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Reid CG, Graham R. A Case of Rickets and Pediatric Iron Deficiency Anemia in Alabama. Cureus 2024; 16:e60140. [PMID: 38864063 PMCID: PMC11165436 DOI: 10.7759/cureus.60140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024] Open
Abstract
A 15-month-old African American male patient presented to the pediatric clinic to establish care. The patient had been seen and treated by a previous pediatrician who had diagnosed him with failure to thrive, anemia, and hepatosplenomegaly, according to the patient's parents. Upon physical examination, the patient was determined to be less than the first percentile for height and in the eighth percentile for weight. Frontal bossing was also observed. The patient's hemoglobin level was measured in the office to help confirm the previous anemia diagnosis and was determined to be 6.3 g/dL (normal: 10.5-13.0 g/dL). At this point, the patient was sent to a pediatric emergency department for continued treatment and workup. At the emergency department, the patient received an extensive laboratory workup for the evaluation of anemia, revealing iron deficiency anemia (hemoglobin: 5.6 g/dL (normal: 10.5-13 g/dL), mean corpuscular volume: 51.4 fl (normal: 70-84 fl), iron: 18 mcg/dL (normal: 30-70 mcg/dL), total iron binding capacity: 598 mcg/dL (normal: 100-400 mcg/dL), and hematocrit: 23.7% (normal: 33-38%)) and decreased levels of vitamin D (<6 ng/mL, normal: >30 ng/mL), ionized calcium (1.17 mg/dL, normal: 4.4-5.2 mg/dL), and phosphorus (2.4 mg/dL, normal: 2.9-5.9 mg/dL). These studies, paired with X-ray images of the patient's shoulders and wrists, further confirmed the diagnosis of rickets. Rickets is a disease in pediatric patients defined as a condition in which the mineralization of epiphyseal plates is defective. A nutritional deficiency in vitamin D, calcium, or phosphate causes acquired rickets. This condition is most commonly found in developing countries; some predisposing factors include poor sun exposure, high altitude, and breastfeeding. The patient was seen in the outpatient pediatric setting after the hospitalization, in which he received a blood transfusion, where he was managed on supplementation of calcium carbonate suspension, polysaccharide iron complex/novaferrum drops, and cholecalciferol drops with referral to endocrinology, hematology, and dietetics. This case serves as an example of how the diagnosis of nutritional deficiencies, such as rickets, can also be found in developed countries like the United States. Other conditions considered in the differential diagnosis were cystic fibrosis, necrotizing enterocolitis, metabolic disorders, inadequate absorption, and mechanical feeding difficulties, each of which must be ruled out to ensure that even an unlikely finding was not missed.
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Affiliation(s)
- Claudia G Reid
- Pediatrics, Edward Via College of Osteopathic Medicine, Auburn, USA
| | - Rhonda Graham
- Pediatrics, Edward Via College of Osteopathic Medicine, Huntsville, USA
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Rios-Leyvraz M, Thacher TD, Dabas A, Elsedfy HH, Baroncelli GI, Cashman KD. Serum 25-hydroxyvitamin D threshold and risk of rickets in young children: a systematic review and individual participant data meta-analysis to inform the development of dietary requirements for vitamin D. Eur J Nutr 2024; 63:673-695. [PMID: 38280944 PMCID: PMC10948504 DOI: 10.1007/s00394-023-03299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/28/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE The objective of this systematic review was to determine a minimum serum 25-hydroxyvitamin D (25OHD) threshold based on the risk of having rickets in young children. This work was commissioned by the WHO and FAO within the framework of the update of the vitamin D requirements for children 0-3 years old. METHODS A systematic search of Embase was conducted to identify studies involving children below 4 years of age with serum 25OHD levels and radiologically confirmed rickets, without any restriction related to the geographical location or language. Study-level and individual participant data (IPD)-level random effects multi-level meta-analyses were conducted. The odds, sensitivity and specificity for rickets at different serum 25OHD thresholds were calculated for all children as well as for children with adequate calcium intakes only. RESULTS A total of 120 studies with 5412 participants were included. At the study-level, children with rickets had a mean serum 25OHD of 23 nmol/L (95% CI 19-27). At the IPD level, children with rickets had a median and mean serum 25OHD of 23 and 29 nmol/L, respectively. More than half (55%) of the children with rickets had serum 25OHD below 25 nmol/L, 62% below 30 nmol/L, and 79% below 40 nmol/L. Analysis of odds, sensitivities and specificities for nutritional rickets at different serum 25OHD thresholds suggested a minimal risk threshold of around 28 nmol/L for children with adequate calcium intakes and 40 nmol/L for children with low calcium intakes. CONCLUSION This systematic review and IPD meta-analysis suggests that from a public health perspective and to inform the development of dietary requirements for vitamin D, a minimum serum 25OHD threshold of around 28 nmol/L and above would represent a low risk of nutritional rickets for the majority of children with an adequate calcium intake.
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Affiliation(s)
- Magali Rios-Leyvraz
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland.
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aashima Dabas
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | | | - Giampiero I Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, and Department of Medicine, University College Cork, Cork, Ireland
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Zhang Y, He TC, Zhang H. The impact of metabolic disorders on management of periodontal health in children. PEDIATRIC DISCOVERY 2024; 2:e38. [PMID: 38784180 PMCID: PMC11115384 DOI: 10.1002/pdi3.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/10/2023] [Indexed: 05/25/2024]
Abstract
Periodontitis is a chronic inflammatory disease caused by plaque biofilm which shares risk factors with systemic chronic diseases such as diabetes, cardiovascular disease, and osteoporosis. Many studies have found increased prevalence and rate of progression of periodontal disease in children with common metabolic disorders. Although the causal relationship and specific mechanism between them has not been determined yet. The aim of this paper is to progress on the impact of metabolic disorders on periodontal health in children and the underlying mechanisms, which provides new evidences for the prevention and intervention of metabolic disorders and periodontitis in children.
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Affiliation(s)
- Yunyan Zhang
- Chongqing Key Laboratory for Oral Diseases and Biomedical Sciences, The Affiliated Hospital of Stomatology, Chongqing Medical University, Chongqing, China
- Department of Pediatric Dentistry, The Affiliated Hospital of Stomatology, Chongqing Medical University, Chongqing, China
| | - Tong-Chuan He
- Molecular Oncology Laboratory, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Medical Center, Chicago, IL, USA
| | - Hongmei Zhang
- Chongqing Key Laboratory for Oral Diseases and Biomedical Sciences, The Affiliated Hospital of Stomatology, Chongqing Medical University, Chongqing, China
- Department of Pediatric Dentistry, The Affiliated Hospital of Stomatology, Chongqing Medical University, Chongqing, China
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Lavu MS, Van Dorn C, Bobak L, Burkhart RJ, Kaelber DC, Mistovich RJ. Does rickets carry an increased risk of osteomyelitis and septic arthritis? An aggregated electronic health record data study. J Pediatr Orthop B 2024:01202412-990000000-00187. [PMID: 38375875 DOI: 10.1097/bpb.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
To investigate the prevalence of osteomyelitis and septic arthritis in pediatric patients with rickets, compared to the general population. A retrospective cohort study was conducted using the TriNetX analytics network, which aggregates deidentified electronic health record data from over 105 million US patients. We queried pediatric patients with rickets, based on ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) encounter diagnoses. Patients with any ICD-10-CM encounter diagnoses of osteomyelitis or septic arthritis were reported. We established a control cohort of pediatric patients without rickets. Of 7337 pediatric patients (≤18 years old) with a rickets diagnosis, 96 [1.31%, 95% confidence interval (CI): 1.05%-1.57%] had a diagnosis of osteomyelitis and 28 (0.38%, 95% CI: 0.24%-0.52%) had a diagnosis of septic arthritis. In comparison, of the 17 240 604 pediatric patients without a rickets diagnosis, 16 995 (0.10%, 95% CI: 0.10%-0.10%) had a diagnosis of osteomyelitis and 8521 (0.05%, 95% CI: 0.05%-0.05%) had a diagnosis of septic arthritis. The relative risk for an osteomyelitis diagnosis in pediatric patients with a rickets diagnosis was 13.27 (95% CI: 10.86-16.23), while the relative risk for a septic arthritis diagnosis was 7.72 (95% CI: 5.33-11.18). Pediatric patients with a diagnosis of rickets have over 10- and 5-times higher relative risks for having a diagnosis of osteomyelitis and septic arthritis, respectively, compared to those without a diagnosis of rickets. This is the first study to explore musculoskeletal infections in rickets patients, highlighting the importance of clinicians being vigilant about these conditions.
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Affiliation(s)
- Monish S Lavu
- Department of Orthopaedics, Case Western Reserve University School of Medicine
| | - Chloe Van Dorn
- Department of Orthopaedics, Case Western Reserve University School of Medicine
| | - Lukas Bobak
- Department of Orthopaedics, Case Western Reserve University School of Medicine
| | - Robert J Burkhart
- Division of Pediatric Orthopaedic Surgery, University Hospitals Rainbow Babies and Children's Hospital
| | - David C Kaelber
- Department of Orthopaedics, Case Western Reserve University School of Medicine
- Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University
- The Center for Clinical Informatics Research and Education, The MetroHealth System
| | - R Justin Mistovich
- Department of Orthopaedics, Case Western Reserve University School of Medicine
- Division of Pediatric Orthopaedic Surgery, University Hospitals Rainbow Babies and Children's Hospital
- Department of Orthopaedic Surgery, The MetroHealth System, Cleveland, Ohio, USA
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Diaz-Thomas A, Iyer P. Global Health Disparities in Childhood Rickets. Endocrinol Metab Clin North Am 2023; 52:643-657. [PMID: 37865479 DOI: 10.1016/j.ecl.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Nutritional rickets is a global health problem reflecting both historical and contemporary health disparities arising from racial, ethnic, environmental, and geopolitical circumstances. It primarily affects marginalized populations and can contribute to long-term morbidity. Deficits in bone health in childhood may also contribute to osteomalacia/osteoporosis. Solutions require a global public health approach.
