler JR. Physiotherapy Management of an Adolescent With Pityriasis Rubra Pilaris Along With Rickets. Cureus 2022; 14:e30518. [PMID: 36415347 PMCID: PMC9674203 DOI: 10.7759/cureus.30518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/20/2022] [Indexed: 01/25/2023] Open
Abstract
Rickets is an ossification and mineralization disorder of the growth plate before skeletal maturity that is peculiar to children and adolescents. Most children are affected by this deficient disorder throughout their skeletal growth stage, characterized by deformed and soft bones, due to a failure to assimilate and utilize calcium and phosphorus properly. It is most frequent in children aged four months to three years in developing countries. In the Indian subcontinent, it continues to be a major health problem. The majority of rickets symptoms include bone pain, deformity of the bones, and impaired growth velocity. In addition to damaging the skeletal system, it also affects other systems, which results in substantial morbidity. The term "rachitic pneumopathy" has long been used to describe respiratory issues caused by rickets. Pityriasis rubra pilaris (PRP) is an inflammatory rare skin disease that affects children as well as adults of all ages. They can develop PRP's clinical characteristics and individual prognoses are quite varied. Rickets occurring in association with skin diseases is rare. Here, we report an instance of a 15-year-old boy who gave a history of pain and swelling in the knees for the past three months. He couldn't bear weight and had walking difficulty as well. Along with this, he also complained of itchy lesions for nine years. Initially, the lesions were on the right arm, which progressed to the left arm, chest, back and abdomen. Later, they were seen on the lower limbs. After appropriate diagnostic work, he was diagnosed with rickets with pityriasis rubra pilaris. The patient received both medical and physical therapy treatment. The physical therapy rehabilitation program used in this case study significantly improved the patient's functional independence by reducing pain and improving joint mobility, muscle strength, endurance, and gait. After six weeks of rehabilitation, there was an improvement in the ranges of the joint, strength of muscle, gait, and functional independence significantly using physical therapy techniques. This case study shows the value of comprehensive physical therapy in a case of pityriasis rubra pilaris with rickets in a 15-year-old boy.
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Önal ZE, Tekin A, Gürbüz T, Sağ Ç, Nuhoğlu Ç. Vitamin D status in pubertal children. Minerva Pediatr (Torino) 2021; 73:173-179. [PMID: 33880905 DOI: 10.23736/s2724-5276.16.04334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Optimal vitamin D status has a great importance in puberty, which is a period of peak bone mineral acquisition. In this study, we aimed to assess the effect of pubertal period on vitamin D status. METHODS The study included totally 200 healthy children, aged between 4 and 14 years. Group 1 included 100 prepubertal, children, aged between 4 and 8 years. Group 2 included 100 pubertal children, aged between 9 and 14 years. They had no chronic illnesses. Ages, heights, weights, genders, Body Mass Indexes (BMIs), socioeconomic and educational status of families were established. Serum 25-hydroxyvitamin D (25(OH)D) levels were measured by high performance liquid chromatography (HPLC). Serum parathyroid hormone (PTH) was evaluated using an immunoradiometric assay kit. Serum calcium (Ca), phosphorus (P) and alkaline phosphatase (ALP) levels were measured. RESULTS We determined that 25(OH)D levels were lower with higher PTH levels in the group aged 9 to 14 years (pubertal children), compared to the group aged 4 to 8 (prepubertal children). Gender, weight, height or BMI, family socioeconomic and education status did not affect serum 25(OH)D levels of children in each group. CONCLUSIONS We demonstrated that vitamin D deficiency was more commonly seen in the pubertal children, compared to pre pubertal period. Children should be supported with vitamin D supplements during the puberty, which has a great importance for rapid increase in bone mass.
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Affiliation(s)
- Zehra E Önal
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey -
| | - Abdülkadir Tekin
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Tamay Gürbüz
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Çiğdem Sağ
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Çağatay Nuhoğlu
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
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Prevalence of Vitamin D Deficiency in a Large Newborn Cohort from Northern United States and Effect of Intrauterine Drug Exposure. Nutrients 2020; 12:nu12072085. [PMID: 32674386 PMCID: PMC7400905 DOI: 10.3390/nu12072085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022] Open
Abstract
Vitamin D is not only a vital element in bone health but is also a prohormone. Data regarding distribution of vitamin D status among preterm and term neonates in the United States are limited. There are no data on the effect of intrauterine drug exposure on vitamin D status. Our objective was to determine the distribution of vitamin D levels among preterm and term neonates and the effect of intrauterine illicit drug exposure. We did a retrospective chart review of neonates admitted from 2009 to 2016 to our neonatal intensive care unit with serum 25-hydroxycholecalciferol (25[OH]D) levels measured during the hospital stay. Of 1517 neonates, the median 25[OH]D level was 19 ng/mL with 31% deficient and 49% insufficient, even though 75% of mothers took prenatal vitamins. In pregnant women, 38% were vitamin-D-deficient and 44% were vitamin-D-insufficient. Four hundred seventy-one neonates had intrauterine drug exposure, with a median 25[OH]D level of 22.9 ng/mL versus 17.8 ng/mL in nonexposed neonates (p = 0.001). Despite maternal prenatal vitamin intake, neonates are at risk of vitamin D deficiency. Maternal illicit drug use was not related to lower 25[OH]D levels in neonates.
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Chibuzor MT, Graham‐Kalio D, Osaji JO, Meremikwu MM. Vitamin D, calcium or a combination of vitamin D and calcium for the treatment of nutritional rickets in children. Cochrane Database Syst Rev 2020; 4:CD012581. [PMID: 32303107 PMCID: PMC7164979 DOI: 10.1002/14651858.cd012581.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Nutritional rickets is a disease which affects children, especially in low- and middle-income countries. It causes problems such as skeletal deformities and impaired growth. The most common cause of nutritional rickets is vitamin D deficiency. Vitamin D administered with or without calcium is commonly regarded as the mainstay of treatment. In some sunny countries, however, where children are believed to have adequate vitamin D production from exposure to ultraviolet light, but who are deficient in calcium due to low dietary intake, calcium alone has also been used in the treatment of nutritional rickets. Therefore, it is important to compare the effects of vitamin D, calcium or a combination of vitamin D and calcium for the treatment of nutritional rickets in children living in different settings. OBJECTIVES To assess the effects of vitamin D, calcium or a combination of vitamin D and calcium for the treatment of nutritional rickets in children. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search of all databases was 25 July 2019. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCT) involving children aged 0 to 18 years with nutritional rickets which compared treatment with vitamin D, calcium or a combination of vitamin D and calcium. DATA COLLECTION AND ANALYSIS Two review authors independently screened the title and abstracts of all studies, extracted data and assessed the risk of bias of included studies. We resolved any disagreements by consensus or recourse to a third review author. We conducted meta-analyses for the outcomes reported by study authors. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI) and, for continuous outcomes, we calculated mean differences (MD) with 95% CIs. We assessed the certainty of the evidence of the included studies using GRADE. MAIN RESULTS We identified 4562 studies; of these, we included four RCTs with 286 participants. The studies compared two or more of the following: vitamin D, calcium or vitamin D plus calcium. The number of participants randomised to receive vitamin D was 64, calcium was 102 and vitamin D plus calcium was 120. Two studies were conducted in India and two were conducted in Nigeria. None of the included studies had a low risk of bias in all domains. Three studies had a high risk of bias in at least one domain. The age of the participants ranged between six months and 14 years. The duration of follow-up ranged between 12 weeks and 24 weeks. Two studies compared vitamin D to calcium. There is low-certainty evidence that, at 24 weeks' follow-up, calcium alone improved the healing of rickets compared to vitamin D alone (RR 3.26, 95% CI 1.59 to 6.69; P = 0.001; 1 study, 71 participants). Comparing vitamin D to calcium showed no firm evidence of an advantage or disadvantage in reducing morbidity (fractures) (RR 0.27, 95% CI 0.03 to 2.32; P = 0.23; 1 study, 71 participants; very low-certainty evidence). Adverse events were not reported. Two studies compared vitamin D plus calcium to vitamin D at 12 or 24 weeks. Vitamin D plus calcium improved healing of rickets compared to vitamin D alone at 24 weeks' follow-up (RR 3.06, 95% CI 1.49 to 6.29; P = 0.002; 1 study, 75 participants; low-certainty evidence). There is no conclusive evidence in favour of either intervention for reducing morbidity (fractures) (RR 0.24, 95% CI 0.03 to 2.08; P = 0.20; 1 study, 71 participants; very low-certainty evidence) or adverse events (RR 4.76, 95% CI 0.24 to 93.19; P = 0.30; 1 study, 39 participants; very low-certainty evidence). All four included studies compared vitamin D plus calcium to calcium at different follow-up times. There is no conclusive evidence on whether vitamin D plus calcium in comparison to calcium alone improved healing of rickets at 24 weeks' follow-up (RR 1.17, 95% CI 0.72 to 1.90; P = 0.53; 2 studies, 140 participants; very low-certainty evidence). Evidence is also inconclusive for morbidity (fractures) (RR 0.89, 95% CI 0.06 to 13.76; P = 0.94; 1 study, 72 participants; very low-certainty evidence) and adverse events (RR 4.29, 0.22 to 83.57; P = 0.34; 1 study, 37 participants; very low-certainty evidence). Most of the evidence in the review is low or very low certainty due to risk of bias, imprecision or both. None of the included studies assessed all-cause mortality, health-related quality of life or socioeconomic effects. One study assessed growth pattern but this was not measured at the time-point stipulated in the protocol of our review (one or more years after commencement of therapy). AUTHORS' CONCLUSIONS This review provides low-certainty evidence that vitamin D plus calcium or calcium alone improve healing in children with nutritional rickets compared to vitamin D alone. We are unable to make conclusions on the effects of the interventions on adverse events or morbidity (fractures).
