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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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Korkmaz HA, Padidela R, Ozkan B. Approach to nutritional rickets. J Pediatr Endocrinol Metab 2023; 36:335-341. [PMID: 36843296 DOI: 10.1515/jpem-2023-0051] [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: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/28/2023]
Abstract
Rickets is the disease of a growing skeleton and results from impaired apoptosis of hypertrophic chondrocytes and mineralization of the growth plate. Nutritionally induced rickets, secondary to vitamin D and/or calcium deficiency, remains a major global problem. In this review, we discuss pathogenesis, clinical signs, investigation and management of nutritional rickets.
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Affiliation(s)
- Hüseyin Anıl Korkmaz
- Department of Pediatrics, Division of Pediatric Endocrinology, Dr. Behçet Uz Pediatric Diseases and Surgery training and Research hospital, İzmir, Türkiye
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital and Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Behzat Ozkan
- Department of Pediatrics, Division of Pediatric Endocrinology, Dr. Behçet Uz Pediatric Diseases and Surgery training and Research hospital, İzmir, Türkiye
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3
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Abstract
Hypophosphatemic rickets typically presents in infancy or early childhood with skeletal deformities and growth plate abnormalities. The most common causes are genetic (such as X-linked hypophosphatemia), and these typically will result in lifelong hypophosphatemia and osteomalacia. Knowledge of phosphate metabolism, including the effects of fibroblast growth factor 23 (FGF23) (an osteocyte produced hormone that downregulates renal phosphate reabsorption and 1,25-dihydroxyvitamin-D (1,25(OH)2D) production), is critical to determining the underlying genetic or acquired causes of hypophosphatemia and to facilitate appropriate treatment. Serum phosphorus should be measured in any child or adult with musculoskeletal complaints suggesting rickets or osteomalacia. Clinical evaluation incudes thorough history, physical examination, laboratory investigations, genetic analysis (especially in the absence of a guiding family history), and imaging to establish etiology and to monitor severity and treatment course. The treatment depends on the underlying cause, but often includes active forms of vitamin D combined with phosphate salts, or anti-FGF23 antibody treatment (burosumab) for X-linked hypophosphatemia. The purpose of this article is to explore the approach to evaluating hypophosphatemic rickets and its treatment options.
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Affiliation(s)
- Sarah A Ackah
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Erik A Imel
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Beyazgül G, Bağ Ö, Yurtseven İ, Coşkunol F, Başer S, Çiçek D, Kanberoğlu Gİ, Çelik F, Nalbantoğlu Ö, Özkan B. How Vitamin D Levels of Children Changed During COVID-19 Pandemic: A Comparison of Pre-pandemic and Pandemic Periods. J Clin Res Pediatr Endocrinol 2022; 14:188-195. [PMID: 35135185 PMCID: PMC9176086 DOI: 10.4274/jcrpe.galenos.2022.2021-10-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The synthesis of vitamin D is related to sun exposure, thus the restrictions during the Coronavirus disease-2019 (COVID-19) pandemic may have affected the levels of vitamin D in all age groups. The aim of this study was to evaluate vitamin D levels of healthy children and adolescents during the first year of the pandemic. METHODS The study group included healthy children and adolescents who were admitted for general check-ups and evaluated with 25(OH)D levels. Then, it was divided into two groups: Group 1 “pre-pandemic”, and Group 2 “pandemic”. Vitamin D levels were recorded from the hospital database and were compared according to age groups, gender, and the season, retrospectively. RESULTS The study group [mean age=90.29±59.45 median age=79 interquartile range (IQR): 102 months, male/female: 1409/1624] included 3033 children and adolescents (Group 1/Group 2 n=1864/1169). Although the mean 25(OH)D levels among preschool children did not differ between groups, the vitamin D levels of school-aged children and adolescents were significantly lower in the pandemic period than in the pre-pandemic period [Group 1 median=16.50 (IQR: 10.5) vs Group 2 median=15.9 (IQR: 11.3) in 6-12 age group (p=0.026); Group 1 median=13.30 (IQR: 10.2) vs Group 2 median=11.20 (IQR: 9.7) in 12-18 age group (p=0.003)]. Moreover, the 25(OH)D levels of adolescents showed seasonal variance with lower levels in winter, and unexpectedly, in summer. CONCLUSION Pandemic-related restrictions have caused significant decreases in vitamin D levels of school-aged children and adolescents. We suggest that children and adolescents should be given vitamin D supplementation in order to maintain sufficient levels of vitamin D during the pandemic.
