NUTRITION: Vitamin D-Bones and beyond
Screening high-risk patients for vitamin D deficiency can circumvent problems including rickets in younger children (peak incidence, 3-18 months) and bone fragility in older children, said Neville H. Golden, MD, FAAP, in “Vitamin D-Bones and Beyond: When to Screen, When to Treat, and How to Treat.”
Screening high-risk patients for vitamin D deficiency can circumvent problems including rickets in younger children (peak incidence, 3-18 months) and bone fragility in older children, said Neville H. Golden, MD, FAAP, in “Vitamin D-Bones and Beyond: When to Screen, When to Treat, and How to Treat.” Vitamin D also may reduce cardiovascular and metabolic risk, boost immunity, and prevent some cancers, particularly of the breast, colon, and prostate, he said.
American Academy of Pediatrics (AAP) and Pediatric Endocrine Society (PES) criteria define vitamin D deficiency as having less than 20 ng/mL 25-hydroxyvitamin D (25[OH]D). Measuring 25(OH)D levels provides a more accurate gauge than does 1,25(OH)D because of the former's longer half-life (2-3 weeks vs 4 hours for 1,25[OH]D, respectively), he said, and 1,25(OH)D levels have little if any predictive value relative to bone health.
Using the 20 ng/mL 25(OH)D criterion, 29% to 49% of overweight and obese children are vitamin D deficient, as are 71% to 87% of African Americans and 44% to 52% of Latino children.1
Golden departed from 2011 PES guidelines by advising against universal vitamin D screening for obese patients and those with darker skin.2 In concert with these guidelines, he suggested screening patients with risk factors such as:
- Osteoporosis;
- Malabsorption syndromes (cystic fibrosis, inflammatory bowel disease, Crohn disease, celiac disease);
- Hyperparathyroidism;
- Medications (glucocorticoids, anticonvulsants, antiretrovirals, and antifungals);
- Conditions linked with reduced bone mass (such as eating disorders and chronic illnesses); and
- Recurrent low-impact fractures.
To treat vitamin D deficiency in infants and toddlers, Golden recommended 50,000 international units (IU) once weekly or 2000 IU daily for 6 weeks, followed by recheck, then 400 IU to 1000 IU daily (maintenance). For children aged 1 to 18 years, induction doses can continue for up to 8 weeks; maintenance doses range from 600 IU to 1000 IU daily.
Neville H. Golden, MD, FAAP, is chief, Division of Adolescent Medicine, Lucile Packard Children's Hospital, Palo Alto, California.
REFERENCES
1. Turer CB, Lin H, Flores G. Prevalence of vitamin D deficiency among overweight and obese US children. Pediatrics. 2013;131(1):e152-e161).
2. Golden NH, Abrams SA; Committee on Nutrition. Optimizing bone health in children and adolescents. Pediatrics. 2014;134(4):e1229-e1243.
Dr. Golden's AAP presentation covers the "bread and butter" of what is known about vitamin D and bone-why vitamin D is important to bone health, who's at risk of deficiency, and how to treat vitamin D deficiency. Golden's 2014 article2 goes much more in-depth regarding the known factors that are important during childhood and adolescence to achieve peak bone mass in the second or third decade of life. Any chronic illness can affect the achievement of peak bone mass. Vitamin D and calcium are key factors in optimizing bone health.
Other important factors promoting bone health in childhood include bone-pounding exercise and achievement of a healthy weight. Exercise during the peripubertal and pubertal time is especially important to optimizing bone mass. Some hormonal deficiencies or excesses also affect bone health. A healthy hormonal milieu helps ensure strong bones. Making sure a patient has normal growth hormone, thyroid function, and sex hormone production is very important. Deficiencies in these hormones are most often picked up because of abnormal growth.
Weight is an important factor in optimizing bone health. For example, being underweight or having a low body mass index (BMI) usually predisposes patients to lower bone mass and a higher risk of fracture. Often this occurs in the setting of anorexia nervosa or the athletic triad: a teenaged girl who has a low BMI, is not menstruating, and has low bone mass. Some studies have shown that obesity may increase fracture risk, although further study is needed.
Vitamin D is the exception to the rule that eating healthy should provide adequate nutrients. Ingesting the recommended amount of 600 IU for children aged older than 1 year would require drinking 6 8-ounce glasses of milk daily, or the equivalent. It's very difficult to obtain adequate vitamin D from your diet without vitamin D supplementation.
Sun exposure can be a source of vitamin D. However, vitamin D is unable to be produced by the skin in most places in the United States between October and March. Increasing rates of melanoma and the significance of sunburn in childhood as a risk factor for melanoma should keep the focus on dietary intake of vitamin D in most patients.
Dominique N. Long, MD, is an instructor, Johns Hopkins Hospital Division of Pediatric Endocrinology, Baltimore, Maryland.
Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.