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Affiliation(s)
- Moriam T Chibuzor
- Cochrane Nigeria, Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching HospitalCalabarCross RiverNigeria540261
| | | | - Joy O Osaji
- University of Calabar Teaching HospitalInstitute of Tropical Diseases Research and PreventionCalabarNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
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Brody J, Pinhas-Hamiel O, Landau Z, Adar A, Bistritzer T, Rachmiel M. Vitamin D status in Israeli pediatric type 1 diabetes patients: the AWeSoMe Study Group experience and literature review. J Pediatr Endocrinol Metab 2020; 33:323-330. [PMID: 27760014 DOI: 10.1515/jpem-2016-0137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/29/2016] [Indexed: 02/05/2023]
Abstract
Background The prevalence of both vitamin D (VitD) deficiency and type 1 diabetes mellitus (T1DM) has increased worldwide over the last few decades. The objectives of this study were: (1) to evaluate the prevalence of VitD deficiency and insufficiency among Israeli youth with T1DM and (2) to assess the association between VitD status, seasonality and T1D glycemic control characteristics. Methods This was a multi-centered, cross-sectional study. VitD levels were routinely tested during the years 2008-2011 in T1DM patients aged up to 21 years. Medical records were reviewed for demographic, clinical and laboratory characteristics. Results The study population consisted of 199 participants (53% males), mean age 12.24±4.11 years, mean T1DM duration 3.77±3.43 years. VitD levels were within the normal range in 19.6%, insufficient (15-29 ng/mL, 37-72 nmol/L) in 62.3% and deficient (<15 ng/mL, <37 nmol/L) in 18.1%. Mean VitD level was higher during the summer than during spring, autumn and winter (28.65 ng/mL, 23.16 ng/mL, 21.65 ng/mL, 17.55 ng/mL, respectively, p<0.001). Mean VitD level was higher among secular patients compared to the religious (whole-year heavily dressed) population (23.57 ng/mL, 15.54 ng/mL, respectively, p<0.001). VitD level was negatively associated with body mass index calculation of standard deviation scores (BMI-SDS), high-density lipoprotein (HDL) and age at diagnosis (r=-0.171, p=0.016; r=-0.149, p=0.043; r=-0.150, p=0.037, respectively). No association was demonstrated with disease duration and glycemic control indices and metabolic parameters. Conclusions VitD insufficiency is largely prevalent among Israeli youth with T1DM, as is in Israeli youth in general. The VitD level is associated with seasonality, clothing habits and BMI.
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Affiliation(s)
- Judith Brody
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Pinhas-Hamiel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Juvenile Diabetes Center, Maccabi Health Care Services, Raanana, Israel
| | - Zohar Landau
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Juvenile Diabetes Center, Maccabi Health Care Services, Raanana, Israel
- Pediatric Diabetes Service, Wolfson Medical Center, Holon, Israel
| | - Adi Adar
- Pediatric Endocrinology Service, Division of Pediatrics, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin, Israel
| | - Tzvy Bistritzer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology Service, Division of Pediatrics, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin, Israel
| | - Marianna Rachmiel
- Pediatric endocrinology and Diabetes Unit, Assaf Harofeh Medical Center, Zerifin 70300, Israel
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Sayehmiri K, Shohani M, Kalvandi G, Najafi R, Tavan H. Biochemical parameters of rickets in Iranian children: A systematic review and meta-analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:76. [PMID: 31523262 PMCID: PMC6734666 DOI: 10.4103/jrms.jrms_354_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/19/2018] [Accepted: 05/05/2019] [Indexed: 12/13/2022]
Abstract
Background: Many causes can lead to childhood rickets. We aimed to investigate the biochemical symptoms of childhood rickets with systematic review and meta-analysis. Materials and Methods: Seven articles published from 1975 to 2018 were recruited. The literature search was performed in the Scientific Information Database, Google Scholar, PubMed, and Elsevier databases using related keywords. For meta-analysis, the results of the studies were pooled using the random-effects model. The heterogeneity between the studies was checked using Q test and I2 index. Results: The total sample population consisted of 933 children with biochemical symptoms of rickets (133 participants per article). According to our findings, the mean serum levels of PO4, Ca, and alkaline phosphatase in children with rickets were 4.18 (95% confidence interval [CI]: 3.75–4.61, I2 = 98.3%, P < 0.001), 9.23 (95% CI: 8.78–9.68, I2 = 99.6%, P < 0.001), and 1.33 (95% CI: 1.23–1.44, I2 = 95.6%, P < 0.001), respectively. Conclusion: Characterizing the biochemical symptoms of rickets in children can help to early diagnose and prevent the disease in children. Furthermore, educating parents about biochemical symptoms can lead to early diagnosis and successful treatment of rickets in children.
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Affiliation(s)
- Kourosh Sayehmiri
- Professor of Biostatistics, School of Medicine, Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Masoumeh Shohani
- Assistant Professor, PhD of Nursing, Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
| | - Gholamreza Kalvandi
- Associate Professor of Pediatrics Gastroenterology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Reza Najafi
- Assistant Professor of Pediatric Endocrinology & Metabolism, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Hamed Tavan
- Faculty of Nursing and Midwifery, Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
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Powers JM, Murphy JEJ. Sunlight radiation as a villain and hero: 60 years of illuminating research. Int J Radiat Biol 2019; 95:1043-1049. [PMID: 31157572 DOI: 10.1080/09553002.2019.1627440] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the 60 years since the inaugural edition of the International Journal of Radiation Biology, much of our understanding of the biological effects of solar radiation has changed. Earlier in the century, sunlight played a 'hero's' role in reducing disabling rickets, while today debate still continues on the amount of sun required before exposure reveals the 'villainous' side of solar radiation. Although knowledge of the ultra violet (UV) component of sunlight as a carcinogen has become widespread, skin cancer rates are still rising yearly. Twentieth century attitudes have seen an about-face in the field of dermatological sun protection, with sunscreens changing from recipes designed to promote a 'healthy tan' to formulations proven to block both ultraviolet B (UVB) and more recently, ultraviolet A (UVA), to minimize premature sun-aging and skin cancer risk. In the early 1960s, DNA was first found to exist within mitochondria, while recently the connections between mitochondrial changes and UV radiation exposure have been expanded. Sixty years ago, understanding of the endocrine systems of mammals was enjoying its infancy. Early discoveries that light, particularly natural light, could have profound effects on functions such as sleep patterns and hormonal balance were made, while today more advanced knowledge has led to lighting improvements having pronounced effects on human wellbeing. Photosensitization 60 years ago was a health concern for both humans and their domestic animals, while today chemically engineered photosensitizing drugs can be administered along with highly directed light to pinpoint delivery targets for drug action. Life on earth is inextricably bound up with solar radiation. This article attempts to outline many of the ways in which our opinions about solar radiation have changed since the journal's inception.
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Affiliation(s)
- Julia Montelin Powers
- a Cellular Health and Toxicology Research Group, Department of Health and Nutritional Sciences , Institute of Technology Sligo , Sligo , Ireland
| | - James Edward John Murphy
- a Cellular Health and Toxicology Research Group, Department of Health and Nutritional Sciences , Institute of Technology Sligo , Sligo , Ireland
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Zhang YF, Xu JW, Yang Y, Huang X, Yu XQ. The association between body lead levels and childhood rickets: A meta-analysis based on Chinese cohort. Medicine (Baltimore) 2019; 98:e14680. [PMID: 30813216 PMCID: PMC6407931 DOI: 10.1097/md.0000000000014680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
China has serious lead pollution and a high incidence of childhood rickets. High lead levels have been reported in childhood rickets, but the results were inconsistent.To evaluate the association between body lead levels and childhood rickets.After a systematic literature search, we identified 15 studies determining body lead levels between rickets children and healthy controls, and 4 studies focusing on the cases of different disease severity. Standard mean differences (SMD) and the corresponding 95% confidence intervals (CI) were pooled to compare the lead levels between different groups.Sixteen case-control studies were included with a total of 5082 cases and 6054 controls. Compared with healthy controls, the body lead levels in rickets children were significantly higher (SMD (95%CI): 0.67 (0.41-0.93)), and subgroup analyses showed consistent results. The cases with moderate-to-severe disease activity also had a significantly higher lead level than mild-to-moderate cases (SMD (95%CI): 0.64 (0.31-0.97)).This meta-analysis suggested an association between body lead levels and childhood rickets, and lead exposure might be a risk factor for rickets.
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Affiliation(s)
| | - Jiang-wei Xu
- The Third Department of Orthopedics, The Central Hospital of Enshi Autonomous Prefecture, Enshi, China
| | - Yao Yang
- The Second Department of Pediatrics
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Maternal and neonatal vitamin D status, genotype and childhood celiac disease. PLoS One 2017; 12:e0179080. [PMID: 28686601 PMCID: PMC5501391 DOI: 10.1371/journal.pone.0179080] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/23/2017] [Indexed: 12/16/2022] Open
Abstract
Background Low concentration of 25-hydroxyvitamin D during pregnancy may be associated with offspring autoimmune disorders. Little is known about environmental triggers except gluten for celiac disease, a common immune-mediated disorder where seasonality of birth has been reported as a risk factor. We therefore aimed to test whether low maternal and neonatal 25-hydroxyvitamin D predicted higher risk of childhood celiac disease. Methods and Findings In this Norwegian nationwide pregnancy cohort (n = 113,053) and nested case-control study, we analyzed 25-hydroxyvitamin D in maternal blood from mid-pregnancy, postpartum and cord plasma of 416 children who developed celiac disease and 570 randomly selected controls. Mothers and children were genotyped for established celiac disease and vitamin D metabolism variants. We used mixed linear regression models and logistic regression to study associations. There was no significant difference in average 25-hydroxyvitamin D between cases and controls (63.1 and 62.1 nmol/l, respectively, p = 0.28), and no significant linear trend (adjusted odds ratio per 10 nM increase 1.05, 95% CI: 0.93–1.17). Results were similar when analyzing the mid-pregnancy, postpartum or cord plasma separately. Genetic variants for vitamin D deficiency were not associated with celiac disease (odds ratio per risk allele of the child, 1.00; 95% CI, 0.90 to 1.10, odds ratio per risk allele of the mother 0.94; 95% CI 0.85 to 1.04). Vitamin D intake in pregnancy or by the child in early life did not predict later celiac disease. Adjustment for established genetic risk markers for celiac disease gave similar results. Conclusions We found no support for the hypothesis that maternal or neonatal vitamin D status is related to the risk of childhood celiac disease.