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Affiliation(s)
- Alicia Diaz-Thomas
- Department of Pediatrics, Division of Pediatric Endocrinology, The University of Tennessee Health Science Center, 910 Madison Avenue, Suite 1010, Memphis, TN 38163, USA.
| | - Pallavi Iyer
- Department of Pediatrics, Division of Endocrinology and Diabetes, Medical College of Wisconsin, Children's Corporate Center, Suite 520, 9000 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Dubowy SM. Vitamin D deficiency rickets in a toddler. JAAPA 2023; 36:24-28. [PMID: 37884036 DOI: 10.1097/01.jaa.0000977680.82301.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
ABSTRACT Nutritional rickets is the failure of normal bone formation in children, caused by vitamin D deficiency, low calcium intake, or a combination of both. In the United States, prolonged breastfeeding without vitamin D supplementation is a major risk factor. Increasing awareness of the rationale for and importance of vitamin D supplements for all breastfed infants and children should reduce the incidence of vitamin D deficiency rickets and prevent bone deformity.
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Affiliation(s)
- Susan Martin Dubowy
- At the time this article was written, Susan Martin Dubowy practiced in orthopedic surgery at Nemours Children's Hospital in Wilmington, Del. She is now a clinical research coordinator in orthopedic surgery at the hospital. The author has disclosed no potential conflicts of interest, financial or otherwise
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Darraj H, Hakami KM, Maghrabi R, Bakri N, Alhazmi MH, Names AA, Akkur A, Sayegh M, Alhazmi A, Khubrani SM, Gohal G, Alomar AH, Alhazmi AH. Nutritional Rickets Among Children: A Retrospective Study from Saudi Arabia. Pediatric Health Med Ther 2023; 14:301-308. [PMID: 37849986 PMCID: PMC10577373 DOI: 10.2147/phmt.s425459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023] Open
Abstract
Background Nutritional rickets remains a significant concern in certain countries, with increasing prevalence attributed to factors such as limited sunlight exposure and undernourishment. This study aimed to identify the factors associated with rickets due to nutritional deficiency in children from Jazan Province, southwestern Saudi Arabia. Methods A retrospective cross-sectional study was conducted using descriptive data from medical records at a tertiary hospital in Jazan Province. Records of patients diagnosed with rickets between January 2010 and December 2020 were analyzed. Symptomatic rickets cases from pediatric clinics were included, and diagnoses were based on biochemical and clinical tests. Risk factors were assessed using patient medical records. Data were analyzed using percentages, mean, and standard deviation. Results The study included 84 patients with rickets (53 females and 31 males), primarily between 11-18 years old. The mean body mass index (BMI) of the participants was 21.21. The most common risk factor was nutritional deficiencies, including vitamin D deficiency or calcium deficiency, with 75 patients reporting a family history of vitamin D deficiency. The children had limited sunlight exposure and low levels of calcium and vitamin D. Malnutrition was identified as the highest risk factor for rickets in the study population. Conclusion Nutritional rickets appears to be prevalent in the Jazan Province, emphasizing the need for government organizations to address this preventable disease. Adequate sun exposure and recommended dietary vitamin D intake are crucial to prevent rickets, as this study detected inadequate levels of calcium and vitamin D in children. National studies are required to further identify risk factors and develop appropriate strategies.
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Affiliation(s)
- Hussam Darraj
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Khalid M Hakami
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Rawan Maghrabi
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Nawaf Bakri
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | | | - Abdellh A Names
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Ahmed Akkur
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Maram Sayegh
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Asma Alhazmi
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Saad M Khubrani
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Gassem Gohal
- Faculty of Medicine, Jazan University, Jazan, 45142, Saudi Arabia
| | - Amro H Alomar
- King Fahad Central Hospital, Ministry of Health, Jazan, 85534, Saudi Arabia
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Fischer PR, Johnson CR, Leopold KN, Thacher TD. Treatment of vitamin D deficiency in children. Expert Rev Endocrinol Metab 2023; 18:489-502. [PMID: 37861060 DOI: 10.1080/17446651.2023.2270053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Vitamin D deficiency affects from 10% to 50% in various pediatric population groups and causes life-threatening hypocalcemia in infants, crippling rickets in infants and children, and increased risk of subsequent adult metabolic and neurologic problems. AREAS COVERED An English language literature search of PubMed was performed since 1940 as were the authors' personal literature collections. References identified in the reviewed literature are considered. DIAGNOSIS The diagnosis of vitamin D deficiency is based on serum 25-hydroxyvitamin D levels. Clinical features of rickets include bone deformities and elevated alkaline phosphatase. Most children and adolescents who are biochemically vitamin D deficient do not have specific symptoms or signs of deficiency. PREVENTION Prevention of vitamin D deficiency is via exposure to sunshine, food and beverage fortification, and dietary supplementation. TREATMENT Effective treatment of vitamin D deficiency is via oral or injectable administration of vitamin D. Dosing and duration of vitamin D therapy have been described for healthy children and for children with underlying medical conditions, but recommendations vary. EXPERT OPINION Further investigation is needed to determine long-term non-skeletal effects of childhood vitamin D deficiency, benefits of supplementation in asymptomatic individuals with biochemical vitamin D deficiency, and appropriate screening for vitamin D deficiency in asymptomatic children and adolescents.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Health and Medical Science, Abu Dhabi, UAE
| | - Casey R Johnson
- Pediatric Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MN, USA
| | - Kaitlin N Leopold
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
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Zurynski Y, Munns CF, Sezgin G, Imai C, Georgiou A. Vitamin D testing in children and adolescents in Victoria, Australia: are testing practices in line with global recommendations? Arch Dis Child 2023; 108:742-747. [PMID: 37197895 PMCID: PMC10447398 DOI: 10.1136/archdischild-2022-325000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/16/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To describe changing primary care ordering of serum 25-hydroxyvitamin D (25OHD) tests in Australian children. DESIGN Longitudinal, population-based descriptive study of 25OHD testing using a large administrative dataset of pathology orders and results, 2003-2018. SETTING AND PARTICIPANTS Three primary health networks in Victoria, Australia. Patients aged ≤18 years with a serum 25OHD test ordered by the general practitioner (GP). MAIN OUTCOME MEASURES Trends over 15 years in the number of 25OHD tests ordered, proportion indicating low levels or vitamin D deficiency and details of repeat testing. RESULTS Of 970 816 laboratory tests, 61 809 (6.4%) included an order for a 25OHD test. The 61 809 tests were performed in 46 960 children or adolescents. The odds of ordering a 25OHD test in 2018 was 30.4 times higher compared with 2003 (95%CI 22.6 to 40.8, p<0.001). The odds of detecting a low 25OHD (<50 nmol/L) compared with the baseline in 2003 remained steady (adjusted OR<1.5) over time. Repeat tests (14 849) were undertaken in 9626 patients (median intertest interval 357 days, IQR 172-669 days). A total of 4603 test results indicated vitamin D deficiency (<30 nmol/L), but in only 180 (3.9%) of these was a repeat test performed within 3 months as recommended. CONCLUSION Testing volumes increased 30-fold, but the odds of detecting low 25OHD remained steady. Current Australian policy and the Global Consensus Recommendations for the prevention and management of nutritional rickets do not support routine 25OHD testing. Education and electronic pathology ordering tools may assist GPs to better align practice with current recommendations.
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Affiliation(s)
- Yvonne Zurynski
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Craig Frank Munns
- Mayne Academy of Paediatrics and Child Health Research Centre, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Gorkem Sezgin
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Chisato Imai
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrew Georgiou
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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Bottai V, Filoni G, Andreani L, Creati G, Di Sacco F, Bonadio AG, Giannotti S, Capanna R. Bone turnover profile and muscular status in major orthopaedic surgery: a case series. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023099. [PMID: 37326278 PMCID: PMC10308471 DOI: 10.23750/abm.v94i3.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/20/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Sarcopenia refers to a chronic loss of skeletal muscle mass, often associated with hypovitaminosis D and advanced age, which involves a greater risk of falls and fractures. The association of sarcopenia and osteoporosis defines osteo-sarcopenia. In this work, the authors analyzed the osteometabolic profile and the loco-regional muscular state of patients undergoing major orthopedic surgery, in order to define the incidence of district osteosarcopenic states, linked to a condition of disuse. METHODS 19 patients (10M-9F), between 15 and 85 years old, underwent major orthopedic surgery (15 resection prosthesis and custom made, 2 resection and reconstruction with transplant) were evaluated, of which 9 on an oncological basis. In all patients, the phospho-calcium metabolism was assessed by blood tests and intraoperative muscle biopsy was performed at the intervention site and contralaterally; in 3 cases a densitometric comparative study of the affected/contralateral limb was performed. RESULTS Results shows 5 patients with hypovitaminosis D; 7 pcs with hypocalcemia; 5 with PTH rise; 4pcs with ALP increase. In 100% of cases, the biopsy revealed sarcopenic patterns exclusively on the affected limb. 2 out of 3 DEXAs (66%) showed loco-regional osteoporosis compared to the contralateral. CONCLUSIONS The fact that in our sample sarcopenia is unilateral affecting only the pathological limb, that it is frequently associated with osteoporosis which is also unilateral and that for the most part it is not associated with vitamin D deficiency, suggests that it is an independent condition, with etiopathogenetic mechanisms different from osteosarcopenia itself. In major orthopedic surgery, bone integration and muscle status are both essential for achieving and lasting positive results. Considering the high incidence of district osteosarcopenia, an integrated surgical, pharmacological, and rehabilitative approach is desirable for the optimization of results, as well as more studies for the definition of the etiopathogenesis of this pathological condition.
