Differential low uptake of free vitamin D supplements in preterm infants: the Quebec experience

The impact of vitamin D food fortification and health outcomes in children: a systematic review and meta-regression

OBJECTIVE

Vitamin D (vitD) deficiency is a global childhood health problem. Food fortification is a promising strategy to curb vitD deficiency. We aimed to assess the effectiveness of utilizing vitD fortification in staple foods to improve 25hydroxyvitamin D (25(OH)D) concentration and to reduce the prevalence of vitD deficiency among healthy children.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the use of vitD fortified food products compared to no fortification among healthy children aged 1-18 years old. We searched Medline, Embase, Global Health, and Cochrane (CENTRAL) databases from database inception until May 2019. Independently, six reviewers in pairs screened titles and abstracts, assessed the full text for eligibility, and performed data extraction and quality assessment. The primary outcome is the impact of fortification on 25(OH)D concentration. The secondary outcomes included the impact of fortification on the prevalence of vitD deficiency, school performance, cognitive function, school absences, infection rate, hospital admission length, and compliance with fortified food product consumption.

RESULTS

We identified 2229 articles. After assessing eligibility, 20 RCTs met the inclusion criteria. The eligible RCTs assessed the fortification of milk, cereal, juice, bread, yogurt, and cheese compared with no fortification. All RCTs, except for three, had a low risk of bias. Food fortification improved 25(OH)D concentration by a mean difference (MD) of 15.51 nmol/L (95% confidence interval (CI) 6.28, 24.74; I² = 99%), which resulted in a mean increase of 3 nmol/l for every 100 IU of vitD, when adjusted for baseline 25(OH)D concentration and country latitude. Additionally, the prevalence of vitD deficiency decreased by a risk ratio of 0.53 (95% CI 0.41, 0.69; I² = 95%), and cognitive function improved by a MD of 1.22 intelligence quotient (IQ) points (95% CI 0.65, 1.79; I² = 0%). The overall evidence quality was high.

CONCLUSION

VitD food fortification is an effective way to improve 25(OH)D concentration, prevent vitD deficiency, and improve IQ levels.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017057631.

Feeding the Late and Moderately Preterm Infant: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent, although they represent the largest population of preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a review of the literature with the aim to provide guidance on how to feed infants born LMPT, and identify gaps in the literature and research priorities.Only limited data from controlled trials are available. Late preterm infants have unique, often unrecognized, vulnerabilities that predispose them to high rates of nutritionally related morbidity and hospital readmissions. They frequently have feeding difficulties that delay hospital discharge, and poorer rates of breastfeeding initiation and duration compared with term infants. This review also identified that moderately preterm infants frequently exhibit postnatal growth restriction.The ESPGHAN CoN strongly endorses breast milk as the preferred method of feeding LMPT infants and also emphasizes that mothers of LMPT infants should receive qualified, extended lactation support, and frequent follow-up. Individualized feeding plans should be promoted. Hospital discharge should be delayed until LMPT infants have a safe discharge plan that takes into account local situation and resources.In the LMPT population, the need for active nutritional support increases with lower gestational ages. There may be a role for enhanced nutritional support including the use of human milk fortifier, enriched formula, parenteral nutrition, and/or additional supplements, depending on factors, such as gestational age, birth weight, and significant comorbidities. Further research is needed to assess the benefits (improved nutrient intakes) versus risks (interruption of breast-feeding) of providing nutrient-enrichment to the LMPT infant.

A closer look at rickets and vitamin D deficiency in Manitoba: The tip of the iceberg

Objectives

Vitamin D deficiency rickets remains a problem in Canada. Our primary objective was to determine the annual incidence of rickets and/or early vitamin D deficiency in Manitoba. Secondarily, we investigated if there was an increase in the annual incidence.

Methods

A retrospective chart review was undertaken to identify cases in our catchment area from 2003 to 2015. Data sources included endocrine and hospital charts and radiology reports. Early vitamin D deficiency was determined by review of all 25(OH)D tests from 2011 to 2015. Values less than 30 nmol/L with an elevated bone marker prompted a chart review in children under 7 years.

Results

We identified 46 cases of rickets and 68 with early vitamin D deficiency. For Manitoba, the annual incidence of rickets was 8.2 cases per 100,000 in infants, and 1.6 per 100,000 in children aged 1 to 7 years. Those with early vitamin D deficiency had annual incidences of 2.7 per 100,000 infants and 9.9 per 100,000 Manitoban children. No temporal trends were noted for either. For both disorders, most cases were from northern or rural locales; about 50% were of self-declared Indigenous or Inuit heritage, and the majority (>75%) of children were from families with high material deprivation using area-based socioeconomic measures.

Conclusion

Despite several decades of preventative efforts, the incidence of rickets was comparable to previous Canadian reports, particularly in infants. Greater education across the lifespan and engagement with communities and public health agencies will be needed to reduce the high incidence of this preventable disease.

Rickets

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.