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Koçyiğit C, Çatlı G, İnce G, Özkan EB, Dündar BN. Can Stoss Therapy Be Used in Children with Vitamin D Deficiency or Insufficiency without Rickets? J Clin Res Pediatr Endocrinol 2017; 9:150-155. [PMID: 28077342 PMCID: PMC5463288 DOI: 10.4274/jcrpe.3842] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Stoss vitamin D treatment has been recommended for its non-skeletal benefits in adults, but there is a lack of data on the optimal dose of vitamin D stoss therapy in children with vitamin D deficiency/insufficiency without rickets. This study aimed to compare efficiency/side effects of two different stoss therapy regimens (10 000 IU/kg and 300 000 IU vitamin D3) administered in children with vitamin D deficiency/insufficiency without rickets. METHODS Sixty-four children who had vitamin D deficiency/insufficiency were studied. A serum 25-hydroxyvitamin-D (25-OH-D) level of 15-20 ng/mL was considered as vitamin D insufficient and <15 ng/mL was considered as vitamin D deficient. The patients were divided into two groups according to the stoss therapy doses they received. Serum calcium, phosphate, alkaline phosphatase, 25-OH-D, parathyroid hormone levels, and spot urine calcium/creatinine ratios before/after treatment were recorded. Wrist radiography and renal ultrasonography were performed. RESULTS The mean age of the subjects was 10.6±4.4 years. Thirty-two children were treated with a single vitamin D3 dose of 10 000 IU/kg and 32 patients received 300 000 IU. No difference was found in 25-OH-D levels between the two groups at presentation. The mean level of 25-OH-D was higher in the 10 000 IU/kg group at the second week of therapy. There was no difference between the groups at post-treatment weeks 4 and 12. The 25-OH-D was found to be below optimal levels (≥30 ng/mL) in 66.5% and <20 ng/mL in 21.8% of patients at the third month in both groups. None developed hypercalcemia and/or hypercalciuria. Nephrolithiasis was not detected in any patient. CONCLUSION This study showed that both doses of stoss therapy used in the treatment of vitamin D insufficiency/deficiency are effective and safe. However, an optimal level of 25-OH-D cannot be maintained for more than three months.
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Affiliation(s)
- Cemil Koçyiğit
- İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey, E-mail:
| | - Gönül Çatlı
- İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Gülberat İnce
- Tepecik Training and Research Hospital, Clinic of Pediatrics, İzmir, Turkey
| | - Elif Büşra Özkan
- İzmir Katip Çelebi University Faculty of Medicine, İzmir, Turkey
| | - Bumin Nuri Dündar
- İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
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Chibuzor MT, Graham-Kalio D, Meremikwu MM, Adukwu JO. Vitamin D, calcium or a combination of vitamin D and calcium for the treatment of nutritional rickets in children. Hippokratia 2017. [DOI: 10.1002/14651858.cd012581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Moriam T Chibuzor
- Nigerian Branch of South African Cochrane Centre; Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching Hospital Calabar Cross River Nigeria 540261
| | | | - Martin M Meremikwu
- University of Calabar Teaching Hospital; Department of Paediatrics; PMB 1115 Calabar Cross River State Nigeria
| | - Joy O Adukwu
- University of Calabar Teaching Hospital; Institute of Tropical Diseases Research and Prevention; Calabar Nigeria
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Matter M, El-Sherbiny E, Elmougy A, Abass M, Aldossary S, Ali WA. Myocardial function in Saudi adolescents with vitamin D deficiency: Tissue Doppler imaging study. J Saudi Heart Assoc 2015; 28:22-30. [PMID: 26778902 PMCID: PMC4685207 DOI: 10.1016/j.jsha.2015.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 06/03/2015] [Accepted: 06/17/2015] [Indexed: 12/20/2022] Open
Abstract
Vitamin D deficiency is a common health problem in Saudi Arabia especially in children and adolescents. Many studies have reported the relation between low 25-Hydroxyvitamin D (25(OH)D) levels with cardiovascular diseases risk factors as well as cardiovascular events, including stroke, myocardial infarction, and congestive heart failure. This study was conducted to evaluate the effect of 25(OH)D deficiency on the myocardial function and other echocardiographic variables in adolescent, using tissue Doppler imaging (TDI) and to correlate these parameters with 25(OH)D level. The study included 84 healthy adolescents, consecutively selected from adolescents attending the outpatient clinic of Saad Specialist Hospital, KSA between September 2013 and October 2014. The study population was classified into two groups; vitamin D deficient group with 25(OH)D level less than 20 ng/mL and normal vitamin D (control group) with 25(OH)D equal or more than 30 ng/mL. Both groups were subjected to measuring hemoglobin level, serum albumin, creatinine, total calcium, Phosphorous, intact parathyroid hormone (iPTH), B-type natriuretic peptide (BNP), and 25(OH)D levels. Both conventional and pulsed wave TDI were done for all participants. TDI measurements showed significant higher LV Tei Index and RV Tei index when compared to the control group (0.61 ± 0.11 Vs 0.32 ± 0.05 p < 0.0001), (0.54 ± 0.14 Vs 0.40 ± 0.06 p < 0.0001) respectively. Mitral and tricuspid annular systolic velocities were significantly lower in vitamin D deficient group (6.99 ± 1.92 Vs 10.69 ± 0.31 cm/sec p < 0.0001 and 12.30 ± 2.14 Vs 13.89 ± 0.29 p < 0.0001 respectively). The mitral and tricuspid E/Em ratio was significantly higher in vitamin D deficient group than control group (p < 0.0001, p 0.005) respectively. Left ventricular internal diameter at end-diastole (LVIDd) was significantly higher in vitamin D deficient group (44.72 ± 6.33 Vs 40.36 ± 6.21 p 0.003). Serum 25(OH)D level showed significant negative correlation with LV Tei index (r = −0.668, p < 0.0001), RV Tei index (r = −0.421, p < 0.0001). Vitamin D deficiency is associated with subtle systolic and diastolic myocardial dysfunction in Saudi adolescents. TDI is a useful tool for detecting early changes in the myocardium in this particular group.
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Affiliation(s)
- Mohamed Matter
- Pediatric Department, Mansoura University Children Hospital, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Enas El-Sherbiny
- Community Medicine Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Atef Elmougy
- Pediatric Department, Mansoura University Children Hospital, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Mohamed Abass
- Pediatric Department, Mansoura University Children Hospital, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Sahar Aldossary
- Pediatric Department, Saad Specialist Hospital, Alkhobar, Saudi Arabia
| | - Waleed Abu Ali
- Pediatric Department, King Fahad University Hospital, Medical College Dammam University, Dammam, Saudi Arabia
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Erol M, Yiğit Ö, Küçük SH, Bostan Gayret Ö. Vitamin D Deficiency in Children and Adolescents in Bağcılar, İstanbul. J Clin Res Pediatr Endocrinol 2015; 7:134-9. [PMID: 26316436 PMCID: PMC4563185 DOI: 10.4274/jcrpe.1888] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the frequency of seasonal 25-hydroxyvitamin D [25(OH)D] deficiency and insufficiency in children and adolescents living in Bağcılar, district of İstanbul city. METHODS Serum vitamin D levels of 280 children aged 3-17 years old were measured at the end of winter and at the end of summer. Of the total group, vitamin D levels were re-measured in 198 subjects. Vitamin D deficiency was defined as a serum 25(OH)D level less than 15 ng/mL and insufficiency-as levels between 15 and 20 ng/mL. Patients whose vitamin D levels were less than 15 ng/mL at the end of winter were treated with 2000 units/day of vitamin D for 3 months. RESULTS In the "end of winter" samples, 25(OH)D deficiency was present in 80.36% of the subjects and insufficiency in 11.79%. In the "end of summer" samples, vitamin D deficiency was detected in 3.44% and insufficiency in 27.75%. Vitamin D levels in the "end of winter" samples were not significantly different between boys and girls, while "end of summer" levels were significantly lower in girls (p=0.015). Sunlight exposure was significantly higher in boys (p=0.011). The group with sufficient dairy product consumption had significantly higher vitamin D levels in both "end of summer" and "end of winter" samples. Limb pain was frequently reported in children with low vitamin D levels in the "end of winter" samples (p=0.001). Negative correlations were observed between vitamin D levels and season and also between vitamin D levels and age. CONCLUSION It is essential to provide supplemental vitamin D to children and adolescents to overcome the deficiency seen especially at the end of winter.
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Affiliation(s)
- Meltem Erol
- Bağcılar Training and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey Phone: +90 532 457 83 97 E-mail:
| | - Özgül Yiğit
- Bağcılar Training and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
| | - Suat Hayri Küçük
- Bağcılar Training and Research Hospital, Clinic of Biochemistry, İstanbul, Turkey
| | - Özlem Bostan Gayret
- Bağcılar Training and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
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MEHLIG LYSANNMICHAELA, GARVE CLAUDIA, TAUER JOSEPHINETABEA, SUTTORP MEINOLF, BAUER ANDREA. Inhibitory effects of imatinib on vitamin D3 synthesis in human keratinocytes. Mol Med Rep 2014; 11:3143-7. [DOI: 10.3892/mmr.2014.3074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 11/07/2014] [Indexed: 11/06/2022] Open
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Abstract
The prevalence of severe vitamin D deficiency (VDD) in adolescents is variable but considerably high in many countries, especially in Middle-east and Southeast Asia. Different factors attribute to this deficiency including lack of sunlight exposure due to cultural dress codes and veiling or due to pigmented skin, and less time spent outdoors, because of hot weather, and lower vitamin D intake. A potent adaptation process significantly modifies the clinical presentation and therefore clinical presentations may be subtle and go unnoticed, thus making true prevalence studies difficult. Adolescents with severe VDD may present with vague manifestations including pain in weight-bearing joints, back, thighs and/or calves, difficulty in walking and/or climbing stairs, or running and muscle cramps. Adaptation includes increased parathormone (PTH) and deceased insulin-like growth factor-I (IGF-I) secretion. PTH enhances the tubular reabsorption of Ca and stimulates the kidneys to produce 1, 25-(OH) 2D3 that increases intestinal calcium absorption and dissolves the mineralized collagen matrix in bone, causing osteopenia and osteoporosis to provide enough Ca to prevent hypocalcaemia. Decreased insulin like growth factor-I (IGF-I) delays bone growth to economize calcium consumption. Radiological changes are not uncommon and include osteoporosis/osteopenia affecting long bones as well as vertebrae and ribs, bone cysts, decalcification of the metaphysis of the long bones and pseudo fractures. In severe cases pathological fractures and deformities may occur. Vitamin D treatment of adolescents with VDD differs considerably in different studies and proved to be effective in treating all clinical, biochemical, and radiological manifestations. Different treatment regiments for VDD have been discussed and presented in this mini-review for practical use. Adequate vitamin D replacement after treating VDD, improving calcium intake (milk and dairy products), encouraging adequate exposure to the sun and possible enrichment of the stable food with vitamin D in areas with high prevalence of VDD are important measures to prevent the harmful consequences of VDD.