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Affiliation(s)
- Güler Beyazgül
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey,* Address for Correspondence: University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey Phone: +90 232 464 61 67 E-mail:
| | - Özlem Bağ
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - İlkay Yurtseven
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Fulya Coşkunol
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Saynur Başer
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Duygu Çiçek
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Gül İrem Kanberoğlu
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Filiz Çelik
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of General Pediatrics, İzmir, Turkey
| | - Özlem Nalbantoğlu
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey
| | - Behzat Özkan
- University of Health Sciences Turkey, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey
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5
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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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Moreira CA, Costa TMRL, Marques JVO, Sylvestre L, Almeida ACR, Maluf EMCP, Borba VZC. Prevalence and clinical characteristics of X-linked hypophosphatemia in Paraná, southern Brazil. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 64:796-802. [PMID: 33049132 PMCID: PMC10528612 DOI: 10.20945/2359-3997000000296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this cross-sectional study was to estimate the prevalence of XLH in Paraná, a state in southern Brazil, and report the clinical features and complications of the disease. METHODS We invited all endocrinologists (n = 205), nephrologists (n = 221), orthopedic surgeons (n = 1020), and pediatricians (n = 1000) in Paraná to fill out an electronic survey with information on patients with X-linked hypophosphatemia (XLH), and searched the records of the state's health department for all calcitriol prescriptions in 2018. RESULTS In all, 244 (10%) specialists responded to the email, of whom 18 (7.4%) reported to be taking care of patients with XLH and answered the online survey. A total of 57 patients with XLH were identified (prevalence 5 per million inhabitants). The median age at diagnosis was 22 years, and 42.2% were children and adolescents. Fifteen patients had genetic testing showing a PHEX mutation. Overall, 91.2% had bone deformities, 30.8% had a history of fragility fractures, and 22.4% had renal complications. CONCLUSION This study demonstrated a prevalence of XLH of 5 cases per million inhabitants in the state of Paraná, a rate lower than the one reported in other countries. Manifestations of renal calcification and bone fragility were frequent among the patients. This is the first epidemiological study evaluating the prevalence and clinical presentation of XLH in Latin America.
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Affiliation(s)
- Carolina Aguiar Moreira
- Divisão de Endocrinologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil,
- Lab PRO, Seção de Histomorfometria Óssea, Fundação Pró-Renal, Curitiba, PR, Brasil
| | - Tatiana M R Lemos Costa
- Divisão de Endocrinologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | | | - Lucimary Sylvestre
- Serviço de Nefrologia Pediátrica, Hospital Pequeno Príncipe, Curitiba, PR, Brasil
- Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brasil
| | - Ana Cristina R Almeida
- Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brasil
- Secretaria de Saúde do Paraná, Curitiba, PR, Brasil
| | - Eliane M C P Maluf
- Universidade Positivo, Curitiba, PR, Brasil
- Programa de Pós-Graduação, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Victória Z C Borba
- Divisão de Endocrinologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
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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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Laird E, Walsh JB, Lanham-New S, O’Sullivan M, Kenny RA, Scully H, Crowley V, Healy M. A High Prevalence of Vitamin D Deficiency Observed in an Irish South East Asian Population: A Cross-Sectional Observation Study. Nutrients 2020; 12:nu12123674. [PMID: 33260572 PMCID: PMC7760119 DOI: 10.3390/nu12123674] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023] Open
Abstract
At northern latitudes, non-ethnic population groups can be at an increased risk of vitamin D deficiency (defined as a 25-hydroxyvitamin D [25(OH)D] status ≤30 nmol/L). The vitamin D status of ethnic minority groups has been examined both in UK and European populations, but not in the Irish context. The aim of this study is to assess the vitamin D status from a selection of the Dublin population of South East Asian descent. A search was conducted, using the laboratory information system of St James's Hospital, Dublin, for vitamin D requests by General practitioners. From 2013 to 2016, 186 participants were identified and 25(OH)D analysis was quantified using liquid chromatography-tandem mass spectrometry (LC-MS-MS). Overall, the median age was 32 years, 51% were male, and the 25(OH)D concentration ranged from 10 to 154 nmol/L. In total, 66.7% of the total sample were vitamin D deficient and 6.7% had a 25(OH)D status greater than 50 nmol/L (the 25(OH)D concentration defined by the EU as 'sufficient'). Females had a significantly higher 25(OH)D concentration than males (25.0 vs. 18.0 nmol/L; p = 0.001) but both groups had a significant proportion with deficient status (56% and 76.8%, respectively). Seasonal variation of 25(OH)D was not evident while high rates of deficiency were also observed in those aged <18 years and >50 years. Given the importance of vitamin D for health, this sub-population could be at a significantly increased risk of rickets, impaired bone metabolism, and osteoporosis. In addition, vitamin D deficiency has been associated with several non-bone related conditions, including cardiovascular disease and diabetes. Currently, there is no unique vitamin D intake or vitamin D status maintenance guidelines recommended for adults of non-Irish descent; this needs to be considered by the relevant public health bodies in Ireland.
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Affiliation(s)
- Eamon Laird
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland; (M.O.); (R.A.K.)
- Correspondence: ; Tel.: +353-1896-4342
| | - James Bernard Walsh
- Mercer’s Institute for Successful Ageing, St. James’s Hospital, Dublin 8, Ireland; (J.B.W.); (H.S.)
| | - Susan Lanham-New
- Department of Nutritional Science, University of Surrey, Surrey GU2 7YW, UK;
| | - Maria O’Sullivan
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland; (M.O.); (R.A.K.)
| | - Rose Anne Kenny
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland; (M.O.); (R.A.K.)
| | - Helena Scully
- Mercer’s Institute for Successful Ageing, St. James’s Hospital, Dublin 8, Ireland; (J.B.W.); (H.S.)
| | - Vivion Crowley
- Department of Biochemistry, Central Pathology, St. James’s Hospital, Dublin 8, Ireland; (V.C.); (M.H.)
| | - Martin Healy
- Department of Biochemistry, Central Pathology, St. James’s Hospital, Dublin 8, Ireland; (V.C.); (M.H.)