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Affiliation(s)
- Vanna Bottai
- Ortopedia e Traumatologia Universitaria II - Universita' di Pisa - Azienda Ospedaliera Universitaria Pisana.
| | - Gabriele Filoni
- a:1:{s:5:"en_US";s:88:"Resident Doctor on Orthopedic and Traumatologic Clinic, University of Pisa, Pisa, Italy ";}.
| | - Lorenzo Andreani
- Ortopedia e Traumatologia Universitaria II - Universita' di Pisa - Azienda Ospedaliera Universitaria Pisana.
| | - Gabriele Creati
- Ortopedia e Traumatologia Universitaria II - Universita' di Pisa - Azienda Ospedaliera Universitaria Pisana.
| | - Federico Di Sacco
- Ortopedia e Traumatologia Universitaria II - Universita' di Pisa - Azienda Ospedaliera Universitaria Pisana.
| | | | - Stefano Giannotti
- Ortopedia e Traumatologia - Universita' degli Studi di Siena - Azienda Ospedaliera Universitaria Senese.
| | - Rodolfo Capanna
- Ortopedia e Traumatologia Universitaria II - Universita' di Pisa - Azienda Ospedaliera Universitaria Pisana.
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Burkhardt R. Vitamin D: review of physiology and clinical uses. Minerva Endocrinol (Torino) 2023; 48:88-105. [PMID: 36920117 DOI: 10.23736/s2724-6507.22.03652-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Interest in vitamin D has increased within the scientific community due to the impact of osteoporosis in the aging population. Vitamin D receptors are present in many tissues and low vitamin D status has been associated with many diseases in observational studies. There was hope that enhanced vitamin D provision might help prevent and treat some widespread disorders. Some of these hopes have been refuted by the results of recent large and well-conducted randomized trials. This review provides an overview of the basic physiology of vitamin D and an update on the evidence base for its clinical applications.
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Establishing the Prevalence of Osteomalacia in Arab Adolescents Using Biochemical Markers of Bone Health. Nutrients 2022; 14:nu14245354. [PMID: 36558513 PMCID: PMC9784134 DOI: 10.3390/nu14245354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Nutrition-acquired osteomalacia is a bone mineralization disorder associated with dietary calcium and/or solar vitamin D deficiency, risk factors considered common in the Middle Eastern region. Establishing less invasive, cheap, and widely available diagnostic markers for this underdiagnosed entity is essential, in particular for screening in high-risk groups. This study assessed the prevalence of biochemical osteomalacia in Arab adolescents. In this cross-sectional study performed between September 2019 and March 2021, adolescents aged 12−17 years from 60 different secondary and preparatory year schools in Riyadh, Saudi Arabia were included. Anthropometrics and fasting blood samples were collected. Biochemical osteomalacia was defined as any two of the following four serum markers of hypomineralization, namely low 25 hydroxyvitamin D (25OHD < 30 nmol/L), high alkaline phosphatase (ALP), low calcium (Ca), and/or inorganic phosphorous (Pi). A total of 2938 Arab adolescents [1697 girls; mean age (years) 14.8 ± 1.8; 1241 boys; mean age 15.1 ± 1.6] were recruited. Vitamin D deficiency was noted in 56.2% (n = 953) of girls and 27.1% (n = 336) of boys (p < 0.001). The overall prevalence of biochemical osteomalacia was 10.0% (n = 295/2938) and was higher in girls than boys (14.7% vs. 3.6%, p < 0.001). The prevalence of low serum Ca and/or Pi was also higher in girls than in boys (24.2% vs. 12.5%, respectively, p < 0.001), as well as elevated ALP (5.1% vs. 1.5%, p < 0.001). Overall, girls were 4.6 times (95% CI 3.3−6.4) more likely to have biochemical osteomalacia than boys. Screening of apparently healthy Arab adolescents revealed a high prevalence of deranged mineralization markers suggestive of biochemical osteomalacia, which was significantly more common in girls than boys and was likely associated with Arab traditional clothing and diet. The proposed combination of typically altered mineralization markers for the diagnosis of osteomalacia is, at best, suggestive until further comparisons with established diagnostic tools (histological analysis of bone biopsies) are conducted.
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Diminick NP, Fey JM, Bourque J, Crosby P, Fox L, Tsai-Leonard D, Morin H, Cyr K, Hewitt W, McElwain LL. Interdisciplinary Quality Improvement Project Increases Vitamin D Supplementation in Infants. Pediatrics 2022; 150:189247. [PMID: 36039691 DOI: 10.1542/peds.2021-051252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND American Academy of Pediatrics guidelines recommend 400 IU of vitamin D supplementation daily for certain infants <1 year of age. We aimed to increase the proportion of reported appropriate vitamin D supplementation for infants born at our institution and those who followed up in our resident clinic through 6 months from 49% to 80% over 24 months. METHODS Our interdisciplinary quality improvement effort included vitamin D medication delivery before nursery discharge and family and staff education. The process measure was the percentage of families discharged from birth hospitalization with vitamin D and teaching. The outcome measure was the percentage of families reporting appropriate vitamin D supplementation at 2-, 4-, and 6-month well child visits. The balancing measure was the percentage of infants discharged from the nursery by 2 pm. Data were displayed on Statistical Process Control p charts and established rules for detecting special causes were applied. RESULTS Baseline and improvement data were collected for 587 hospital discharges and 220 outpatient encounters. The percentage of families discharged with vitamin D increased from 24.8% to 98% from 2016 to 2018. Percent of families reporting appropriate vitamin D supplementation at well child visits increased from 49% to 89% from 2016 to 2018. Overall, the percentage of discharges by 2 pm remained stable at 60%. CONCLUSION Bedside medication delivery and education in the newborn nursery improved reported vitamin D supplementation rates in the first 6 months of life. The intervention did not delay newborn hospital discharge.
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Affiliation(s)
- Noah P Diminick
- The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, Massachusetts
| | - Jamie M Fey
- The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, Massachusetts
| | | | | | - Leah Fox
- Cincinnati Children's Hospital, Cincinnati, Ohio
| | | | | | | | | | - Lorraine L McElwain
- The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, Massachusetts
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15
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Milner JD, Hartnett DA, DeFroda SF, Slingsby BA, Silber ZS, Blackburn AZ, Daniels AH, Cruz AI. Orthopedic manifestations of child abuse. Pediatr Res 2022; 92:647-652. [PMID: 34819655 DOI: 10.1038/s41390-021-01850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022]
Abstract
Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.
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Affiliation(s)
- John D Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA.
| | - Davis A Hartnett
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Brett A Slingsby
- Department of Pediatrics, The Lawrence A. Aubin Sr. Child Protection Center, Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Zachary S Silber
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Amy Z Blackburn
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
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Manrique M, Mantilla-Rivas E, Rana MS, Crowder H, Oh N, Oh AK, Keating RF, Rogers GF. Normocephalic sagittal craniosynostosis in young children is common and unrecognized. Childs Nerv Syst 2022; 38:1549-1556. [PMID: 35716184 DOI: 10.1007/s00381-022-05533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sagittal craniosynostosis (SC) is usually diagnosed during early childhood by the presence of scaphocephaly. Recently, our group found 3.3% of children under 5 years of age with normocephalic sagittal craniosynostosis (NSC) using computed tomography (CT) scans. This paper aims to validate our preliminary findings using a larger cohort of patients, and analyze factors associated with incidental NSC. METHODS A retrospective review of head CT scans in patients aged 0 to 71 months who presented to the emergency department of our tertiary care institution between 2008 and 2020 was completed. Patients with syndromes associated with craniosynostosis (CS), history of hydrocephalus, or other brain/cranial abnormalities were excluded. Two craniofacial surgeons reviewed the CT scans to evaluate the presence and extent of CS. Demographic information, gestational age, past medical and family history, medications, and chief complaint were recorded as covariates, and differences between patients with and without CS were analyzed. Furthermore, comparison of the prevalence of CS across age groups was studied. Additional analysis exploring association between independent covariates and the presence of CS was performed in two sub-cohorts: patients ≤ 24 months of age and patients > 24 months of age. RESULTS A total of 870 scans were reviewed. SC was observed in 41 patients (4.71% - 25 complete, 16 incomplete), all with a normal cranial index (width/length > 0.7). The prevalence of SC increased up to 36 months of age, then plateaued through 72 months of age. Patients under 2 years of age with family history of neurodevelopmental disease had 49.32 (95% CI [4.28, 567.2]) times higher odds of developing CS. Sub-cohort of patients above 24 months of age showed no variable independently predicted developing CS. CONCLUSION NSC in young children is common. While the impact of this condition is unknown, the correlation with family history of neurodevelopmental disease is concerning.
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Affiliation(s)
- M Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - E Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - M S Rana
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
| | - H Crowder
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - N Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - A K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - R F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - G F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA.
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Charoenngam N, Ayoub D, Holick MF. Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention. Expert Rev Endocrinol Metab 2022; 17:1-14. [PMID: 35852141 DOI: 10.1080/17446651.2022.2099374] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Rickets is typically characterized by bone deformities due to defective bone mineralization and chondrocyte maturation in growing bones. However, infantile rickets often goes unrecognized, because the skeletal abnormalities are more subtle and often can only be detected radiologically. Nutritional rickets is a major public health concern in several regions worldwide. It is most commonly caused by vitamin D and/or calcium deficiency. AREA COVERED We provide an overview of historical perspective, epidemiology, and pathophysiology of nutritional rickets. Additionally, we outline diagnostic approaches and highlight challenges in radiographic diagnosis of rickets. Finally, we present strategies for prevention and treatment of rickets. EXPERT OPINION Despite the evidence from clinical databases that rickets is a rare disease, it is likely that rickets is clinically underdiagnosed as studies designed to screen healthy children for radiographic evidence of rickets reported surprisingly much higher prevalence. It has been reported that some of the radiologic features of rickets can be misinterpreted as fractures. To prevent nutritional rickets, most if not all infants and young children, should receive vitamin D from formulas and foods that are fortified with vitamin D or supplementation to achieve a serum 25-hydroxyvitamin D of at least 20 ng/mL as recommended by the Institute of Medicine. It has been recommended by the Endocrine Society that to achieve maximum bone health for children and adults, a serum concentration of 25-hydroxyvitamin D should be at least 30 ng/mL and preferably 40-60 ng/mL. Pregnant women who are unable to obtain an adequate amount of vitamin D from sunlight exposure and natural and fortified diets should take a vitamin D supplement of 1500-2000 IUs daily as recommended by the Endocrine Society since it has been demonstrated that 600 IUs daily will not maintain a circulating 25-hydroxyvitamin D of at least 20 ng/mL and most pregnant women. If lactating women take approximately 6400 IUs of vitamin D daily, they provide enough vitamin D in their milk to satisfy their infant's requirement thereby preventing rickets.