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Affiliation(s)
- Ashraf T. Soliman
- Department of Pediatrics, University of Alexandria, Alexandria, Egypt
| | - Vincenzo De Sanctis
- Pediatric and Adolescent Outpatients Clinic, Quisisana Hospital, Ferrara, Italy
| | - Rania Elalaily
- Department of Primary Health Care, AbuNakhla Hospital, Doha, Qatar
| | - Said Bedair
- Department of Radiology, AlKhor Hospital, Hamad Medical Center, Doha, Qatar
| | - Islam Kassem
- Department of Faciomaxillay Surgery, University of Alexandria, Alexandria, Egypt
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Afrand M, Modaresi V. Bony manifestation of rickets in a sunny city - a case report from Yazd, Iran. Electron Physician 2014; 6:728-33. [PMID: 25763137 PMCID: PMC4324285 DOI: 10.14661/2014.728-733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 11/06/2022] Open
Abstract
Rickets is disease that occurs in growing bones in which defective mineralization occurs in both the bone and the cartilage of the epiphyseal growth plate, resulting in the retardation of growth and skeletal deformities. Rickets is more common in areas with less sunlight. However, this case report presents a case of the bony manifestation of rickets with the intake of vitamin D supplements in Yazd, a city in central Iran that has sunshine almost every day. A patient was referred to an out-patient general pediatric clinic for deformities of the legs and growth disturbance, with his height far below the normal range. The changes that were most evident in his X-rays were the bowing of the long bones of the legs and forearms and the cupping of the wrist metaphyseal region. In summary, we present a patient with bony manifestation of rickets despite living in a sunny area and taking vitamin D supplements. Thus, it is important to remember that rickets is still a common disease among children in Iran. More studies of this issue should be conducted, including the identification of abnormal cases and rescheduling vitamin D supplementation programs.
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Affiliation(s)
- Mohammadhosain Afrand
- Medical Scientific Association, Student of Public health, Islamic Azad University, Yazd branch, Yazd, Iran.
| | - Vajiheh Modaresi
- Assistant professor of Pediatric Gastroenterology, Pediatric Department, Islamic Azad University, Yazd branch, Yazd, Iran.
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Vitamin d status in thalassemia major: an update. Mediterr J Hematol Infect Dis 2013; 5:e2013057. [PMID: 24106607 PMCID: PMC3787712 DOI: 10.4084/mjhid.2013.057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/20/2013] [Indexed: 01/17/2023] Open
Abstract
The survival of patients with thalassemia major has progressively improved with advances in therapy; however, osteoporosis and cardiac dysfunction remain frequent complications. Adequate circulating levels of vitamin D are essential for optimal skeletal health and reducing fracture risk. Vitamin D deficiency and insufficiency is reported to be high in thalassemic patients in many countries despite the presence of good sunshine and routine prescription of 400-1,000 IU vitamin D per day. The risk of vitamin D deficiency in thalassemia and its relation to bone disease; including osteoporosis, rickets, scoliosis, spinal deformities and fractures as well as to cardiac dysfunction is discussed in this mini-review. Monitoring and maintaining normal serum level of 25-OH vitamin D through oral intake of vitamin D and early correction of VDD by oral or parental use of vitamin D may significantly improve bone mineral accretion and ameliorate cardiac function.
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Lee JH, Park JH, Ha TS, Han HS. Refractory rickets caused by mild distal renal tubular acidosis. Ann Pediatr Endocrinol Metab 2013; 18:152-5. [PMID: 24904870 PMCID: PMC4027071 DOI: 10.6065/apem.2013.18.3.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/24/2013] [Accepted: 09/25/2013] [Indexed: 12/04/2022] Open
Abstract
Type I (distal) renal tubular acidosis (RTA) is a disorder associated with the failure to excrete hydrogen ions from the distal renal tubule. It is characterized by hyperchloremic metabolic acidosis, an abnormal increase in urine pH, reduced urinary excretion of ammonium and bicarbonate ions, and mild deterioration in renal function. Hypercalciuria is common in distal RTA because of bone resorption, which increases as a buffer against metabolic acidosis. This can result in intractable rickets. We describe a case of distal RTA with nephrocalcinosis during follow-up of rickets in a patient who presented with clinical manifestations of short stature, failure to thrive, recurrent vomiting, dehydration, and irritability.
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Affiliation(s)
- Ji-Ho Lee
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joo Hyun Park
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Tae-Sun Ha
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Heon-Seok Han
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Affiliation(s)
- Ashraf Soliman
- Department of Pediatrics and Endocrinology, Hamad Medical Center, Doha, Qatar
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and B.R.I.D.E, Karnal, India
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Choi YJ, Kim MK, Jeong SJ. Vitamin D deficiency in infants aged 1 to 6 months. KOREAN JOURNAL OF PEDIATRICS 2013; 56:205-10. [PMID: 23741234 PMCID: PMC3668201 DOI: 10.3345/kjp.2013.56.5.205] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 12/07/2012] [Accepted: 01/25/2013] [Indexed: 12/04/2022]
Abstract
Purpose The aim of this study was to recognize the state of vitamin D among healthy infants aged 1 to 6 months in South Korea, and also to identify the risk factors affecting the level of vitamin D. Methods A total of 117 infants were enrolled in this study for 12 months, from March 1, 2011 to February 29, 2012. Serum levels of 25-hydroxyvitamin D (25[OH]D), calcium, phosphorus, and alkaline phosphatase were measured and data including birth weight, body weight, sex, feeding pattern, delivery mode, siblings and maternal age and occupation were collected. Data was mainly analyzed with independent t-test model. Results We determined that the prevalence of vitamin D deficiency (serum 25[OH]D<20 ng/mL [50 mmol/L]) was 48.7% in the population investigated. Particularly in breastfed infants, the prevalence of vitamin D deficiency was strikingly high (90.4%). The mean serum level of 25(OH)D in breastfed infants was lower than that of formula fed infants (9.35 ng/mL vs. 28.79 ng/mL). Also female infants showed lower mean serum level of 25(OH)D than male. Mean serum values of calcium and phosphorus had positive correlation with vitamin D state (P<0.001). Conclusion Vitamin D deficiency was found to be very common in infants aged 1 to 6 months in South Korea, and breast feeding was the most critical risk factor of vitamin D deficiency. Therefore we suggest to start vitamin D supplementation in South Korea, as soon as possible, to all infants, including breastfed and female infants.
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Affiliation(s)
- You Jin Choi
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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23
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Winzenberg T, Jones G. Vitamin D and bone health in childhood and adolescence. Calcif Tissue Int 2013; 92:140-50. [PMID: 22710658 DOI: 10.1007/s00223-012-9615-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 05/03/2012] [Indexed: 10/28/2022]
Abstract
Vitamin D plays a key role in bone metabolism. The link between vitamin D deficiency and rickets is well understood. However, subclinical vitamin D deficiency may also be detrimental to bone health in childhood. Its effects on bone mineralization have the potential to result in lower peak bone mass being attained, which could in turn contribute to increased fracture risk in both childhood and older adult life. As vitamin D deficiency is common globally, any detrimental effects of vitamin D deficiency on bone health are likely to have substantial public health implications. This review describes the current literature relevant to vitamin D and bone health in childhood and adolescence, with a particular emphasis on evaluating the emerging evidence for the impact of subclinical vitamin D deficiency on bone health and the effectiveness of vitamin D supplementation. The evidence suggests that subclinical vitamin D deficiency does affect bone acquisition, potentially beginning in utero and extending into adolescence. However, the effectiveness of vitamin D supplementation for improving bone health in situations of subclinical deficiency remains unclear, particularly in early life where there are few trials with bone density outcomes. The available evidence suggests that benefits are likely to be greatest in or even restricted to children with serum 25-hydroxyvitamin D levels at least below 50 nmol/L and possibly even lower than this. Trials of sufficient duration in deficient pregnant mothers, infants, and children are urgently required to address critical evidence gaps.
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Affiliation(s)
- T Winzenberg
- Menzies Research Institute Tasmania, Private Bag 23, Hobart, TAS, 7000, Australia.
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Marshall I, Mehta R, Petrova A. Vitamin D in the maternal-fetal-neonatal interface: clinical implications and requirements for supplementation. J Matern Fetal Neonatal Med 2012; 26:633-8. [PMID: 23131182 DOI: 10.3109/14767058.2012.746306] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Identification of the current evidence regarding the pathophysiological and clinical facets of vitamin D in the maternal-fetal-neonatal interface is of value because of the significance of the vitamin D endocrine system in human health and high prevalence of vitamin D deficiency in mothers and their infants. Although many questions have still not been answered by the existing literature, we found evidence that: (i) during pregnancy vitamin D participates in fetal skeletal mineralization and growth, (ii) neonatal vitamin D levels are dependent on the maternal vitamin D status at delivery, (iii) a vitamin D sufficient status at birth may decrease the risk for the development of asthma and type 1 diabetes mellitus in later life, (iv) recommendations for maintaining serum 25-hydroxyvitamin D [25(OH)D] levels ≥32 ng/mL to avoid secondary hyperparathyroidism in adults have not been applied to mothers and their infants, (v) American Academy of Pediatrics recommended supplementation of 400 IU of vitamin D per day is sufficient only for infants who are born with normal vitamin D levels and (vii) supplementation of lactating mothers with high doses of vitamin D (4000 IU/d) allows the achievement of optimal 25(OH)D concentrations (>32 ng/mL) in the maternal and infant serum without any risk of hypervitaminosis D in the mother. We believe that inconsistency in the recognition of sufficient levels of vitamin D in mothers and their infants affects the identification of adequate doses for vitamin D supplementation during pregnancy, lactation and infancy.