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Wändell P, Li X, Carlsson AC, Sundquist J, Sundquist K. Distal forearm fractures in immigrant groups: A national Swedish study. Bone 2020; 138:115508. [PMID: 32599220 DOI: 10.1016/j.bone.2020.115508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim was to analyse risk of forearm fractures in first- and second-generation immigrants to Sweden. METHODS A nationwide study of individuals 20 years of age and older was conducted. Forearm fractures were defined as at least one registered diagnosis in the National Patient Register between January 1, 1998 and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident forearm fractures compared to Swedish-born individuals, or in second-generation immigrant groups relative to individuals with Swedish-born parents. Cox regression models were stratified by sex and adjusted for age, sociodemographic status, and co-morbidities. RESULTS A total of 5,953,764 individuals were included in the first-generation study (2,861,256 men, and 3,092,508 women), and a forearm fracture was registered in 166,955 individuals (2.8%). The second-generation study included 4,656,023 individuals (2,368,585 men, and 2,287,438 women) with a registered forearm fracture in 111,576 individuals (2.4%). Fully adjusted HRs showed marginally lower risks when all immigrants were studied, for first-generation men 0.95 (95% CI 0.92-0.98) and women 0.95 (95% CI 95 0.92-0.97), and for second-generation men 0.93 (95% CI 0.90-0.97) and women 0.90 (95% CI 0.88-0.93). An increased risk was found among some first-generation immigrant men, especially in men from the Middle East. CONCLUSIONS We observed a marginally lower overall risk of fractures among immigrants, but with differences among the immigrant groups.
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Affiliation(s)
- Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
| | - Xinjun Li
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Axel C Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Academic Primary Health Care Centre, Stockholm Region, Stockholm, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA; Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Matsue, Japan
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA; Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Matsue, Japan
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Bouillon R, Antonio L. Nutritional rickets: Historic overview and plan for worldwide eradication. J Steroid Biochem Mol Biol 2020; 198:105563. [PMID: 31809867 DOI: 10.1016/j.jsbmb.2019.105563] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/10/2019] [Accepted: 12/02/2019] [Indexed: 02/01/2023]
Abstract
Rickets was first described in great detail in the mid 17th century and was affecting a great number of children in major European cities. The disease, however, existed already in the Roman times. The etiology of this disease remained enigmatic until the 1920s when two different mechanisms, lack of exposure to sunlight and lack of a dietary factor were finally solved by the discovery of vitamin D and its dual origin. Soon thereafter, the implementation of vitamin D supplementation for all infants and small children largely eliminated nutritional rickets in Europe and North America. It took nearly a century to elucidate the complex chemistry, metabolism, mode and spectrum of activity of the vitamin D endocrine system. Nutritional rickets, whether due to simple vitamin D or calcium deficiency or both, remains widely ravaging many infants and children around the world. Asian countries and the Middle East are mainly confronted with vitamin D deficiency whereas many African and some Asian countries face calcium deficiency rickets. Immigrants and refugees or in general people with a darker skin living in moderate climate zone are also confronted with this disease. There is great consensus how this disease could be prevented or cured. In collaboration with most international professional societies, we prepare a memorandum, in line with the successful battle against iodine deficiency disorders, to convince the World Health Organization and its member states to start an implementation program to eradicate nutritional rickets by 2030.
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Affiliation(s)
- Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium.
| | - Leen Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium
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11
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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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12
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Bouillon R, Marcocci C, Carmeliet G, Bikle D, White JH, Dawson-Hughes B, Lips P, Munns CF, Lazaretti-Castro M, Giustina A, Bilezikian J. Skeletal and Extraskeletal Actions of Vitamin D: Current Evidence and Outstanding Questions. Endocr Rev 2019; 40:1109-1151. [PMID: 30321335 PMCID: PMC6626501 DOI: 10.1210/er.2018-00126] [Citation(s) in RCA: 512] [Impact Index Per Article: 102.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/17/2018] [Indexed: 02/06/2023]
Abstract
The etiology of endemic rickets was discovered a century ago. Vitamin D is the precursor of 25-hydroxyvitamin D and other metabolites, including 1,25(OH)2D, the ligand for the vitamin D receptor (VDR). The effects of the vitamin D endocrine system on bone and its growth plate are primarily indirect and mediated by its effect on intestinal calcium transport and serum calcium and phosphate homeostasis. Rickets and osteomalacia can be prevented by daily supplements of 400 IU of vitamin D. Vitamin D deficiency (serum 25-hydroxyvitamin D <50 nmol/L) accelerates bone turnover, bone loss, and osteoporotic fractures. These risks can be reduced by 800 IU of vitamin D together with an appropriate calcium intake, given to institutionalized or vitamin D-deficient elderly subjects. VDR and vitamin D metabolic enzymes are widely expressed. Numerous genetic, molecular, cellular, and animal studies strongly suggest that vitamin D signaling has many extraskeletal effects. These include regulation of cell proliferation, immune and muscle function, skin differentiation, and reproduction, as well as vascular and metabolic properties. From observational studies in human subjects, poor vitamin D status is associated with nearly all diseases predicted by these extraskeletal actions. Results of randomized controlled trials and Mendelian randomization studies are supportive of vitamin D supplementation in reducing the incidence of some diseases, but, globally, conclusions are mixed. These findings point to a need for continued ongoing and future basic and clinical studies to better define whether vitamin D status can be optimized to improve many aspects of human health. Vitamin D deficiency enhances the risk of osteoporotic fractures and is associated with many diseases. We review what is established and what is plausible regarding the health effects of vitamin D.