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Affiliation(s)
- Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
| | | | - Michael F Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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18
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Gallo S, Gahche J, Kitsantas P, Makwana P, Wang Y, Chen X, Rajbhandari-Thapa J. Vitamin D Intake and Meeting Recommendations Among Infants Participating in WIC Nationally. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2022; 54:499-509. [PMID: 35288058 PMCID: PMC9149040 DOI: 10.1016/j.jneb.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To report and examine associations with infant vitamin D intake and meeting recommendations among a national sample participating in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN Secondary analysis from the 2013-2015 WIC Infant Toddler Feeding Practices Study-2. PARTICIPANTS US Infants. VARIABLES MEASURED Total reported vitamin D intake from diet and supplementation at the time of data collection. ANALYSIS Descriptive statistics and generalized estimating equations. RESULTS The median total vitamin D intake ranged from 5.43 (95% confidence interval, 5.40-5.46) mcg/d at month 1 to 8.18 (95% confidence interval, 8.11-8.20) mcg/d at month 13, with 16% to 36% of infants meeting the infant vitamin D recommendation over that time. Overall, 6% to 12% of all participants reported supplementation across all time points. Although most (between 78% to 98%) of supplemented breastfed infants met the recommendation, very few were supplemented as a group. Hence, breastfed infants were less likely to meet the recommendation than those who were formula fed across at time points except month 1 (P < 0.001 for all). Whereas infant age, feeding type, and/or their interaction were significant predictors of both receiving supplementation and meeting the recommendation, mother/caregiver nativity (P = 0.006) and parity (P = 0.01 and P < 0.001) predicted receiving supplementation, and child sex (P < 0.001) and mother/caregiver race/ethnicity (P < 0.001) predicted meeting the recommendation. CONCLUSIONS AND IMPLICATIONS Among a national sample of infants participating in WIC between 2013-2015, a high proportion were not meeting the current vitamin D recommendation. The WIC program is 1 resource for promoting strategies for increasing the number of American infants meeting D recommendations, but a coordinated approach involving other health care providers is likely needed. Future research exploring the reason for lack of supplementation, from both the perspective of parents and providers and the clinical impact of low vitamin D intake, is warranted.
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Affiliation(s)
- Sina Gallo
- Department of Nutritional Sciences, University of Georgia, Athens, GA.
| | - Jaime Gahche
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| | - Priyal Makwana
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| | - Yu Wang
- Department of Statistics, University of Georgia, Athens, GA
| | - Xianyan Chen
- Department of Statistics, University of Georgia, Athens, GA
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19
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Fischer PR, Almasri NI. Nutritional rickets - Vitamin D and beyond. J Steroid Biochem Mol Biol 2022; 219:106070. [PMID: 35143980 DOI: 10.1016/j.jsbmb.2022.106070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
Vitamin D deficiency has been considered to be the cause of nutritional rickets for most of the past century. During the past two decades, however, it has become clear that nutritional rickets may be caused by vitamin D deficiency or by dietary insufficiency of calcium. The combined deficiencies of calcium and vitamin D interact, and several other factors are also relevant in the pathogenesis of nutritional rickets.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA; Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates; Khalifa University, Abu Dhabi, United Arab Emirates.
| | - Neamat I Almasri
- Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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20
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Kurnaz E, Çetinkaya S, Elmaoğulları S, Araslı Yılmaz A, Muratoğlu Şahin N, Keskin M, Savaş Erdeve Ş. A major health problem facing immigrant children: nutritional rickets. J Pediatr Endocrinol Metab 2022; 35:223-229. [PMID: 34610231 DOI: 10.1515/jpem-2021-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nutritional rickets (NR) is still an important problem and one which increasing influxes of immigrants are further exacerbating. This study evaluated cases of mostly immigrant children followed up with diagnoses of NR in our pediatric endocrinology clinic. METHODS Details of 20 cases diagnosed with NR between 2017 and 2020 were retrieved from file records. RESULTS Twenty (11 male) cases were included in the study. Three (15%) were Turkish nationals and the others (85%) were immigrants. Hypocalcemia and hypophosphatemia were detected in 17 and 13, respectively. Alkaline phosphatase (ALP) values were normal in two cases, while ALP and parathyroid hormone (PTH) values were elevated in all other cases, and PTH levels were very high (473.64 ± 197.05 pg/mL). 25-hydroxyvitamin D levels were below 20 ng/mL in all cases. Patients with NR received high-dose long-term vitamin D or stoss therapy. Six patients failed to attend long-term follow-up, while PTH and ALP levels and clinical findings improved at long-term follow-up in the other 14 cases. CONCLUSIONS The elevated PTH levels suggest only the most severe cases of NR presented to our clinic. Clinically evident NR is therefore only the tip of the iceberg, and the true burden of subclinical rickets and osteomalacia remains unidentified. Public health policies should therefore focus on universal vitamin D supplementation and adequate dietary calcium provision, their integration into child surveillance programs, adequate advice and support to ensure normal nutrition, exposure to sunlight, and informing families of the increased risk not only for resident populations but also for refugee and immigrant children.
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Affiliation(s)
- Erdal Kurnaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Semra Çetinkaya
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Selin Elmaoğulları
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Aslıhan Araslı Yılmaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Nursel Muratoğlu Şahin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Melikşah Keskin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Şenay Savaş Erdeve
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
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Witard OC, Bath SC, Dineva M, Sellem L, Mulet-Cabero AI, van Dongen LH, Zheng JS, Valenzuela C, Smeuninx B. Dairy as a Source of Iodine and Protein in the UK: Implications for Human Health Across the Life Course, and Future Policy and Research. Front Nutr 2022; 9:800559. [PMID: 35223949 PMCID: PMC8866650 DOI: 10.3389/fnut.2022.800559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/11/2022] [Indexed: 12/03/2022] Open
Abstract
This narrative review summarizes key concepts in dairy nutrition for supporting human health throughout the life course. Milk and dairy products have been a staple component of our diet for thousands of years and provide a wide range of important nutrients that are otherwise difficult to obtain from dairy-free diets. In this review, we provide a broad perspective on the nutritional roles of iodine and dairy protein in supporting human health during pregnancy and early life, childhood and adolescence, mid- and later-life. New methodologies to identify biomarkers of dairy intake via high-throughput mass spectrometry are discussed, and new concepts such as the role of the food matrix in dairy nutrition are introduced. Finally, future policy and research related to the consumption of dairy and non-dairy alternatives for health are discussed with a view to improving nutritional status across the lifespan.
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Affiliation(s)
- Oliver C. Witard
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- *Correspondence: Oliver C. Witard
| | - Sarah C. Bath
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Mariana Dineva
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Laury Sellem
- Hugh Sinclair Unit of Human Nutrition, Department of Food and Nutritional Science, University of Reading, Reading, United Kingdom
| | - Ana-Isabel Mulet-Cabero
- Food Innovation and Health, Quadram Institute Bioscience, Norwich Research Park, Norwich, United Kingdom
| | - Laura H. van Dongen
- Division of Human Nutrition, Wageningen University and Research Centre, Wageningen, Netherlands
| | - Ju-Sheng Zheng
- School of Life Sciences, Westlake University, Hangzhou, China
| | - Carina Valenzuela
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
| | - Benoit Smeuninx
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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22
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O'Donoghue R, Walker D, Beaumont J. Children of the abyss: Investigating the association between isotopic physiological stress and skeletal pathology in London during the Industrial Revolution. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2021; 35:61-80. [PMID: 34715484 DOI: 10.1016/j.ijpp.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE This project sought to investigate whether an association may be observed between isotopic stress indicators and skeletal evidence of pathological conditions. MATERIALS Deciduous and permanent teeth of 15 non-adults from two contemporaneous mid-19th century London burial grounds (City Bunhill, Lukin Street). METHODS δ13C and δ15N was measured in the incrementally sectioned dentine collagen. Isotopic profiles for each individual included death during tooth development. RESULTS Individuals with skeletal evidence of chronic pathological conditions (e.g., rickets, tuberculosis) exhibited raised δ15N values of 0.5-1.7‰ in the months prior to death. Isotopic change consistent with chronic physiological stress prior to death was also recorded in two individuals with no skeletal evidence of disease. An offset was observed between co-forming bone and dentine δ15N values in both populations, indicating that bone and dentine are not recording the same isotopic changes. CONCLUSIONS Isotopic change consistent with chronic physiological stress was observed in both those with and without skeletal evidence of disease, suggesting that adaptation to chronic stress in childhood was not uncommon within these 19th century London populations. SIGNIFICANCE Chronic physiological stress prior to death may be seen in the incrementally sampled dentine of non-adults who die during tooth formation. LIMITATIONS The temporal resolution of current dentine micro-sampling methods may mask or minimise visibility of shorter-term periods of stress or dietary change. SUGGESTIONS FOR FURTHER RESEARCH Future research should further explore the relationship between specific skeletal pathologies and isotopic evidence for stress.