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Affiliation(s)
- Ian Marshall
- Department of Pediatrics, UMDNJ/Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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Rajah J, Haq A, Pettifor JM. Vitamin D and calcium status in urban children attending an ambulatory clinic service in the United Arab Emirates. DERMATO-ENDOCRINOLOGY 2012; 4:39-43. [PMID: 22870351 PMCID: PMC3408991 DOI: 10.4161/derm.18250] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Maintaining a normal vitamin D status is important for both skeletal and extra-skeletal health. Recent data show that vitamin D deficiency is endemic in women residing in the Arabian Gulf and is common in pregnant women and their newborns. The purpose of this study was to establish the vitamin D and calcium status of children in an urban ambulatory pediatric clinic in Abu Dhabi to determine for the prevalence of vitamin D deficiency in this cohort. Methods: Patients were recruited prospectively from the pediatric outpatient clinic visits, if they were having blood taken for laboratory investigations other than those related to vitamin D and calcium status. The vitamin D status was compared between 4 age groups (0–0.9 y, 1–1.9 y, 2–7.9 y and 8 -14 y) using the following definitions: deficiency < 25 nmol/l, insufficiency 25–50 nmol/l and sufficiency > 50 nmol/l. Results: A total of 183 children were included in the study. The percentage of females and males in the deficient range was 21% and 16% respectively, while 32% and 46% of females and males respectively were vitamin D sufficient. The highest prevalence of vitamin D deficiency occurred in the 8–14 y old age group with 31.2% being deficient. Conclusions: The study highlights that in an ambulatory pediatric clinic population, peri-pubescent children are most at risk of vitamin D deficiency. This age group is often not considered in the discussion for the need for vitamin D supplementation. Serious consideration should be given to including vitamin D supplementation in a school public health program in the UAE.
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Dittmer K. It’s not just bones anymore: The new and exciting world of vitamin D. Vet J 2012; 194:5-6. [DOI: 10.1016/j.tvjl.2012.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 07/22/2012] [Indexed: 10/28/2022]
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Vitamin D and calcium status in South African adolescents with alcohol use disorders. Nutrients 2012; 4:1076-94. [PMID: 23016133 PMCID: PMC3448088 DOI: 10.3390/nu4081076] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/05/2012] [Accepted: 07/24/2012] [Indexed: 01/06/2023] Open
Abstract
Adequate vitamin D and calcium are essential for optimal adolescent skeletal development. Adolescent vitamin D insufficiency/deficiency and poor calcium intake have been reported worldwide. Heavy alcohol use impacts negatively on skeletal health, which is concerning since heavy adolescent drinking is a rising public health problem. This study aimed to examine biochemical vitamin D status and dietary intakes of calcium and vitamin D in 12-16 year-old adolescents with alcohol use disorders (AUD), but without co-morbid substance use disorders, compared to adolescents without AUD. Substance use, serum 25-hydroxyvitamin D (s-25(OH)D) concentrations, energy, calcium and vitamin D intakes were assessed in heavy drinkers (meeting DSM-IV criteria for AUD) (n = 81) and in light/non-drinkers without AUD (non-AUD) (n = 81), matched for age, gender, language, socio-economic status and education. Lifetime alcohol dose was orders of magnitude higher in AUD adolescents compared to non-AUD adolescents. AUD adolescents had a binge drinking pattern and "weekends-only" style of alcohol consumption. Significantly lower (p = 0.038) s-25(OH)D (adjusted for gender, smoking, vitamin D intake) were evident in AUD adolescents compared to non-AUD adolescents. High levels of vitamin D insufficiency/deficiency (s-25(OH)D < 29.9 ng/mL) were prevalent in both groups, but was significantly higher (p = 0.013) in the AUD group (90%) compared to the non-AUD group (70%). All participants were at risk of inadequate calcium and vitamin D intakes (Estimated Average Requirement cut-point method). Both groups were at risk of inadequate calcium intake and had poor biochemical vitamin D status, with binge drinking potentially increasing the risk of the latter. This may have negative implications for peak bone mass accrual and future osteoporosis risk, particularly with protracted binge drinking.
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Griffin AC, Kern MJ, Kirkwood KL. MKP-1 is essential for canonical vitamin D-induced signaling through nuclear import and regulates RANKL expression and function. Mol Endocrinol 2012; 26:1682-93. [PMID: 22899855 DOI: 10.1210/me.2012-1033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vitamin D(3,) and its most active form, 1,25(OH)(2)D(3), are well known to stimulate osteoclastogenesis through stromal cell induction of the receptor activator of nuclear factor-κB ligand (RANKL). MAPK phosphatase-1 (MKP-1) is a phosphatase classically known to negatively regulate the innate immune response through dephosphorylation of p38, ERK, and c-Jun N-terminal kinase activity. This paper describes a new function of MKP-1 in permitting genomic 1,25(OH)(2)D(3) signaling and downstream osteoclastogenesis through RANKL. Initially, quantitative RT-PCR (qRT-PCR) and immunoblot analysis comparing bone marrow stromal cells (BMSC) revealed that 1,25(OH)(2)D(3)-induced vitamin D receptor (VDR), cytochrome P 45024a1, and RANKL mRNA expression and protein were significantly attenuated or absent in MKP-1(-/-) BMSC. Immunoblot analysis from cellular fractions of wild type and MKP-1(-/-) BMSC stimulated with 10(-7) m 1,25(OH)(2)D(3) revealed retinoid X receptor (RXR)α nuclear import was impaired in MKP-1(-/-) BMSC, whereas VDR import was not. Proximity ligation assays revealed that baseline VDR-RXRα heterodimer translocation was unchanged, yet 1,25(OH)(2)D(3)-induced nuclear translocation of VDR-RXRα heterodimers was reduced in MKP-1(-/-) BMSC. A functional consequence was observed as BMSC from MKP-1(-/-) mice treated with 1,25(OH)(2)D(3) and cocultured with RAW 264.7 cells had a 91% decrease in osteoclastogenesis and a 94.5% decrease in mineralized matrix resorption compared with wild-type cocultures (P < 0.01). These results reveal an unexpected, permissive role for MKP-1 in canonical 1,25(OH)(2)D(3) signaling via VDR-RXRα heterodimer nuclear import and downstream osteoclastogenesis through stromal cell RANKL expression.
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Affiliation(s)
- Alfred C Griffin
- Department of Craniofacial Biology, Medical University of South Carolina, Charleston, 173 Ashley Avenue, BSB 449, Charleston, South Carolina 29425, USA
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Abstract
• Based on strong research evidence, all infants should receive 400 IU/day of vitamin D beginning in the first few days of age to prevent vitamin D deficiency and rickets. • Based on strong research evidence, children and adolescents age >1 year may require as much as 600IU/day of vitamin D. • Based on strong research evidence, all newborns should receive 1 mg of vitamin K at birth to prevent vitamin K deficiency bleeding. • Based on strong research evidence, preconceptional and pregnant women should be supplemented with folate to decrease the likelihood of neural tube defects.
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Affiliation(s)
- Bryon Lauer
- Drexel University College of Medicine, St Christopher's Hospital for Children, Philadelphia, PA, USA
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30
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Thandrayen K, Pettifor JM. Maternal vitamin D status: implications for the development of infantile nutritional rickets. Rheum Dis Clin North Am 2012; 38:61-79. [PMID: 22525843 DOI: 10.1016/j.rdc.2012.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The mother is the major source of circulating 25-OHD concentrations in the young infant. Thus maternal vitamin D status is an important factor in determining the vitamin D status of the infant and their risk of developing vitamin D deficiency and infantile nutritional rickets. As a result, breastfed infants of mothers with vitamin D deficiency who are unsupplemented and who receive little sunlight exposure are at high risk of developing vitamin D deficiency or rickets. Despite food fortification policies in many countries and recommendations for vitamin D supplementation of at-risk groups, vitamin D deficiency and infantile rickets remain major public health challenges in many developed and developing countries. There is evidence that the current supplementation recommendations, particularly for pregnant and lactating women, are inadequate to ensure vitamin D sufficiency in these groups. A widespread and concerted effort is needed to ensure daily supplementation of breastfed and other infants at high risk with vitamin D 400 IU from birth and pregnant women in high risk communities with at least 600 IU; awareness needs to be developed among the public and medical practitioners of the urgent need to improve the vitamin D status of pregnant and lactating mothers and their infants. Further studies are required to determine the optimal doses of vitamin D supplementation in pregnancy and during lactation, and for normalizing vitamin D stores in infancy to reduce the prevalence of infantile nutritional rickets. Operational research studies also need to be conducted to understand the best methods of implementing supplementation programs and the factors that are likely to impede their success.
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Affiliation(s)
- Kebashni Thandrayen
- MRC Developmental Pathways for Health Research Unit, Deptartment of Pediatrics, Chris Hani Baragwanath Hospital, PO Bertsham, Johannesburg 2013, South Africa.
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Vanstone MB, Oberfield SE, Shader L, Ardeshirpour L, Carpenter TO. Hypercalcemia in children receiving pharmacologic doses of vitamin D. Pediatrics 2012; 129:e1060-3. [PMID: 22412034 PMCID: PMC8194455 DOI: 10.1542/peds.2011-1663] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Vitamin D deficiency causes rickets, requiring vitamin D at doses greater than daily dietary intake. Several treatment regimens are found in the literature, with wide dosing ranges, inconsistent monitoring schedules, and lack of age-specific guidelines. We describe 3 children, ages 2 weeks to 2 and 9/12 years, who recently presented to our institution with hypercalcemia and hypervitaminosis D (25-hydroxyvitamin D levels >75 ng/mL), associated with treatment of documented or suspected vitamin D-deficient rickets. The doses of vitamin D used were within accepted guidelines and believed to be safe. The patients required between 6 weeks and 6 months to correct the elevated serum calcium, with time to resolution of hypercalcemia related to age and peak serum calcium, but not to peak 25-hydroxyvitamin D level. With recent widespread use of vitamin D in larger dosages in the general population, we provide evidence that care must be taken when using pharmacologic dosing in small children. With limited dosing guidelines available on a per weight basis, the administration of dosages to infants that are often used in older children and adults has toxic potential, requiring a cautious approach in dose selection and careful follow-up. Dosage recommendations may need to be reassessed, in particular, where follow-up and monitoring may be compromised.