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Affiliation(s)
- Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Belgium
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Geert Carmeliet
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Belgium
| | - Daniel Bikle
- Veterans Affairs Medical Center and University of California San Francisco, San Francisco, California
| | - John H White
- Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Bess Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts
| | - Paul Lips
- Department of Internal Medicine, Endocrine Section, VU University Medical Center, HV Amsterdam, Netherlands
| | - Craig F Munns
- Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Andrea Giustina
- Chair of Endocrinology, Vita-Salute San Raffaele University, Milan, Italy
| | - John Bilezikian
- Department of Endocrinology, Columbia University College of Physicians and Surgeons, New York, New York
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Lips P, Cashman KD, Lamberg-Allardt C, Bischoff-Ferrari HA, Obermayer-Pietsch B, Bianchi ML, Stepan J, El-Hajj Fuleihan G, Bouillon R. Current vitamin D status in European and Middle East countries and strategies to prevent vitamin D deficiency: a position statement of the European Calcified Tissue Society. Eur J Endocrinol 2019; 180:P23-P54. [PMID: 30721133 DOI: 10.1530/eje-18-0736] [Citation(s) in RCA: 365] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/31/2019] [Indexed: 12/11/2022]
Abstract
Vitamin D deficiency (serum 25-hydroxyvitamin D (25(OH)D) <50 nmol/L or 20 ng/mL) is common in Europe and the Middle East. It occurs in <20% of the population in Northern Europe, in 30-60% in Western, Southern and Eastern Europe and up to 80% in Middle East countries. Severe deficiency (serum 25(OH)D <30 nmol/L or 12 ng/mL) is found in >10% of Europeans. The European Calcified Tissue Society (ECTS) advises that the measurement of serum 25(OH)D be standardized, for example, by the Vitamin D Standardization Program. Risk groups include young children, adolescents, pregnant women, older people (especially the institutionalized) and non-Western immigrants. Consequences of vitamin D deficiency include mineralization defects and lower bone mineral density causing fractures. Extra-skeletal consequences may be muscle weakness, falls and acute respiratory infection, and are the subject of large ongoing clinical trials. The ECTS advises to improve vitamin D status by food fortification and the use of vitamin D supplements in risk groups. Fortification of foods by adding vitamin D to dairy products, bread and cereals can improve the vitamin D status of the whole population, but quality assurance monitoring is needed to prevent intoxication. Specific risk groups such as infants and children up to 3 years, pregnant women, older persons and non-Western immigrants should routinely receive vitamin D supplements. Future research should include genetic studies to better define individual vulnerability for vitamin D deficiency, and Mendelian randomization studies to address the effect of vitamin D deficiency on long-term non-skeletal outcomes such as cancer.
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Affiliation(s)
- Paul Lips
- Endocrine Section, Department of Internal Medicine, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, Department of Medicine, University College Cork, Cork, Ireland
| | - Christel Lamberg-Allardt
- Calcium Research Unit, Department of Food and Nutritional Sciences, University of Helsinki, Helsinki, Finland
| | | | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | | | - Jan Stepan
- Institute of Rheumatology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roger Bouillon
- Clinic and Laboratory of Endocrinology, Gasthuisberg, KU Leuven, Leuven, Belgium
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Egge S, Christensen N, Lykkedegn S, Jensen TK, Christesen HT. Cord serum 25-hydroxyvitamin D is not associated with cranial anthropometrics in infants up to 6 months of age. An Odense Child Cohort study. J Bone Miner Metab 2018; 36:700-709. [PMID: 29128970 DOI: 10.1007/s00774-017-0881-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
Skull changes are poorly described in vitamin D insufficiency [serum 25-hydroxyvitamin D (s-25(OH)D) 25-50 nmol/L]. We aimed to investigate factors associated with cranial anthropometrics in infants, especially s-25(OH)D. In infants 2.5-6 months old from the Odense Child Cohort, associations between cord and pregnancy s-25(OH)D and anterior fontanel area (n = 765), head circumference (HC, n = 1776) and head shape (n = 1527) were investigated along with other factors. Age was corrected for preterm birth. The mean (SD) s-25(OH)D in early pregnancy was 65.97 (21.33) nmol/L; late pregnancy 78.61 (27.18) nmol/L; and cord 47.1 (21.7) nmol/L. At median (IQR) age 3.7 (2.5-5.9) months, the fontanel area was 225 (0-1690) mm2, and mean (SD) HC was 41.5 (1.5) cm. Asymmetric/flat head shape was present in 846 infants (55.3%). No associations were found between cord, early or late pregnancy s-25(OH)D and any cranial measure by univariate or adjusted analysis. Among significant, independent associations in multivariate analysis, fontanel area was associated inversely with gestational age (GA); HC was associated directly with GA, maternal pre-pregnancy overweight and caesarean section and inversely with smoking; and asymmetrical head shape showed a novel association with male sex: adjusted OR = 1.54 (95% CI 1.25; 1.89), p < 0.001. Other associations with asymmetrical head shape included parity 3+, gestational age and maternal age 30+ years (all protective). In conclusion, neither pregnancy nor cord s-25(OH)D was associated with fontanel size, HC or asymmetrical head shape despite a high prevalence of cord s-25(OH)D < 50 nmol/L. Lower GA was associated with larger fontanel size, lower HC and asymmetrical head shape, and boys more frequently had asymmetrical head shape, probably due to heavier heads.