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Affiliation(s)
- Ruth O'Donoghue
- School of Archaeological and Forensic Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP, UK.
| | - Don Walker
- Museum of London Archaeology, Mortimer Wheeler House, 46 Eagle Wharf Road, London, N1 7ED, UK
| | - Julia Beaumont
- School of Archaeological and Forensic Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP, UK
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23
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Lips P, de Jongh RT, van Schoor NM. Trends in Vitamin D Status Around the World. JBMR Plus 2021; 5:e10585. [PMID: 34950837 PMCID: PMC8674774 DOI: 10.1002/jbm4.10585] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 01/01/2023] Open
Abstract
Vitamin D status varies across all continents and countries. Vitamin D status usually is adequate in Latin America and Australia, but in contrast it is very low in the Middle East and some countries in Asia. Trends in vitamin D status, whether it improves or declines over the years, carry important messages. Trends usually are small, but can be predictors and indicators of general health. Vitamin D status has improved in the older population in the United States, and improvement relates to dairy use and vitamin D supplements. To the contrary, vitamin D status has declined in the Inuit population of Canada due to a change from a traditional fish diet to a Western diet. A large improvement was seen in Finland after mandatory fortification of dairy products was introduced. Determinants of decline are less sun exposure, increased use of sunscreen, increase of body mass index (BMI), less physical activity, and poor socioeconomic status. Determinants of increase are food fortification with vitamin D and vitamin D supplements. Food fortification can lead to a population-wide increase in vitamin D status as shown by the Finnish example. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Paul Lips
- Department of Internal Medicine, Endocrine SectionAmsterdam University Medical Centre, location VUMCAmsterdamThe Netherlands
| | - Renate T. de Jongh
- Department of Internal Medicine, Endocrine SectionAmsterdam University Medical Centre, location VUMCAmsterdamThe Netherlands
| | - Natasja M. van Schoor
- Department of Epidemiology and Data ScienceAmsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Public Health Research InstituteAmsterdamThe Netherlands
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24
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Affiliation(s)
- Lindsey A Warner
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B158, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel L Sewell
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B158, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nina S Ma
- Bone and Mineral Metabolism Program, Section of Endocrinology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B265, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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Rickets in Children: An Update. Biomedicines 2021; 9:biomedicines9070738. [PMID: 34199067 PMCID: PMC8301330 DOI: 10.3390/biomedicines9070738] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Rickets refers to a deficient mineralization of the growth plate cartilage, predominantly affecting longer bones. Despite the fact that preventive measures are available, it is still a common disease worldwide; nutritional rickets, due to vitamin D deficiency or dietary calcium inadequate intake, remains the most common form. Medical history, physical examination, radiologic features and biochemical tests are essential for diagnosis. Although recent studies suggest hypophosphatemia as the leading alteration, rickets is classically divided into two categories: calcipenic rickets and phosphopenic rickets. Knowledge of this categorization and of respective clinical and laboratory features is essential for rapid diagnosis and correct management. The aim of this review is to analyze the epidemiological, pathogenetic, clinical, and therapeutic aspects of the different forms of rickets, describing the novelties on this “long-lived” disease.
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Diaz Escagedo P, Fiscaletti M, Olivier P, Hudon C, Miranda V, Miron MC, Campeau PM, Alos N. Rickets manifestations in a child with metaphyseal anadysplasia, report of a spontaneously resolving case. BMC Pediatr 2021; 21:248. [PMID: 34022834 PMCID: PMC8140414 DOI: 10.1186/s12887-021-02716-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction Rickets is not an unusual diagnosis for pediatricians even currently in developed countries. Children typically present with leg bowing, enlargement of wrists, rachitic rosary (swelling of costochondral junctions) and/or waddling gait. But not every child with growth delay and enlarged metaphyses is diagnosed with rickets. Metaphyseal anadysplasia (MAD) is a disorder of variable severity with metaphyseal flaring and irregularities, without vertebral abnormalities. MAD is characterized by an early onset and a regressive course in late childhood without treatment, despite persistent short stature. Autosomal dominant or recessive variants in the matrix metalloproteinase 13 gene (MMP13) are responsible for these transient metaphyseal changes. Case presentation We report a new pathogenic heterozygous variant in MMP13 (NM_002427.4: c.216G>C, p.Gln72His) in a toddler, initially thought to have rickets, and his father, with MAD phenotypes. Additionally, we review the seven reported MMP13 variants. Conclusion One should keep a wide differential diagnosis in cases of suspected rickets, including skeletal dysplasias which might have a regressive course. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02716-x.
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Affiliation(s)
- Patricia Diaz Escagedo
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Melissa Fiscaletti
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Patricia Olivier
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Chloé Hudon
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Valancy Miranda
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Marie-Claude Miron
- Radiology Department, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Philippe M Campeau
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada. .,Research Center, Sainte-Justine Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada.
| | - Nathalie Alos
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada. .,Research Center, Sainte-Justine Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada.
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Constantacos C, Hunter JD, Walsh ET, South AM. Rare PHEX variant with insidious presentation leads to a delayed diagnosis of X-linked hypophosphatemia. BMJ Case Rep 2021; 14:14/5/e240336. [PMID: 34011663 DOI: 10.1136/bcr-2020-240336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 7-year-old girl without a significant previous medical history was diagnosed with X-linked hypophosphatemic rickets (XLHR) due to a rare, most likely pathogenic, PHEX gene variant after a 4-year delayed diagnosis due to mild clinical presentation. At 2 years of age, her intoeing and femoral bowing were attributed to physiologic bowing and borderline vitamin D sufficiency, despite phosphorus not being measured. Hypophosphatemia was eventually detected after incomplete improvement of bowing and leg length discrepancy with suboptimal linear growth. This rare PHEX variant (c.1949T>C, p.Leu650Pro) further supported the clinical diagnosis of XLHR. Treatment with burosumab (an anti-FGF23 monoclonal antibody) normalised phosphorus and alkaline phosphatase levels and improved her bowing. The diverse phenotypic presentation of this variant can result in delayed diagnosis and highlights the importance of prompt assessment of phosphorus levels in patients with skeletal deformities to ensure timely recognition and treatment.
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Affiliation(s)
- Cathrine Constantacos
- Pediatrics, Section of Endocrinology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Janel Darcy Hunter
- Pediatrics, Section of Endocrinology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Elizabeth Tharpe Walsh
- Pediatrics, Section of Endocrinology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Andrew Michael South
- Pediatrics, Section of Nephrology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA.,Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
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Artificial intelligence research within reach: an object detection model to identify rickets on pediatric wrist radiographs. Pediatr Radiol 2021; 51:782-791. [PMID: 33399980 DOI: 10.1007/s00247-020-04895-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/02/2020] [Accepted: 10/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Artificial intelligence models have been successful in analyzing ordinary photographic images. One type of artificial intelligence model is object detection, where a labeled bounding box is drawn around an area of interest. Object detection can be applied to medical imaging tasks. OBJECTIVE To demonstrate object detection in identifying rickets and normal wrists on pediatric wrist radiographs using a small dataset, simple software and modest computer hardware. MATERIALS AND METHODS The institutional review board at Children's Healthcare of Atlanta approved this study. The radiology information system was searched for radiographic examinations of the wrist for the evaluation of rickets from 2007 to 2018 in children younger than 7 years of age. Inclusion criteria were an exam type of "Rickets Survey" or "Joint Survey 1 View" with reports containing the words "rickets" or "rachitic." Exclusion criteria were reports containing the words "renal," "kidney" or "transplant." Two pediatric radiologists reviewed the images and categorized them as either rickets or normal. Images were annotated by drawing a labeled bounding box around the distal radial and ulnar metaphases. The training dataset was created from images acquired from Jan. 1, 2007, to Dec. 31, 2017. This included 104 wrists with rickets and 264 normal wrists. This training dataset was used to create the object detection model. The testing dataset consisted of images acquired during the 2018 calendar year. This included 20 wrists with rickets and 37 normal wrists. Model sensitivity, specificity and accuracy were measured. RESULTS Of the 20 wrists with rickets in the testing set, 16 were correctly identified as rickets, 2 were incorrectly identified as normal and 2 had no prediction. Of the 37 normal wrists, 33 were correctly identified as normal, 2 were incorrectly identified as rickets and 2 had no prediction. This yielded a sensitivity and specificity of 80% and 95% for wrists with rickets and 89% and 90% for normal wrists. Overall model accuracy was 86%. CONCLUSION Object detection can identify rickets on pediatric wrist radiographs. Object detection models can be developed with a small dataset, simple software tools and modest computing power.
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Abstract
Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology & Diabetes, Birmingham Women's & Children's NHS Foundation Trust; Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Wolfgang Högler
- Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK; Department of Paediatrics & Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Med Campus IV, Linz, Austria
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Comparison of Vitamin D and 25-Hydroxyvitamin D Concentrations in Human Breast Milk between 1989 and 2016-2017. Nutrients 2021; 13:nu13020573. [PMID: 33572283 PMCID: PMC7915017 DOI: 10.3390/nu13020573] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Breast milk is considered the optimal source of nutrition during infancy. Although the vitamin D concentration in human breast milk is generally considered poor for infants, vitamin D in breast milk is an important source for exclusively breastfed infants. Increases in vitamin D insufficiency and deficiency in lactating mothers may reduce vitamin D concentrations in breast milk. This study aimed to compare vitamin D and 25-hydroxyvitamin D (25OHD) concentrations in breast milk collected in 1989 and 2016-2017 and simultaneously analyze them with liquid chromatography-tandem mass spectrometry (LC-MS/MS); the association between the lifestyle of recent lactating mothers (2016-2017) and vitamin D status in human breast milk was also evaluated. METHOD Lactating mothers were recruited from three regions of Japan in 1989 (n = 72) and 2016-2017 (n = 90), and milk from 3-4 months was collected in summer and winter. The samples were strictly sealed and stored at -80℃ until measurement. Breast milk vitamin D and 25OHD concentrations were analyzed by LC-MS/MS. Vitamin D intake, sun exposure, and sunscreen use of the lactating mothers in 2016-2017 were assessed. RESULTS Both vitamin D and 25OHD concentrations in breast milk were higher in the summer regardless of the survey year. Significantly lower vitamin D and 25OHD concentrations were observed in 2016-2017 compared with 1989 in summer, but no survey year difference was observed in winter. The stepwise multiple regression analyses identified season, daily outdoor activity, and suntan in the last 12 months as independent factors associated with vitamin D3 concentrations. CONCLUSION The results suggest that low vitamin D status in recent lactating mothers may have decreased vitamin D and 25OHD concentrations in breast milk compared with the 1980s. These results are helpful for developing public health strategies to improve vitamin D status in lactating mothers and infants.