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Affiliation(s)
- Michelle B. Vanstone
- Department of Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, Connecticut
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Morgan Stanley Children's Hospital of New York, Columbia University Medical Center, New York, New York; and
| | - Laurel Shader
- Fairhaven Community Health Center, New Haven, Connecticut
| | - Laleh Ardeshirpour
- Department of Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, Connecticut
| | - Thomas O. Carpenter
- Department of Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, Connecticut
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Martínez Suárez V, Moreno Villares JM, Dalmau Serra J. [Recommended intake of calcium and vitamin D: positioning of the Nutrition Committee of the AEP]. An Pediatr (Barc) 2012; 77:57.e1-8. [PMID: 22341774 DOI: 10.1016/j.anpedi.2011.11.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 11/23/2011] [Indexed: 11/29/2022] Open
Abstract
Both calcium and vitamin D are essential nutrients with a crucial role in bone health, although in recent years there has been much controversy about the contributions required from both molecules to ensure adequate health. For vitamin D, in a short time, we have seen how it has gone from a recommendation of 400 IU daily, to 200 IU and again to 400 IU, with some statements that not only its influence on skeletal tissue has been taken into account, but also on the development of chronic diseases, which has led to new expectations. Our goal is to provide an update to paediatricians on this issue and propose recommendations for intake in the light of the latest information. For vitamin D the Committee proposes an intake of 400 IU/day in children under 1 year and 600 IU/day after that age.
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Affiliation(s)
- V Martínez Suárez
- Servicio de Salud del Principado de Asturias, Centro de Salud El Llano, Gijón, España
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33
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D'Eufemia P, Parisi P, Celli M, Finocchiaro R, Roggini M, Raccio I, Zambrano A, Villa MP. Vitamin D deficiency rickets in five "at-risk" children. Pediatr Int 2012; 54:152-5. [PMID: 22335329 DOI: 10.1111/j.1442-200x.2011.03408.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Patrizia D'Eufemia
- Department of Pediatrics, First Faculty of Medicine, Sapienza University, Rome, Italy.
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34
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Akman AO, Tumer L, Hasanoglu A, Ilhan M, Caycı B. Frequency of vitamin D insufficiency in healthy children between 1 and 16 years of age in Turkey. Pediatr Int 2011; 53:968-73. [PMID: 21988338 DOI: 10.1111/j.1442-200x.2011.03486.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to establish the frequencies of vitamin D deficiency and insufficiency among healthy children aged 1-16 years and also to determine the factors affecting the levels of vitamin D in Turkey. METHODS A total of 849 healthy individuals whose ages ranged from 1 to 16 years were included in the study. Serum 25(OH)D, calcium, phosphorous and alkaline phosphatase l levels were measured at the end of the winter period. The approximate daily calcium intake was calculated by using a 1-week diet history. RESULTS We determined that the prevalence of vitamin D deficiency (<20 ng/mL) was 8% and that of vitamin D insufficiency (20-29 ng/mL) was 25.5% in the population investigated. The average daily intake of calcium was especially low in the >8-year-old age group (<1300 mg/day). CONCLUSION Vitamin D insufficiency was found to be very common in the population investigated. The daily calcium intake was below the adequate levels especially in school children. Vitamin D supplementation after the first year of life could be beneficial especially for school children and adolescents. The government must develop public policies for the fortification of milk, milk products, and fruit juices with vitamin D.
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Affiliation(s)
- Alkim Oden Akman
- Pediatrics Department, Gazi University Hospital, Ankara, Turkey.
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35
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Perez-Rossello JM, Feldman HA, Kleinman PK, Connolly SA, Fair RA, Myers RM, Gordon CM. Rachitic changes, demineralization, and fracture risk in healthy infants and toddlers with vitamin D deficiency. Radiology 2011; 262:234-41. [PMID: 22106354 DOI: 10.1148/radiol.11110358] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine radiographic findings in children with vitamin D deficiency in comparison with biochemical marker levels and prevalence of fractures. MATERIALS AND METHODS The parents or guardians of all participants provided written informed consent at the time of enrollment. The institutional review board approved the protocol, and HIPAA guidelines were followed. From a prospective sample of children seen for routine clinical care, 40 children with vitamin D deficiency (25-hydroxyvitamin D [25-OHD] level, ≤ 20 ng/mL) were identified, and high-detail computed radiographs of the wrists and knees were obtained. The children ranged in age from 8 to 24 months. Radiographs were scored by three readers with use of the 10-point Thacher score for rachitic changes and a five-point scale for demineralization. Serum calcium, phosphorus, alkaline phosphatase, and parathyroid hormone levels were determined. Fracture history was obtained for 35 of the 40 patients (88%). RESULTS All readers identified rachitic changes at both readings in two patients (5%) and demineralization in two patients (5%). Interrater agreement was 65% for rachitic changes (κ = 0.33) and 70% for demineralization (κ = 0.37). When the majority of the raters determined that rachitic changes were absent at both readings, alkaline phosphatase levels were lower than those with other assessments (median, 267 vs 515 U/L [4.4589 vs 8.6005 μkat/L]; P = .01). When most raters determined that demineralization was present at both readings, serum 25-OHD levels were lower than those at other assessments (median, 9.0 vs 17.5 ng/mL [22.464 vs 43.68 nmol/L]; P = .02). No fractures were reported or identified radiographically. CONCLUSION In infants and toddlers with vitamin D deficiency, rachitic changes and definite demineralization are uncommon and fracture risk is low.
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Liang GY, Qin R, Li J, Liang GX, Guan YJ, Gao ZH. Optimal level of 25-(OH)D in children in Nanjing (32°N Lat) during winter. Pediatr Int 2011; 53:541-5. [PMID: 21159027 DOI: 10.1111/j.1442-200x.2010.03309.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal serum level of 25-hydroxyvitamin D (25-(OH)D) for bone health is still unclear, especially in children. Hypovitaminosis D is also re-emerging in developed and developing countries. The purpose of the present study was therefore to determine optimal serum 25-(OH)D level and preliminarily identify the vitamin D nutritional status in Nanjing children. METHODS All subjects (76 healthy, 66 suffering from infectious diseases) aged 0-10 years were recruited during the period December 2007-March 2008. Venous blood samples were collected before breakfast and the levels of serum 25-(OH)D, parathyroid hormone (PTH), bone-specific alkaline phosphatase (BAP), calcium (Ca), phosphorus (P) were determined. The optimal level of serum 25-(OH)D was explored using the three response curves of 25-(OH)D versus PTH, 25-(OH)D versus BAP, and 25-(OH)D versus Ca×P product. RESULTS For 25-(OH)D ≤ 50 nmol/L, PTH and BAP were both inversely correlated with 25-(OH)D (PTH, r=-0.864, P < 0.01; BAP, r=-0.856, P < 0.01). For 25-(OH)D > 50-60 nmol/L, levels of PTH and BAP remained steady. With regard to the Ca×P product, for 25-(OH)D ≤ 50 nmol/L, Ca×P product increased as 25-(OH)D increased (r= 0.037, P > 0.05). For 25-(OH)D > 50-60 nmol/L, Ca×P product remained steady. The mean serum level of 25-(OH)D was 80.5 ± 29.3 nmol/L (mean ± SD) in the healthy children, and 65.7 ± 32.3 nmol/L in the sick children. CONCLUSION The optimal 25-(OH)D level may be 50-60 nmol/L for bone health in Nanjing children. The vitamin D nutritional status of Nanjing children is relatively good in winter.
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Affiliation(s)
- Guan-Yu Liang
- Department of Child Care, Hexi Branch of First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Agarwal A, Gupta SK, Sukumar R. Hyperparathyroidism and malnutrition with severe vitamin D deficiency. World J Surg 2010; 33:2303-13. [PMID: 19404706 DOI: 10.1007/s00268-009-0044-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vitamin D deficiency and its associated problems are common in developing Asian countries and countries of the Middle East. Various factors, including poor nutritional status and other compounding factors such as dietary, cultural, ethnic, and environmental factors, play a major role in contributing to the poor calcium and vitamin D homeostasis. Vitamin D deficiency is thought to exacerbate signs and symptoms of hyperparathyroidism (HPT). In this overview, we present evidence of the impact of vitamin D and calcium deficiency on primary HPT (PHPT). METHODS We performed an evidence-based review of articles published in the English language between January 1960 and June 2008. RESULTS Level IV evidence suggests widespread calcium and vitamin D deficiency in developing countries (issue 1). Limited level IV evidence suggests malnutrition as a primary cause of calcium and vitamin D deficiency (issue 2). Level IV evidence suggests that calcium and vitamin deficiencies cause secondary HPT and possibly PHPT as well (issues 3 and 4). A literature search revealed only six studies that correlated vitamin D levels with clinical, biochemical, and pathologic features of PHPT (issue 5). These studies provide level IV evidence suggesting that vitamin D deficiency causes some specific clinical features of PHPT as well as exacerbating other features of the disease. CONCLUSIONS In the developing countries, which have severe vitamin D and calcium deficient population, PHPT patients present with advanced disease and particularly severe bone symptoms. There is presently only level IV evidence of vitamin D status affecting the clinical severity of PHPT.
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Affiliation(s)
- Amit Agarwal
- Department of Endocrine Surgery, SGPGIMS, Lucknow 226014, Uttar Pradesh, India.
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38
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Ponnapakkam T, Bradford E, Gensure R. A treatment trial of vitamin D supplementation in breast-fed infants: universal supplementation is not necessary for rickets prevention in Southern Louisiana. Clin Pediatr (Phila) 2010; 49:1053-60. [PMID: 20724336 DOI: 10.1177/0009922810376320] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was conducted to determine if vitamin D supplementation is required to prevent rickets in breast-fed infants. Breast-feeding rates are increasing, and there are concerns about whether the vitamin D content of breast milk is sufficient. There are a few treatment trials of vitamin D supplementation in breast-fed infants; these were conducted in northern climates. The authors therefore performed a prospective clinical trial comparing vitamin D supplementation with placebo as control in southern Louisiana. Blood samples and questionnaires were collected at birth, 2, 4, and 6 months of age. There were no cases of rickets observed, and no differences in alkaline phosphatase levels between groups. Thus, there was no evidence that vitamin D supplementation reduced rickets risk in the authors' study population. This suggests that the current recommendations for universal vitamin D supplementation of breast-fed infants throughout the United States may need to be revised.