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Affiliation(s)
- Sissil Egge
- Hans Christian Andersen Children's Hospital, Odense University Hospital, J. B. Windsløws Vej 4, 5000, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
| | - Nikolas Christensen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, J. B. Windsløws Vej 4, 5000, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
| | - Sine Lykkedegn
- Hans Christian Andersen Children's Hospital, Odense University Hospital, J. B. Windsløws Vej 4, 5000, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
| | - Tina Kold Jensen
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 3, 5000, Odense C, Denmark
- Department of Environmental Medicine, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 17, 2, 5000, Odense C, Denmark
- OPEN Odense Patient Data Explorative Network, University of Southern Denmark, J.B. Winsløws Vej 9 A, 5000, Odense C, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, J. B. Windsløws Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 3, 5000, Odense C, Denmark.
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Abstract
Vitamin D deficiency and rickets are more common in non-western immigrants and refugees than in the native population. Severe vitamin D deficiency (serum 25-hydroxyvitamin D <25 nmol/l) may occur in up to 50% of children and adults of non-western origin. They are not used to sunshine exposure due to the often excessive sunshine in the country of origin. They usually have a more pigmented skin. Non-western immigrants and refugees often wear skin-covering clothes due to religious or cultural tradition. The food contains little vitamin D with the exception of fatty fish. In addition, many immigrants have a low calcium intake. Complaints may include fatigue, pain in shoulders, ribs, lower back and thighs. Neonates and young children may have spasms and convulsions due to hypocalcemia. Older children and adolescents may have bone pain, muscle weakness and skeletal deformities. Widening of the wrist, chest deformities and bowing of the legs may occur, and longitudinal growth is delayed. In adults, muscle weakness and bone pain are predominant. Laboratory examination may show hypocalcemia and hypophosphatemia and elevated alkaline phosphatase. The serum 25(OH)D is below 25 nmol/l in case of severe vitamin D deficiency with symptoms. Impaired 25-hydroxylation or 1α-hydroxylation may occur in case of severe liver or renal disease or by genetic causes. Radiographs of wrists or knees may show widening of the growth plates and cupping of radius and ulna may confirm the diagnosis. In adolescents and adults, radiographs of painful bones may show pseudofractures or Looser zones. Rickets and osteomalacia are treated by vitamin D3 2000 IU/d in infants, 3000-6000 IU/d in older children in combination with calcium 500 mg /d. In osteomalacia, the adult vitamin D3 dose is 2000-3000 IU/d, combined with calcium 1000-2000 mg/d. Prevention of vitamin D deficiency can be done with vitamin D3 400-800 IU/d, depending on age. Nutritional measures include fortification of milk or other foods.
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Creo AL, Thacher TD, Pettifor JM, Strand MA, Fischer PR. Nutritional rickets around the world: an update. Paediatr Int Child Health 2017; 37:84-98. [PMID: 27922335 DOI: 10.1080/20469047.2016.1248170] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.
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Affiliation(s)
- Ana L Creo
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
| | - Tom D Thacher
- b Department of Family Medicine , Mayo Clinic , Rochester , MN , USA
| | - John M Pettifor
- c Wits/SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics , University of the Witwatersrand , Johannesburg , South Africa
| | - Mark A Strand
- d Pharmacy Practice, Department of Public Health , North Dakota State University , Fargo , ND , USA
| | - Philip R Fischer
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
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Zhang M, Shen F, Petryk A, Tang J, Chen X, Sergi C. "English Disease": Historical Notes on Rickets, the Bone-Lung Link and Child Neglect Issues. Nutrients 2016; 8:E722. [PMID: 27854286 PMCID: PMC5133108 DOI: 10.3390/nu8110722] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/14/2022] Open
Abstract
Nutritional or classical rickets (here labeled as "rickets") is a worldwide disease involving mostly infants and young children having inadequate sunlight exposure, often associated with a low dietary intake of Vitamin D. Rickets targets all layers of society independently of economic status with historical information spanning more than two millennia. Vitamin D is critical for the absorption of calcium and prevention of rickets in children as well as osteomalacia in adults. The initial and misleading paradigm of the 19th and 20th centuries that rickets may have been the consequence of infection has been, indeed, reversed following the identification of the Vitamin D molecule's important role in the function of the immune system. Although traditionally considered limited to osteopathology, Vitamin D deficiency is now known to be linked to infection, inflammation, and carcinogenesis. In this review, we consider the key historical (Whistler, pre-Whistler and post-Whistler descriptors) and social facts around rickets; highlight the osteo-pathological features of rickets and the pathology of the upper and lower respiratory tract, stressing the fact that lungs remain the main secondary organ affected by Vitamin D deficiency; and emphasize the public health role in identifying the cases of child neglect or abuse based on the evaluation of the costochondral region.