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Givens DI. MILK Symposium review: The importance of milk and dairy foods in the diets of infants, adolescents, pregnant women, adults, and the elderly. J Dairy Sci 2021; 103:9681-9699. [PMID: 33076181 DOI: 10.3168/jds.2020-18296] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
Abstract
The ongoing increase in life expectancy is not always accompanied by an increase in healthy life span. There is increasing evidence that dietary exposure in early life can substantially affect chronic disease risk in later life. Milk and dairy foods are important suppliers of a range of key nutrients, with some being particularly important at certain life stages. It is now recognized that milk protein can stimulate insulin-like growth factor-1 (IGF-1), essential for longitudinal bone growth and bone mass acquisition in young children, thus reducing the risk of stunting. Low milk consumption during adolescence, particularly by girls, may contribute to suboptimal intake of calcium, magnesium, iodine, and other important nutrients. Given the generally low vitamin D status of European populations, this may have already affected bone development, and any resulting reduced bone strength may become a big issue when the populations are much older. Suboptimal iodine status of many young women has already been reported together with several observational studies showing an association between suboptimal iodine status during pregnancy and reduced cognitive development in the offspring. There is now good evidence that consumption of milk and dairy foods does not lead to an increased risk of cardiovascular diseases and type 2 diabetes. Indeed, some negative associations are seen, notably between yogurt consumption and type 2 diabetes, which should be researched with urgency. Greater emphasis should be placed on reducing malnutrition in the elderly and on dietary approaches to reduce their loss of muscle mass, muscle functionality, and bone strength. Whey protein has been shown to be particularly effective for reducing muscle loss; this needs to be developed to provide simple dietary regimens for the elderly to follow. There is an ongoing, often too simplistic debate about the relative value of animal versus plant food sources for protein in particular. It is important that judgments on the replacement of dairy products with those from plants also include the evidence on relative functionality, which is not expressed in simple nutrient content (e.g., hypotensive and muscle synthesis stimulation effects). Only by considering such functionality will a true comparison be achieved.
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Affiliation(s)
- D I Givens
- Institute for Food, Nutrition and Health, University of Reading, Reading RG6 6AR, UK.
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Virkud YV, Fernandes ND, Lim R, Mitchell DM, Rothwell WT. Case 39-2020: A 29-Month-Old Boy with Seizure and Hypocalcemia. N Engl J Med 2020; 383:2462-2470. [PMID: 33326719 DOI: 10.1056/nejmcpc2027078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Yamini V Virkud
- From the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Massachusetts General Hospital, and the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Harvard Medical School - both in Boston
| | - Neil D Fernandes
- From the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Massachusetts General Hospital, and the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Harvard Medical School - both in Boston
| | - Ruth Lim
- From the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Massachusetts General Hospital, and the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Harvard Medical School - both in Boston
| | - Deborah M Mitchell
- From the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Massachusetts General Hospital, and the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Harvard Medical School - both in Boston
| | - William T Rothwell
- From the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Massachusetts General Hospital, and the Departments of Pediatrics (Y.V.V., N.D.F., D.M.M.), Radiology (R.L.), and Pathology (W.T.R.), Harvard Medical School - both in Boston
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Abstract
PURPOSE OF REVIEW The goal of this review is to give an overview of diagnosis and up-to-date management of major pediatric metabolic bone diseases that are associated with bone fragility, including nutritional rickets, hypophosphatemic rickets, osteogenesis imperfecta, Ehlers--Danlos syndrome, Marfan's syndrome, hypophosphatasia, osteopetrosis and skeletal fluorosis. RECENT FINDINGS During the past decade, a number of advanced treatment options have been introduced and shown to be an effective treatment in many metabolic bone disorders, such as burosumab for hypophosphatemic rickets and asfotase alfa for hypophosphatasia. On the other hand, other disorders, such as nutritional rickets and skeletal fluorosis continue to be underrecognized in many regions of the world. Genetic disorders of collagen-elastin, such as osteogenesis imperfecta, Ehlers--Danlos syndrome and Marfan's syndrome are also associated with skeletal fragility, which can be misdiagnosed as caused by non-accidental trauma/child abuse. SUMMARY It is essential to provide early and accurate diagnosis and treatment for pediatric patients with metabolic bone disorders in order to maintain growth and development as well as prevent fractures and metabolic complications.
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Abstract
OBJECTIVE To determine the prevalence and predictors of hypocalcaemia in under-five children (1-59 months) hospitalised with severe acute malnutrition (SAM). DESIGN A cross-sectional study was designed to determine the prevalence of hypocalcaemia among children hospitalised with SAM. Serum Ca and 25-hydroxycholecalciferol (25-(OH)D) were estimated. Hypocalcaemia was defined as serum Ca (albumin-adjusted) <2·12 mmol/l. To identify the clinical predictors of hypocalcaemia, a logistic regression model was constructed taking hypocalcaemia as a dependent variable, and sociodemographic and clinical variables as independent variables. SETTING A tertiary care hospital in Delhi, between November 2017 and April 2019. PARTICIPANTS One-hundred and fifty children (1-59 months) hospitalised with SAM were enrolled. RESULTS Hypocalcaemia was documented in thirty-nine (26 %) children hospitalised with SAM, the prevalence being comparable between children aged <6 months (11/41, 26·8 %) and those between 6 and 59 months (28/109, 25·7 %) (P = 0·887). Vitamin D deficiency (serum 25-(OH)D <30 nmol/l) and clinical rickets were observed in ninety-eight (65·3 %) and sixty-three (42 %) children, respectively. Hypocalcaemia occurred more frequently in severely malnourished children with clinical rickets (OR 6·6, 95 % CI 2·54, 17·15, P < 0·001), abdominal distension (OR 4·5, 95 % CI 1·39, 14·54, P = 0·012) and sepsis (OR 2·6, 95 % CI 1·00, 6·57, P = 0·050). CONCLUSION Rickets and hypocalcaemia are common in children with SAM. Routine supplementation of vitamin D should be considered for severely malnourished children. Ca may be empirically prescribed to severely malnourished children with clinical rickets, abdominal distension and/or sepsis.
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Abstract
Vitamin D has important roles in calcium metabolism and in the prevention of rickets and osteomalacia; low levels of 25-hydroxyvitamin D are common in the general population and amongst pregnant women. Whilst there is a wealth of observational evidence linking vitamin D deficiency to a wide range of disease outcomes, there are currently few high-quality randomised controlled trials to confirm any causal associations, although many are currently in progress. Furthermore, currently, the vast majority of published guidelines recommend standard supplemental vitamin D doses for children and pregnant women, yet there is increasing recognition that individual characteristics and genetic factors may influence the response to supplementation. As such, future research needs to concentrate on documenting definite beneficial clinical outcomes of vitamin D supplementation, and establishing personalised dosing schedules and demonstrating effective approaches to optimising initiation and adherence.
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Affiliation(s)
- Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Justin H Davies
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK.
- National Institute for Health Research (NIHR) Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Högberg U, Winbo J, Fellman V. Population-based register study of children born in Sweden from 1997 to 2014 showed an increase in rickets during infancy. Acta Paediatr 2019; 108:2034-2040. [PMID: 31050835 DOI: 10.1111/apa.14835] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 01/18/2023]
Abstract
AIM This population-based study assessed the incidence of rickets in infants up to age of one born in Sweden from 1997 to 2014. We also examined maternal and perinatal factors and co-morbidity. METHODS We used Swedish National Board of Health and Welfare registers and data from Statistics Sweden. The outcome measure was an International Classification of Diseases, Tenth Revision, code for rickets. RESULTS There were 273 cases of rickets, with an incidence of 14.7 per 100 000 and a 10-fold incidence increase between 1997 and 2014. The majority (78.4%) were born preterm, half were small-for-gestational age (SGA) (birthweight <10th percentile), 4.8% were born to Asian-born mothers and 3.5% to African-born mothers. The adjusted odds ratios by birth week were 182 (95% CI: 121-272) before 32 weeks and 10.8 (95% CI: 6.72-17.4) by 32-36 weeks. Preterm infants with necrotising enterocolitis had very high odds for rickets and so did SGA term-born infants and those born to African-born mothers. The odds for rickets among preterm infants increased considerably during the later years. CONCLUSION Rickets increased 10-fold in Sweden from 1997 to 2014 and was mainly associated with prematurity, SGA and foreign-born mothers. Possible reasons may include increased preterm survival rates and improved clinical detection and registration.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Jenny Winbo
- Department of Gynaecology and Obstetrics Region Gävleborg Gävle Sweden
| | - Vineta Fellman
- Department of Clinical Sciences, Lund, Pediatrics Lund University Lund Sweden
- Children's Hospital University of Helsinki and Folkhälsan Research Center Helsinki Finland
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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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Aul AJ, Fischer PR, O'Grady JS, Mara KC, Maxson JA, Meek AM, Petterson TM, Thacher TD. Population-Based Incidence of Potentially Life-Threatening Complications of Hypocalcemia and the Role of Vitamin D Deficiency. J Pediatr 2019; 211:98-104.e4. [PMID: 30954245 PMCID: PMC6661008 DOI: 10.1016/j.jpeds.2019.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the incidence of potentially life-threatening complications of hypocalcemia in infants and children in Olmsted County, Minnesota; and to determine if vitamin D deficiency contributed to these events and was, at the time of clinical presentation, considered as a possible cause. STUDY DESIGN In this population-based descriptive study, data were abstracted from the Rochester Epidemiology Project, a medical record linkage system covering 95% of patients in Olmsted County, Minnesota. Participants were children aged 0-5 years who resided in Olmsted County between January 1, 1996 and June 30, 2017, and who received diagnoses of seizures, cardiomyopathy, cardiac arrest, respiratory arrest, laryngospasm, and/or tetany. The incidence of hypocalcemia plus a potentially life-threatening complication was calculated. RESULTS Among 15 419 patients aged 0-5 years in Olmsted County during the study period, 1305 had eligible complications: 460 had serum calcium checked within 14 days of presentation and 85 had hypocalcemia. Patients were excluded when causes other than hypocalcemia likely triggered the complication, leaving 16 children whose complication was attributed to hypocalcemia. Three of these 16 patients had a serum 25-hydroxyvitamin D measurement and 2 were deficient (≤6 ng/mL [15 nmol/L]). Among children aged 0-5 years, the incidence of hypocalcemia plus a potentially life-threatening complication was 6.1 per 100 000 person-years (95% CI, 3.5-10.0). CONCLUSIONS Vitamin D deficiency is an underinvestigated cause of complications of hypocalcemia in children. Serum calcium and 25-hydroxyvitamin D should be measured in children with these complications to identify possibly life-threatening vitamin D deficiency.