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Hill KM, McCabe GP, McCabe LD, Gordon CM, Abrams SA, Weaver CM. An inflection point of serum 25-hydroxyvitamin D for maximal suppression of parathyroid hormone is not evident from multi-site pooled data in children and adolescents. J Nutr 2010; 140:1983-8. [PMID: 20861214 PMCID: PMC2955877 DOI: 10.3945/jn.110.124966] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In adults, maximal suppression of serum parathyroid hormone (PTH) has commonly been used to determine the sufficiency of serum 25-hydroxyvitamin D [25(OH)D]. In children and adolescents, the relationship between serum 25(OH)D and PTH is less clear and most studies reporting a relationship are derived from relatively small samples and homogeneous cohorts. Our objective was to determine the relationship between serum 25(OH)D and PTH in children and adolescents from a large and diverse U.S. cohort and to identify a point of inflection of serum 25(OH)D for maximal suppression of serum PTH. Data from 735 participants, ages 7-18 y, were pooled from 3 study sites located in Indiana, Texas, and Massachusetts. A two-phase linear spline was used to model the relationship between serum 25(OH)D and PTH. The value of serum 25(OH)D for maximal suppression of serum PTH was identified as the inflection point of the spline. Before adjustment for site, the inflection point of serum 25(OH)D for maximal suppression of serum PTH was 92.4 nmol/L (95% CI: 62.2, 130.7). After adjusting for site, the point of inflection was poorly defined and the relationship between serum 25(OH)D and PTH appeared to be linear. The lack of an inflection point of serum 25(OH)D for maximal suppression of PTH brings into question the value of using maximal suppression of serum PTH as a basis for determining optimal serum 25(OH)D for healthy children and adolescents.
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Affiliation(s)
- Kathleen M. Hill
- Department of Foods and Nutrition, Purdue University, West Lafayette, IN 47906
| | - George P. McCabe
- Department of Statistics, Purdue University, West Lafayette, IN 47906
| | - Linda D. McCabe
- Department of Foods and Nutrition, Purdue University, West Lafayette, IN 47906
| | - Catherine M. Gordon
- Divisions of Adolescent Medicine and Endocrinology, Children’s Hospital Boston, Boston, MA 02115
| | - Steven A. Abrams
- Department of Pediatrics, USDA/ARS Children’s Nutrition Research Center, Houston, TX 77030
| | - Connie M. Weaver
- Department of Foods and Nutrition, Purdue University, West Lafayette, IN 47906,To whom correspondence should be addressed. E-mail:
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Blazina S, Bratanic N, Campa AS, Blagus R, Orel R. Bone mineral density and importance of strict gluten-free diet in children and adolescents with celiac disease. Bone 2010; 47:598-603. [PMID: 20601293 DOI: 10.1016/j.bone.2010.06.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 05/23/2010] [Accepted: 06/10/2010] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Low bone mineral density (BMD) is common in children and adolescents with celiac disease. Strict gluten-free diet (GFD) improves bone mineralization, even in 1 year. The effect of occasional gluten intake is not known. The aims of this study were to compare BMD and prevalence of low BMD in children and adolescents on strict and not strict GFD. METHODS We measured BMD in 55 children and adolescents (strict GFD) with negative endomysium antibodies (EMA) in the last 2 years and in 19 (not strict GFD) with positive EMA at the time of the study. Lumbar, left hip and total body BMD were measured by dual-energy X-ray absorptiometry. Four-day weighted dietary protocols were obtained by means of a self-completed questionnaire of total food and beverage intake. Energy and calcium intake were calculated using nutrition data software. EMA, tissue transglutaminase antibodies, serum calcium, phosphate, 25-hydroxy vitamin D, intact parathormone, albumin, urea and creatinine levels were determined in all patients. RESULTS BMD in patients on strict GFD was significantly higher than in patients on not strict GFD (lumbar p=0.01; total body p=0.005). There were significantly more patients with total body BMD below -1.0 in not strictly compliant group (71% compared to 38%; p=0.03). Calcium intake and vitamin D levels were below recommendations in both groups. CONCLUSION Children and adolescents on not strict GFD are at increased risk for low BMD. We therefore recommend that BMD should be evaluated in patients with positive EMA. In addition, patients on strict GFD are at risk for low BMD because of low calcium intake or vitamin D deficiency. Therefore, strict GFD with recommended calcium intake and vitamin D supplementation during winter and spring should be encouraged in all children and adolescents with celiac disease.
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Affiliation(s)
- Stefan Blazina
- University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana, Slovenia.
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41
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Dittmer KE, Thompson KG. Vitamin D metabolism and rickets in domestic animals: a review. Vet Pathol 2010; 48:389-407. [PMID: 20634407 DOI: 10.1177/0300985810375240] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Rickets and osteomalacia are increasing in prevalence in people because of cultural practices, breast-feeding, decreased sun exposure, and increased sunscreen usage. Several hereditary forms of rickets owing to either renal phosphate wasting or defects in vitamin D metabolism are also reported in people. Rickets is well recognized in domestic animals, but published reports are not always supported by microscopic findings, and diagnoses based on clinical signs and radiology are unreliable. Most cases in domestic animals are caused by dietary deficiency of either vitamin D or phosphorus, but occasional inherited forms are reported in pigs, sheep, cats, and dogs. There is variation between species in susceptibility to dietary vitamin D and phosphorus deficiency and in the ability to manufacture vitamin D in their skin. A number of mouse models have been discovered or created to study human skeletal diseases and skeletal homeostasis. With the discovery that vitamin D is involved in not only calcium and phosphorus homeostasis but also in the immune system and cancer, there is great potential for new and existing animal models to generate valuable information about vitamin D and its many functions. This review presents an overview of vitamin D metabolism and rickets in domestic and laboratory animals and makes comparisons where appropriate with the disease in humans.
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Affiliation(s)
- K E Dittmer
- Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Palmerston North, New Zealand.
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Thandrayen K, Pettifor JM. Maternal vitamin D status: implications for the development of infantile nutritional rickets. Endocrinol Metab Clin North Am 2010; 39:303-20, table of contents. [PMID: 20511053 DOI: 10.1016/j.ecl.2010.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The mother is the major source of circulating 25-hydroxyvitamin D concentration in the young infant. Maternal vitamin D status is an important factor in determining the vitamin D status of the infant and their risk of developing vitamin D deficiency and infantile nutritional rickets. There is evidence that the current supplementation recommendations, particularly for pregnant and lactating women, are inadequate to ensure vitamin D sufficiency in these groups. A widespread and concerted effort is needed to ensure daily supplementation of breastfed and other infants at high risk with vitamin D 400 IU from birth and of pregnant women in high-risk communities with 2000 IU. Future studies are required to determine the optimal doses of vitamin D supplementation in pregnancy and during lactation, and for normalizing vitamin D stores in infancy to reduce the prevalence of infantile nutritional rickets. Operational research studies are needed to understand the best methods of implementing supplementation programs and the factors that are likely to impede their success.
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Affiliation(s)
- Kebashni Thandrayen
- MRC Mineral Metabolism Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Soliman AT, El-Dabbagh M, Adel A, Al Ali M, Aziz Bedair EM, Elalaily RK. Clinical responses to a mega-dose of vitamin D3 in infants and toddlers with vitamin D deficiency rickets. J Trop Pediatr 2010; 56:19-26. [PMID: 19506025 DOI: 10.1093/tropej/fmp040] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Was to investigate the effect of treatment with an IM injection, a mega dose of vitamin D3 (10,000 IU/kg) on the clinical, biochemical and radiological parameters of 40 rachitic children with vitamin D deficiency (VDD) over a period of 3 months. DESIGN In this prospective study we evaluated the clinical, biochemical and radiological responses of an IM injection of cholecalciferol (10,000 IU/kg) for 3 months. RESULTS At presentation, the most frequent manifestations were enlarged wrist joints, hypotonia, irritability, cranial bossing, wide anterior fontanel, bow legs, delayed teething and walking and Harrison's sulcus with chest rosaries. Short stature (length SDS < -2) was recorded in 30% of patients. Craniotabes and hypocalcemic tetany were the least common presentations. In VDD children the most frequent biochemical abnormality was high alkaline phosphatase (ALP) (100%), followed by low phosphate (PO(4)) (75%) and low calcium (Ca) (12.5%). One month after treatment, serum Ca, PO(4) and 25(OH)D concentrations were normal. Three months after the injection, serum level of ALP and parathormone (PTH) decreased to normal. The majority of patients (87.5%) had serum 25(OH)D level >or= 20 ng/ml, but some (12.5%) had level <20 ng/ml. Hypercalcemia was not recorded in any patient during the 3-month-period. Significant cure of all symptoms and signs related to vitamin D deficiency had been achieved in all children. Leg bowing showed significant improvement in all patients but was still evident in one third. Complete healing of the radiological evidence of rickets was achieved in 95% of all children. CONCLUSION An IM injection of a mega dose of cholecalciferol is a safe and effective therapy for treatment of VDD rickets in infants and toddlers with normalization of all the biochemical parameters and healing of radiological manifestations. Measurement of serum 25(OH)D level is highly recommended in all short children with a clear need for a general vitamin D supplementation for all infants and young children in Qatar.
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Affiliation(s)
- Ashraf T Soliman
- Division of Pediatric Endocrinology, Hamad Medical Centre, Doha, Qatar.