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Affiliation(s)
- Mingyong Zhang
- Department of Orthopedics, Tianyou Hospital, Wuhan University of Science and Technology, Wuhan 430064, China.
| | - Fan Shen
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2B7, Canada.
| | - Anna Petryk
- Comprehensive Pediatric Bone Health Program, Div. Pediatric Endocrinology, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Jingfeng Tang
- Membrane Protein Disease and Cancer Research Centre, Provincial Innovation Center, Hubei University of Technology, Wuhan 430068, China.
| | - Xingzhen Chen
- Membrane Protein Disease and Cancer Research Centre, Provincial Innovation Center, Hubei University of Technology, Wuhan 430068, China.
- Department of Physiology, University of Alberta, Edmonton, AB T6G 2R3, Canada.
| | - Consolato Sergi
- Department of Orthopedics, Tianyou Hospital, Wuhan University of Science and Technology, Wuhan 430064, China.
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2B7, Canada.
- Stollery Children's Hospital, University of Alberta Hospital, Edmonton, AB T6G 2B7, Canada.
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. Horm Res Paediatr 2016; 85:83-106. [PMID: 26741135 DOI: 10.1159/000443136] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Vinkhuyzen AAE, Eyles DW, Burne TH, Blanken LME, Kruithof CJ, Verhulst F, Jaddoe VW, Tiemeier H, McGrath JJ. Prevalence and predictors of vitamin D deficiency based on maternal mid-gestation and neonatal cord bloods: The Generation R Study. J Steroid Biochem Mol Biol 2016; 164:161-167. [PMID: 26385604 DOI: 10.1016/j.jsbmb.2015.09.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/30/2015] [Accepted: 09/12/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Population-based studies have confirmed that the prevalence of vitamin D deficiency is substantial in many societies, and is of particular concern in pregnant women. Vitamin D deficiency during pregnancy is associated with a wide range of adverse maternal and offspring health outcomes. To date, studies of vitamin D deficiency during pregnancy have focused on measurements at one or two time points in isolation. We examined both midgestation and cord blood 25 hydroxyvitamin D (25OHD) concentration and explored the prevalence and correlates of vitamin D deficiency in a large ethnically diverse cohort of pregnant women and their infants in the Netherlands. METHODS This study was embedded in the Generation R Study, a population-based prospective cohort from fetal life onwards in Rotterdam, The Netherlands. Using a highly sensitive tandem mass spectroscopy-based assay, we measured 25OHD in 7256 midgestation samples (mean gestation 20.6 weeks) and 5023 neonatal cord blood samples (mean gestation 40.0 weeks). Using a conservative threshold of less than 25nmol/L to define vitamin D deficiency, we examined the prevalence and socio-demographic correlates of vitamin D deficiency in mothers and infants. We also derived a measure of vitamin D deficiency based on the two time points in order to explore persistent vitamin D deficiency in mother-infant pairs. RESULTS The prevalence of vitamin D deficiency at midgestation was 26%, while in neonates 46% were deficient. 21% of the mother-infant pairs had persistent vitamin D deficiency (i.e., deficient in maternal and cord samples) and an additional 29% were vitamin D deficient in one of the two samples only. Persistent vitamin D deficiency was strongly associated with non-European ancestry and spring birth. CONCLUSIONS A sizeable proportion of women and their neonatal offspring in the Generation R cohort were vitamin D deficient. In light of the large body of evidence linking vitamin D deficiency with adverse health outcomes for pregnant women and their offspring, our findings indicate a large unmet need in this population. In particular, women and infants from non-European ethnic background are at high risk of vitamin D deficiency.
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Affiliation(s)
- Anna A E Vinkhuyzen
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD 4072, Australia
| | - Darryl W Eyles
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD 4072, Australia; Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia
| | - Thomas H Burne
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD 4072, Australia; Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia
| | - Laura M E Blanken
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Claudia J Kruithof
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Frank Verhulst
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Vincent W Jaddoe
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - John J McGrath
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD 4072, Australia; Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia.
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21
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Thacher TD, Pludowski P, Shaw NJ, Mughal MZ, Munns CF, Högler W. Nutritional rickets in immigrant and refugee children. Public Health Rev 2016; 37:3. [PMID: 29450045 PMCID: PMC5810111 DOI: 10.1186/s40985-016-0018-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
Immigrant and refugee populations bring public health challenges to host nations. In the current global refugee crisis, children are the most vulnerable subpopulation. Diseases that were considered rare in the host nation may be highly prevalent among immigrant children. The prevalence of nutritional rickets is increasing in high-income countries, largely driven by an influx of immigrant populations. Nutritional rickets is a bone disease in early childhood resulting in bone pain, delayed motor development, and bending of the bones, caused by vitamin D deficiency and/or inadequate dietary calcium intake. The consequences of nutritional rickets include stunted growth, developmental delay, lifelong bone deformities, seizures, cardiomyopathy, and even death. Nutritional rickets is most commonly seen in children from the Middle East, Africa, and South Asia in high-income countries. Dark skin pigmentation, sun avoidance, covering the skin, and prolonged breast feeding without vitamin D supplementation, are important risk factors for vitamin D deficiency, and combined with a lack of dairy products in the diet, these deficiencies can result in insufficient calcium supply for bone mineralization. We recommend screening all immigrant and refugee children under 5 years of age from these ethnic groups for nutritional rickets, based on clinical features, and confirming the diagnosis with radiographs of the wrists and knees. Because nutritional rickets is entirely preventable, public health policies must address the need for universal vitamin D supplementation and adequate dietary calcium to protect children from this scourge. Vitamin D supplementation of all infants and children with 400 IU/d during the first year of life and dietary or supplemental intakes of at least 600 IU/d of vitamin D and 500 mg/d of calcium thereafter, will effectively prevent nutritional rickets. We call on national health authorities of host countries to implement health check lists and prevention programs that include screening for micronutrient deficiencies, in addition to assessing infections and vaccination programs. Due to their high prevalence of vitamin D deficiency, refugee children of all ages from these ethnic groups should be supplemented with vitamin D, beginning upon arrival.