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Affiliation(s)
- Andrea J Aul
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Julie A Maxson
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Alicia M Meek
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Tanya M Petterson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN.
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DelGiudice NJ, Street N, Torchia RJ, Sawyer SS, Bernard SA, Holick MF. Vitamin D Prescribing Practices in Primary Care Pediatrics: Underpinnings From the Health Belief Model and Use of Web-Based Delphi Technique for Instrument Validity. J Pediatr Health Care 2018; 32:536-547. [PMID: 29804658 DOI: 10.1016/j.pedhc.2018.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/11/2018] [Indexed: 11/26/2022]
Abstract
Vitamin D deficiency and insufficiency is a pandemic problem in children and adolescents in the United States. The problem may be aggravated by the inconsistent implementation of current clinical practice guidelines for vitamin D management by pediatric primary care providers. This study examines the relationship between primary care providers' prescribing vitamin D to children ages 1 through 18 years and their practice actions and knowledge. A descriptive correlation design was used. Participants were recruited from a purposive sample of pediatricians and pediatric nurse practitioners through an online invitation to participate in a survey. Reliability and validity was established for the survey developed by the principal investigator using a web-based Delphi technique. Results from this study indicate that although most providers are aware that vitamin D insufficiency and deficiency are problems, fewer than half currently recommend 600- to 1,000-IU supplementation to their patients ages 1 through 18 years.
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Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci 2018; 1430:44-79. [PMID: 30225965 DOI: 10.1111/nyas.13968] [Citation(s) in RCA: 281] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022]
Abstract
Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.
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Affiliation(s)
- Daniel E Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - John Aloia
- NYU Winthrop Hospital, Mineola, New York
| | - Gilles Bergeron
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Megan W Bourassa
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | | | - Mona S Calvo
- Retired, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, University College Cork, Cork, Ireland
| | | | | | | | - Kerry S Jones
- MRC Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | | | - Adrian R Martineau
- Blizard Institute, Queen Mary University of London, London, United Kingdom
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Kubota T, Nakayama H, Kitaoka T, Nakamura Y, Fukumoto S, Fujiwara I, Hasegawa Y, Ihara K, Kitanaka S, Koyama S, Kusuda S, Mizuno H, Nagasaki K, Oba K, Sakamoto Y, Takubo N, Shimizu T, Tanahashi Y, Hasegawa K, Tsukahara H, Yorifuji T, Michigami T, Ozono K. Incidence rate and characteristics of symptomatic vitamin D deficiency in children: a nationwide survey in Japan. Endocr J 2018. [PMID: 29526992 DOI: 10.1507/endocrj.ej18-0008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There is concern that vitamin D deficiency is prevalent among children in Japan as well as worldwide. We conducted a nationwide epidemiologic survey of symptomatic vitamin D deficiency to observe its incidence rate among Japanese children. A questionnaire inquiring the number of new patients with vitamin D deficiency rickets and/or hypocalcemia for 3 years was sent to 855 randomly selected hospitals with a pediatrics department in Japan. In this survey, we found that 250 children were diagnosed with symptomatic vitamin D deficiency. The estimated number of patients with symptomatic vitamin D deficiency per year was 183 (95% confidence interval (CI): 145-222). The overall annual incidence rate among children under 15 years of age was 1.1 per 100,000 population (95% CI: 0.9-1.4). The second survey has provided detailed information on 89 patients with symptomatic vitamin D deficiency under 5 years of age in hospitals in the current research group. The nationwide and second surveys estimated the overall annual incidence rate of symptomatic vitamin D deficiency in children under 5 years of age to be 3.5 (2.7-4.2) per 100,000 population. The second survey revealed 83% had bowed legs, 88% had exclusive breastfeeding, 49% had a restricted and/or unbalanced diet and 31% had insufficient sun exposure among the 89 patients. This is the first nationwide survey on definitive clinical vitamin D deficiency in children in Japan. Elucidating the frequency and characteristics of symptomatic vitamin D deficiency among children is useful to develop preventative public health strategies.
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Affiliation(s)
- Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Hirofumi Nakayama
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Taichi Kitaoka
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Yosikazu Nakamura
- Department of Public Health, Jichi Medical University, Tochigi 329-0498, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima 770-8503, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Ikuma Fujiwara
- Department of Pediatric Endocrinology and Environmental Medicine, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo 183-8561, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Kenji Ihara
- Department of Pediatrics, Oita University Faculty of Medicine, Oita 879-5593, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Sachiko Kitanaka
- Department of Pediatrics, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Satomi Koyama
- Department of Pediatrics, Dokkyo Medical University, Tochigi 321-0293, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo 181-0004, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Haruo Mizuno
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Aichi 467-8602, Japan
- Department of Pediatrics, International University of Health and Welfare, School of Medicine, Chiba 286-8686, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Keisuke Nagasaki
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8520, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Koji Oba
- Department of Biostatistics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Yuko Sakamoto
- Department of Orthopedics, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Noriyuki Takubo
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Yusuke Tanahashi
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Kosei Hasegawa
- Department of Pediatrics, Okayama University Hospital, Okayama 700-8558, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Hirokazu Tsukahara
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka 534-0021, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Study group of Survey and Estimation of Incidence Rate of Childhood Symptomatic Vitamin D
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Oberhelman SS, Cozine EW, Umaretiya PJ, Maxson JA, Thacher TD. Vitamin D and the Breastfeeding Infant: Family Medicine Clinicians' Knowledge, Attitudes, and Practices. J Hum Lact 2018; 34:331-336. [PMID: 29596761 DOI: 10.1177/0890334418755338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The American Academy of Pediatrics and the National Academy of Medicine recommend vitamin D supplementation for breastfeeding infants. However, compliance with this recommendation is poor. Maternal supplementation with vitamin D is a safe and effective alternative to achieving vitamin D sufficiency in breastfeeding infants, and mothers have indicated a preference for self-supplementation over infant supplementation. Research aim: We sought to explore Family Medicine clinicians' knowledge, attitudes, and practices regarding vitamin D supplementation recommendations for breastfeeding dyads. METHODS Fifty-six Family Medicine clinicians (including faculty physicians, resident physicians, and nurse practitioners/physician assistants) completed an online, anonymous survey regarding their knowledge and practices concerning vitamin D supplementation for breastfeeding infants. RESULTS The vast majority of clinicians (92.9%) correctly identified the American Academy of Pediatrics' 2008 recommended dose for vitamin D supplementation in breastfeeding infants and estimated recommending vitamin D supplementation of exclusively breastfeeding infants 70.1% of the time. If all options were equivalent, clinicians would prefer to offer maternal or infant supplementation (50%) or maternal supplementation (37.5%) over infant supplementation (12.5%). Most (69.6%) preferred daily over monthly supplementation regimens. CONCLUSION Family Medicine clinicians are knowledgeable regarding current recommendations for vitamin D supplementation in breastfeeding infants. They are also open to recommending maternal supplementation or offering parents a choice of maternal or infant vitamin supplementation.
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Affiliation(s)
| | | | - Puja J Umaretiya
- 2 Mayo Clinic School of Medicine, Rochester, MN, USA.,3 Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Julie A Maxson
- 1 Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tom D Thacher
- 1 Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
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Cannell JJ, Holick MF. Multiple unexplained fractures in infants and child physical abuse. J Steroid Biochem Mol Biol 2018; 175:18-22. [PMID: 27641737 DOI: 10.1016/j.jsbmb.2016.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
When an infant presents with X-rays showing multiple unexplained fractures in various stages of healing (MUFVSH), the child is usually diagnosed with child abuse based on criteria of the Academy of Pediatrics' Committee on Child Abuse and Neglect (AAPCCAAN). Almost always, the infant is subsequently removed from the home and civil or criminal proceeding commence. It may be that healing infantile rickets or other poorly understood metabolic bone disorders of infancy are responsible for these x-rays. Activated vitamin D is a seco-steroid hormone, whose mechanism of action is genetic regulation. Lack of it can result in musculoskeletal defects known as rickets. Low calcium can also cause rickets. However, it is clear that experts for the state believe that the x-rays in these cases are so definitive as to be pathognomonic for child abuse. Therefore, if the caregivers deny abusing their infants, experts following American Academy of Pediatric's Committee on Child Abuse and Neglect. guidelines are essentially claiming that x-rays showing multiple unexplained fractures in various stages of healing are lie detector tests. However, it is not widely appreciated that the gold standard for the diagnosis of rickets is a bone biopsy, not x-rays, as radiologists miss biopsy proven rickets 80% of the time; that is, 4 out of 5 infants with rickets will have normal x-rays. In this article we provide reports of two cases and their outcomes. We discuss information about healing infantile rickets and an example of common sense medical conclusions in these cases. This information could lead to a significant reduction in the number of innocent parents having their infant removed or sent to prison.