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Pérez-López FR, Pérez-Roncero G, López-Baena MT. Vitamin D and adolescent health. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2010; 1:1-8. [PMID: 28028383 PMCID: PMC5175574 DOI: 10.2147/ahmt.s7472] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Vitamin D is a hormone sequentially produced at different body sites, and which plays a significant role in human health, particularly bone health. However, other roles are emerging. When the serum concentration of vitamin D is very low, the risk of rickets, osteomalacia and osteoporosis is increased. In children and adolescents there is a high prevalence of low vitamin D status, especially in females and during the winter–the prevalence being lower than during the summer. Although there is no unanimous agreement over the minimum values necessary for good health, serum 25-hydroxyvitamin D [25(OH)D] levels below 20 ng/mL may be regarded as a vitamin D-deficient condition, and levels between 20–30 ng/mL may be the range of vitamin D insufficiency. Mild low levels have been associated with bone mass accrual alterations in children and adolescents, diminished muscle strength, negative cardiovascular outcomes, insulin resistance and obesity, and neurological disorders. Effective preventive strategies are needed to guarantee adequate vitamin D levels throughout childhood and adolescence, taking into account the geographical setting, season of the year, the level of environmental pollution, skin characteristics, eating habits and body weight, with a view to securing optimum health during these phases, and the prevention of complications in adulthood. There needs to be a renewed appreciation of the beneficial effect of moderate sunlight for providing all humans with the vitamin D needed for ensuring good health. Prolonged sun exposure is not advised, however, due to the risk of skin cancer. In addition, a balanced diet is indicated, since vitamin D-rich foods are better assimilated than supplements. When such conditions cannot be met, then the supplementation of 400 IU/day of vitamin D is advised in children and adolescents–though correcting vitamin D insufficiency or deficiency may require 1000 IU/day or more. High-dose calcifediol depots are an alternative for guaranteeing treatment adherence and in patients with liver disease.
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Affiliation(s)
- Faustino R Pérez-López
- Grupo de Investigación sobre Salud de la Mujer en Aragón (GRISAMAR), Universidad de Zaragoza, Hospital Clínico Zaragoza, Spain
| | - Gonzalo Pérez-Roncero
- Grupo de Investigación sobre Salud de la Mujer en Aragón (GRISAMAR), Universidad de Zaragoza, Hospital Clínico Zaragoza, Spain
| | - María T López-Baena
- Grupo de Investigación sobre Salud de la Mujer en Aragón (GRISAMAR), Universidad de Zaragoza, Hospital Clínico Zaragoza, Spain
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45
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Abstract
Vitamin D deficiency is the most common cause of rickets mainly in breast-fed dark-skinned, African or Asian children receiving inadequate sunlight exposure. We report a case of a 1.5 year-old Afro-Italian male infant living in South Italy who came to our observation with the typical clinical picture of vitamin D deficiency rickets. The child was exclusively breast-fed for 8 months without vitamin D supplements. Owing to the rarity of vitamin D deficiency rickets in the South of Italy he underwent several investigations, which demonstrated the association with an abdominal ganglioneuroblastoma. To our knowledge, ganglioneuroblastoma has never been reported in association with vitamin D deficiency rickets. Although the association between these 2 rare conditions may be coincidental, the protective action of vitamin D against cancer suggests that vitamin D deficiency might have contributed to the development of ganglioneuroblastoma in our patient.
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Abstract
Abstract Vitamin D has emerged from obscurity, and its effects on various organ systems throughout the body down to the cellular level are being discovered. What was once thought to be a simple hormone affecting only bone and calcium metabolism has shifted. We no longer see vitamin D as a "vitamin" important only in childhood, but as a complex hormone that is involved not only in calcium homeostasis but also in the integrity of the innate immune system. Vitamin D deficiency is linked to inflammatory and long-latency diseases such as multiple sclerosis, rheumatoid arthritis, tuberculosis, diabetes, and various cancers, to name a few. In this review, we trace how we came to view vitamin D and how that view led to one of the largest epidemics of nutrient deficiency beginning in the late 20(th) century. We then discuss the needs of vitamin D in the context of the breastfeeding mother and her infant and child, why breastfed infants are particularly at risk, and what to do about it.
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Affiliation(s)
- Carol L Wagner
- Department of Pediatrics, Pediatric Nutritional Research Center, Darby Children's Research Institute, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 2008; 122:1142-52. [PMID: 18977996 DOI: 10.1542/peds.2008-1862] [Citation(s) in RCA: 924] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continues to be reported in the United States. There are also concerns for vitamin D deficiency in older children and adolescents. Because there are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase the risk of skin cancer, the recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed and older children and adolescents. It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. The current recommendation replaces the previous recommendation of a minimum daily intake of 200 IU/day of vitamin D supplementation beginning in the first 2 months after birth and continuing through adolescence. These revised guidelines for vitamin D intake for healthy infants, children, and adolescents are based on evidence from new clinical trials and the historical precedence of safely giving 400 IU of vitamin D per day in the pediatric and adolescent population. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer. The new data may eventually refine what constitutes vitamin D sufficiency or deficiency.
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Fischer PR, Thacher TD, Pettifor JM. Pediatric vitamin D and calcium nutrition in developing countries. Rev Endocr Metab Disord 2008; 9:181-92. [PMID: 18604643 DOI: 10.1007/s11154-008-9085-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 06/10/2008] [Indexed: 01/10/2023]
Abstract
Over one billion humans have insufficient circulating levels of vitamin D, and dietary insufficiency of calcium is common in developing countries. Worldwide, nutritional rickets is considered to be the most common non-communicable disease of children. Rickets can be due either to primary deficiencies of vitamin D or calcium or to combined deficiencies of both elements. Vitamin D deficiency is also increasingly linked to non-skeletal complications. Even without laboratory and radiologic resources, the diagnosis of rickets is considered clinically when a child presents with limb deformities and has beaded ribs and widened wrists and ankles. Prevention is possible through increased sun exposure and dietary enhancement. Treatment of nutritional rickets involves provision of adequate vitamin D and calcium. Further research is needed to elucidate the precise epidemiology of vitamin D and calcium deficiencies in developing countries, to determine the roles of additional pathologic factors contributing to the development and morbidity of rickets, to improve affordable and feasible means of diagnosing rickets in resource-limited areas, to better target at-risk populations for preventive interventions, to identify accurate dosing and delivery of therapeutic interventions, and to evaluate the long-term consequences of vitamin D and calcium deficiencies in childhood.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Pitukcheewanont P, Numbenjapon N, Costin G. Ectopic thymic parathyroid adenoma and vitamin D deficiency rickets: a 5-year-follow-up case report and review of literature. Bone 2008; 42:819-24. [PMID: 18242158 DOI: 10.1016/j.bone.2007.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 09/27/2007] [Accepted: 10/04/2007] [Indexed: 11/22/2022]
Abstract
Sixteen patients with primary hyperparathyroidism presenting as rickets have so far been reported in the English literature. However, no report of an ectopic thymic parathyroid adenoma presenting as rickets has been published. We report a 14-year-old Caucasian American, wheelchair-ridden male who presented with signs and symptoms suggestive of vitamin D deficiency rickets subsequently confirmed by laboratory and radiological findings. Following the intramuscular administration of 125,000 U ergocalciferol (vitamin D2), he developed hypercalcemia with persistently elevated parathyroid hormone (PTH) levels suggestive of primary hyperparathyroidism. Sestamibi scan demonstrated significant uptake in the superior chest, without uptake at the normal parathyroid glands location. Surgical exploration revealed normal parathyroid glands and a thymic mass, which was removed and confirmed by pathology to be a parathyroid adenoma. With subsequent oral ergocalciferol solution and calcium carbonate therapies, the patient's symptoms resolved, blood chemistries normalized, and radiological evidence of rickets significantly improved. To our knowledge, this is the first case of an ectopic thymic parathyroid adenoma in a patient presenting with rickets. Our patient demonstrates that hyperparathyroidism-induced hypercalcemia may be masked by severe vitamin D deficiency. Prolonged treatment with ergocalciferol after removal of the parathyroid adenoma was necessary to normalize iPTH and replenish vitamin D store.
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Affiliation(s)
- Pisit Pitukcheewanont
- The Center for Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard MS #61, Los Angeles, CA 90027, USA.
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Abstract
BACKGROUND Nutritional rickets is a disease of growing children leading to bone deformities, bone pain, convulsions or delayed motor development. Today, high-incidence of nutritional rickets is mainly found in low-income countries. OBJECTIVES To assess the effects of various interventions on the prevention of nutritional rickets in term born children. SEARCH STRATEGY Studies were obtained from computerised searches of The Cochrane Library, MEDLINE, EMBASE, LILACS and reference lists of relevant articles. We contacted authors of studies or reviews to obtain further studies. SELECTION CRITERIA Studies were included if they were randomised controlled clinical trials, controlled clinical trials or prospective cohort studies comparing any intervention for the prevention of nutritional rickets in term born children with placebo or no intervention. Minimum duration of the intervention was three months for children under 12 months or six months for children over 12 months. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study quality. Authors of studies were contacted to obtain missing information. MAIN RESULTS Four studies enrolled approximately 1700 participants. Trials lasted between nine months to two years. Three studies were randomised controlled trials, two of which showed a cluster randomised design; one trial probably was a controlled trial with researcher controlled group assignment. In children up to three years of age in Turkey, Vitamin D compared to no intervention showed a relative risk of 0.04 (95% confidence interval (CI) 0 to 0.71). Despite a marked non-compliance, a Chinese trial in children up to three years of age comparing a combined intervention of supplementation of vitamin D, calcium and nutritional counseling showed a relative risk of 0.76 (95% CI 0.61 to 0.95) compared to no intervention. In two studies conducted in older children in China and in France no rickets occurred in both the intervention and control group. AUTHORS' CONCLUSIONS There a only few studies on the prevention of nutritional rickets in term born children. Until new data become available, it appears sound to offer preventive measures (vitamin D or calcium) to groups of high risk, like infants and toddlers; children living in Africa, Asia or the Middle East or migrated children from these regions into areas where rickets is not frequent. Due to a marked clinical heterogeneity and the scarcity of data, the main and adverse effects of preventive measures against nutritional rickets should be investigated in different countries, different age groups and in children of different ethnic origin.
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Affiliation(s)
- C Lerch
- Universitaetsklinikum Duesseldorf, Heinrich-Heine University, Department of General Practice, Metabolic and Endocrine Disorders Group, Moorenstr. 5, Duesseldorf, Germany, 40225.
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