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Affiliation(s)
- Tom D Thacher
- 1Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Pawel Pludowski
- 2Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nick J Shaw
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - M Zulf Mughal
- 4Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Craig F Munns
- 5The Children's Hospital at Westmead, Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Wolfgang Högler
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK.,6Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Abstract
OBJECTIVES Infants with biliary atresia (BA) are at high risk of vitamin D deficiency. We aimed to determine the prevalence and factors influencing vitamin D levels at presentation and post-Kasai portoenterostomy (KPE). METHODS Single-centre retrospective review of infants with BA who underwent KPE. Pre- and postoperatively 25-hydroxyvitamin D (25-OHVD), liver and bone biochemistry data were collected. 25-OHVD levels <10 and 10 to 20 ng/mL were defined as vitamin D "deficiency" and "insufficiency," respectively. RESULTS One hundred twenty-nine infants with BA (isolated n = 101, developmental n = 28, and white n = 79; non-white n = 50) were included in this study. At presentation, 75 of 92 (81%) were vitamin D deficient and only 1 infant had a level >20 ng/mL. Median 25-OHVD levels were 5(2-23), 17(2-72), 15(2-80), 17(2-69), and 23(2-98) ng/mL at pre-KPE, 1, 4, 6, and 12 months postoperation. There was no difference in 25-OHVD levels between the isolated and developmental groups with BA. Pre-KPE, white infants had significantly higher levels than non-white infants (6[2-23] vs 3[2-14] ng/mL, P = 0.01). Post-KPE 25-OHVD levels correlated well with liver and bone biochemical variables (eg, at 6 months: bilirubin rs = -0.34; P < 0.001, alkaline phosphatase rs = -0.46; P < 0.00001, and phosphate rs = 0.49; P < 0.00001). CONCLUSIONS 25-OHVD deficiency is invariable at presentation in infants with BA, irrespective of its likely aetiology, and is more severe in non-white infants. Despite routine parenteral and enteral supplementation, low 25-OHVD levels persist post KPE especially in icteric infants. More aggressive vitamin D supplementation and monitoring in this population is paramount.
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Nama N, Menon K, Iliriani K, Pojsupap S, Sampson M, O’Hearn K, Zhou L(L, McIntyre L, Fergusson D, McNally JD. A systematic review of pediatric clinical trials of high dose vitamin D. PeerJ 2016; 4:e1701. [PMID: 26966655 PMCID: PMC4782742 DOI: 10.7717/peerj.1701] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/27/2016] [Indexed: 12/21/2022] Open
Abstract
Background. Due to inadequate UV exposure, intake of small quantities of vitamin D is recommended to prevent musculoskeletal disease. Both basic science and observational literature strongly suggest that higher doses may benefit specific populations and have non-musculoskeletal roles. Evaluating the evidence surrounding high dose supplementation can be challenging given a relatively large and growing body of clinical trial evidence spanning time, geography, populations and dosing regimens. Study objectives were to identify and summarize the clinical trial literature, recognize areas with high quality evidence, and develop a resource database that makes the literature more immediately accessible to end users. Methods. Medline (1946 to January 2015), Embase (1974 to January 2015), and Cochrane databases (January 2015), were searched for trials. All pediatric (0-18 years) trials administering doses higher than 400 IU (<1 year) or 600 IU (≥1 year) were included. Data was extracted independently by two of the authors. An online searchable database of trials was developed containing relevant extracted information (http://www.cheori.org/en/pedvitaminddatabaseOverview). Sensitivity and utility were assessed by comparing the trials in the database with those from systematic reviews of vitamin D supplementation including children. Results. A total of 2,579 candidate papers were identified, yielding 169 trials having one or more arms meeting eligibility criteria. The publication rate has increased significantly from 1 per year (1970-1979) to 14 per year (2010-2015). Although 84% of the total trials focused on healthy children or known high risk populations (e.g., renal, prematurity), this proportion has declined in recent years due to the rise in trials evaluating populations and outcomes not directly related to the musculoskeletal actions of vitamin D (27% in 2010s). Beyond healthy children, the only pediatric populations with more than 50 participants from low risk of bias trials evaluating a clinically relevant outcome were prematurity and respiratory illness. Finally, we created and validated the online searchable database using 13 recent systematic reviews. Of the 38 high dose trials identified by the systematic review, 36 (94.7%) could be found within the database. When compared with the search strategy reported in each systematic review, use of the database reduced the number of full papers to assess for eligibility by 85.2% (±13.4%). Conclusion. The pediatric vitamin D field is highly active, with a significant increase in trials evaluating non-classical diseases and outcomes. Despite the large overall number there are few high quality trials of sufficient size to provide answers on clinical efficacy of high-dose vitamin D. An open access online searchable data should assist end users in the rapid and comprehensive identification and evaluation of trials relevant to their population or question of interest.