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Affiliation(s)
- John Jacob Cannell
- Vitamin D Council Inc., 1411 Marsh Street, Suite 203, San Luis Obispo, CA, USA.
| | - Michael F Holick
- Professor of Medicine, Physiology, Endocrinology and Biophysics, Boston University School of Medicine, Boston, MA, USA
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Abstract
Rickets is a bone disease associated with abnormal serum calcium and phosphate levels. The clinical presentation is heterogeneous and depends on the age of onset and pathogenesis but includes bowing deformities of the legs, short stature and widening of joints. The disorder can be caused by nutritional deficiencies or genetic defects. Mutations in genes encoding proteins involved in vitamin D metabolism or action, fibroblast growth factor 23 (FGF23) production or degradation, renal phosphate handling or bone mineralization have been identified. The prevalence of nutritional rickets has substantially declined compared with the prevalence 200 years ago, but the condition has been re-emerging even in some well-resourced countries; prematurely born infants or breastfed infants who have dark skin types are particularly at risk. Diagnosis is usually established by medical history, physical examination, biochemical tests and radiography. Prevention is possible only for nutritional rickets and includes supplementation or food fortification with calcium and vitamin D either alone or in combination with sunlight exposure. Treatment of typical nutritional rickets includes calcium and/or vitamin D supplementation, although instances infrequently occur in which phosphate repletion may be necessary. Management of heritable types of rickets associated with defects in vitamin D metabolism or activation involves the administration of vitamin D metabolites. Oral phosphate supplementation is usually indicated for FGF23-independent phosphopenic rickets, whereas the conventional treatment of FGF23-dependent types of rickets includes a combination of phosphate and activated vitamin D; an anti-FGF23 antibody has shown promising results and is under further study.
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Deavenport-Saman A, Britt A, Smith K, Jacobs RA. Milestones and controversies in maternal and child health: examining a brief history of micronutrient fortification in the US. J Perinatol 2017; 37:1180-1184. [PMID: 28749486 DOI: 10.1038/jp.2017.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/26/2017] [Accepted: 06/26/2017] [Indexed: 12/11/2022]
Abstract
Fortification of our food and drinking supply has decreased morbidity rates related to micronutrient deficiencies among mothers and their children, particularly during the perinatal and neonatal periods of development. The purpose of this historical review is to examine the impact of public policy changes related to micronutrient fortification. We provide a historical investigation of achievements and controversies related to iodine, vitamin D, fluoride and folic acid fortifications in our food and drinking supply. We also discuss the current status of fortification recommendations and their significance to maternal and child health.
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Affiliation(s)
- A Deavenport-Saman
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.,USC Center for Excellence in Developmental Disabilities, Los Angeles, CA, USA.,USC Keck School of Medicine, Los Angeles, CA, USA
| | - A Britt
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.,USC Keck School of Medicine, Los Angeles, CA, USA
| | - K Smith
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.,USC Center for Excellence in Developmental Disabilities, Los Angeles, CA, USA.,USC Keck School of Medicine, Los Angeles, CA, USA
| | - R A Jacobs
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.,USC Keck School of Medicine, Los Angeles, CA, USA
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46
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Bilbao NA. Vitamin D Toxicity in Young Breastfed Infants: Report of 2 Cases. Glob Pediatr Health 2017; 4:2333794X17731695. [PMID: 28955720 PMCID: PMC5607921 DOI: 10.1177/2333794x17731695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/08/2017] [Indexed: 11/16/2022] Open
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Fiscaletti M, Stewart P, Munns CF. The importance of vitamin D in maternal and child health: a global perspective. Public Health Rev 2017; 38:19. [PMID: 29450091 PMCID: PMC5809824 DOI: 10.1186/s40985-017-0066-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/21/2017] [Indexed: 12/12/2022] Open
Abstract
Vitamin D and calcium are important nutrients for skeletal growth and bone health. Children and pregnant women are particularly vulnerable to 25-hydroxy vitamin D deficiency (VDD). VDD, with or without dietary calcium deficiency, can lead to nutritional rickets (NR), osteomalacia, and disturbances in calcium homeostasis. Multiple studies have linked VDD to adverse health outcomes in both children and pregnant women that extend beyond bone health. VDD remains an important global public health concern, and an important differentiation must be made between the impact of VDD on children and adults. Reports of increased incidence of NR continue to emerge. NR is an entirely preventable condition, which could be eradicated in infants and children worldwide with adequate vitamin D and calcium supplementation. The desire and necessity to put in place systems for preventing this potentially devastating pediatric disease should not elicit dispute. VDD and NR are global public health issues that require a collaborative, multi-level approach for the implementation of feasible preventative strategies. This review highlights the history, risk factors, and controversies related to VDD during pregnancy and childhood with a particular focus on global NR prevention.
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Affiliation(s)
- M Fiscaletti
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
| | - P Stewart
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
| | - CF Munns
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Abstract
An increasing amount of evidence points to the possibility that gestational and early childhood vitamin D deficiency [25(OH)D < 40 ng/ml] cause some cases of autism. Vitamin D is metabolized into a seco-steroid hormone that regulates about 3% of the 26,000 genes in the coding human genome. It is also a neurosteroid that is active in brain development, having effects on cellular proliferation, differentiation, calcium signaling, neurotrophic and neuroprotective actions; it also appears to have an effect on neurotransmission and synaptic plasticity. Children who are, or who are destined to become, autistic have lower 25(OH)D levels at 3 months of gestation, at birth and at age 8 compared to their unaffected siblings. Two open label trials found high dose vitamin D improves the core symptoms of autism in about 75% of autistic children. A few of the improvements were remarkable. The vitamin D doses used in these children were 300 IU/KG/day up to a maximum of 5000 IU/day (highest final 25(OH)D level reached was 45 ng/ml). The other study used 150,000 IU/month IM as well as 400 IU/day [highest final 25(OH)D level was 52 ng/ml]. These two open label trials were recently confirmed with a randomized controlled trial (RCT) using 300 IU/kg/day with a maximum of 5000 IU/day and resulted in effects similar to the two open label studies. In terms of prevention, a recent small study showed vitamin D supplementation during pregnancy (5000 IU/day) and during infancy and early childhood (1000 IU/day) significantly reduced the expected incidence of autism in mothers who already had one autistic child from 20% to 5%. Vitamin D is safe; for example, over the last 15 years, Poison Control reports there have been approximately 15,000 cases of vitamin D overdose. However only three of these 15,000 people developed clinical toxicity and no one died. Given those facts, practitioners might consider treating autism with 300 IU/kg/day, and seek to prevent autism by supplementing pregnant and lactating women (5000 IU/day) and infants and young children (150 IU/kg/day) checking 25(OH)D levels every 3 months. These doses will increase 25(OH)D blood levels to those recommended by the Endocrine Society. As the American Academy of Pediatrics recommends vitamin D supplementation during infancy and childhood, pediatricians and family practitioners should evaluate the current evidence on autism and vitamin D and act accordingly.
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Affiliation(s)
- John Jacob Cannell
- Vitamin D Council Inc., 1411 Marsh Street, Suite 203, San Luis Obispo, CA, 93401, USA.
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Itoh M, Tomio J, Toyokawa S, Tamura M, Isojima T, Kitanaka S, Kobayashi Y. Vitamin D-Deficient Rickets in Japan. Glob Pediatr Health 2017; 4:2333794X17711342. [PMID: 28607944 PMCID: PMC5456026 DOI: 10.1177/2333794x17711342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 04/27/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives: Our study aimed to clarify the trend of vitamin D deficiency and rickets diagnosed in the past 10 years. Methods: This observational study used health insurance claims data from 2005 to 2014. The number of beneficiaries for 2005 and 2014 were 91 617 and 365 800, respectively. We included children aged 0 to 15 years diagnosed with vitamin D deficiency or vitamin D-deficient rickets; those with congenital/secondary rickets and low-birth-weight infants were excluded. We analyzed the number of patients and the temporal trend of these diseases in Japan. Results: The annual number of patients from 2005 to 2008 was <5. The number of patients in 2009 and 2014 were 3.88 (95% confidence interval = 1.77-7.37) and 12.30/100 000 (95% confidence interval = 8.97-16.46), respectively. Conclusions: Diagnosed cases of vitamin D deficiency and vitamin D-deficient rickets have apparently increased in Japan. Further studies to identify the trend, cause, and prevention of vitamin D-deficient rickets are necessary.
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Affiliation(s)
| | - Jun Tomio
- The University of Tokyo, Tokyo, Japan
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50
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Abstract
OBJECTIVES Poor vitamin D status has been reported to be highly prevalent in many non-western immigrant groups living in Norway and other western countries. However, data on rickets are scarce, and the aim of the current study was to identify new cases of nutritional rickets in Norway in the period 2008-2012 among children under the age of 5 years. DESIGN Register-based cohort study. SETTING The Norwegian population from 2008 to 2012. PARTICIPANTS Children with nutritional rickets under the age of 5 years. MAIN OUTCOME MEASURE Nutritional rickets. Patients with ICD10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) diagnosis code E55.0 (active rickets) treated at all Norwegian hospitals were identified in the Norwegian Patient Registry. We were able to review 85% of the medical records for diagnosis confirmation. In addition, we identified patients with the diagnoses E55.9, E64.3 and E83.3 to identify individuals with rickets who had been given other diagnoses. RESULTS Nutritional rickets was confirmed in 39 children aged 0-4 years with the diagnosis of E55.0. In addition, three patients with the diagnosis of unspecified vitamin D deficiency (E55.9) were classified as having nutritional rickets, giving a total of 42 patients. Mean age at diagnosis was 1.40 years (range 0.1-3.5 years), and 93% had a non-western immigrant background. The incidence rate of rickets was estimated to be 0.3 per 10 000 person-years in the total Norwegian child population under the age of 5 years and 3.1 per 10 000 person-years in those with an immigrant background from Asia or Africa. CONCLUSION The number of children with nutritional rickets in Norway remained low in the period 2008-2012. Nearly all children had a non-western immigrant background.
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Affiliation(s)
- Haakon E Meyer
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kristina Skram
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | | | - Ahmed A Madar
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
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