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Affiliation(s)
- Nassr Nama
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Supichaya Pojsupap
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Margaret Sampson
- Department of Volunteers, Communication and Information Resources, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Katie O’Hearn
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - James D. McNally
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab 2016; 101:394-415. [PMID: 26745253 PMCID: PMC4880117 DOI: 10.1210/jc.2015-2175] [Citation(s) in RCA: 618] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Vitamin D status and its determinants during autumn in children at northern latitudes: a cross-sectional analysis from the optimal well-being, development and health for Danish children through a healthy New Nordic Diet (OPUS) School Meal Study. Br J Nutr 2015; 115:239-50. [PMID: 26563915 DOI: 10.1017/s000711451500433x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Sufficient summer/autumn vitamin D status appears important to mitigate winter nadirs at northern latitudes. We conducted a cross-sectional study to evaluate autumn vitamin D status and its determinants in 782 Danish 8-11-year-old children (55°N) using baseline data from the Optimal well-being, development and health for Danish children through a healthy New Nordic Diet (OPUS) School Meal Study, a large randomised controlled trial. Blood samples and demographic and behavioural data, including 7-d dietary recordings, objectively measured physical activity, and time spent outdoors during school hours, were collected during September-November. Mean serum 25-hydroxyvitamin D (25(OH)D) was 60·8 (sd 18·7) nmol/l. Serum 25(OH)D levels ≤50 nmol/l were found in 28·4 % of the children and 2·4 % had concentrations <25 nmol/l. Upon multivariate adjustment, increasing age (per year) (β -2·9; 95 % CI -5·1, -0·7 nmol/l), female sex (β -3·3; 95 % CI -5·9, -0·7 nmol/l), sampling in October (β -5·2; 95 % CI -10·1, -0·4 nmol/l) and November (β -13·3; 95 % CI -17·7, -9·1), and non-white ethnicity (β -5·7; 95 % CI -11·1, -0·3 nmol/l) were negatively associated with 25(OH)D (all P<0·05). Likewise, immigrant/descendant background was negatively associated with 25(OH)D, particularly in females (β -16·3; 95 % CI -21·9, -10·7) (P<0·001) (P interaction=0·003). Moderate-to-vigorous physical activity (MVPA) (min/d) (β 0·06; 95 % CI 0·01, 0·12), outdoor walking during school hours (min/week) (β 0·4; 95 % CI 0·1, 0·6) and intake of vitamin D-containing supplements ≥3 d/week (β 8·7; 95 % CI 6·4, 11·0) were positively associated with 25(OH)D (all P<0·05). The high proportion of children with vitamin D status below the recommended sufficiency level of 50 nmol/l raises concern as levels expectedly drop further during winter months. Frequent intake of vitamin D supplements was strongly associated with status. MVPA and outdoor activity during school hours should be investigated further in interventions to improve autumn vitamin D status in children at northern latitudes.
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Moon RJ, Harvey NC, Davies JH, Cooper C. Vitamin D and skeletal health in infancy and childhood. Osteoporos Int 2014; 25:2673-84. [PMID: 25138259 PMCID: PMC4224585 DOI: 10.1007/s00198-014-2783-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 01/25/2023]
Abstract
During growth, severe vitamin D deficiency in childhood can result in symptomatic hypocalcaemia and rickets. Despite the suggestion from some studies of a secular increase in the incidence of rickets, this observation may be driven more by changes in population demographics than a true alteration to age, sex and ethnicity-specific incidence rates; indeed, rickets remains uncommon overall and is rarely seen in fair-skinned children. Additionally, the impact of less severe vitamin D deficiency and insufficiency has received much interest in recent years, and in this review, we consider the evidence relating vitamin D status to fracture risk and bone mineral density (BMD) in childhood and adolescence. We conclude that there is insufficient evidence to support the suggestion that low serum 25-hydroxyvitamin D [25(OH)D] increases childhood fracture risk. Overall, the relationship between 25(OH)D and BMD is inconsistent across studies and across skeletal sites within the same study; however, there is evidence to suggest that vitamin D supplementation in children with the lowest levels of 25(OH)D might improve BMD. High-quality randomised trials are now required to confirm this benefit.
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Affiliation(s)
- Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK SO16 6YD
- Paediatric Endocrinology, Southampton University Hospitals NHS Foundation Trust, Southampton, UK SO16 6YD
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK SO16 6YD
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD UK
| | - Justin H Davies
- Paediatric Endocrinology, Southampton University Hospitals NHS Foundation Trust, Southampton, UK SO16 6YD
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK SO16 6YD
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Nuffield Orthopedic Centre, Headington, Oxford, OX3 7HE
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Knutsen KV, Madar AA, Brekke M, Meyer HE, Natvig B, Mdala I, Lagerlv P. Effect of vitamin D on musculoskeletal pain and headache: A randomized, double-blind, placebo-controlled trial among adult ethnic minorities in Norway. Pain 2014; 155:2591-2598. [PMID: 25261164 DOI: 10.1016/j.pain.2014.09.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/04/2014] [Accepted: 09/16/2014] [Indexed: 11/17/2022]
Abstract
Immigrants from South Asia, the Middle East, and Africa living in Northern Europe frequently have low vitamin D levels and more pain compared to the native Western population. The aim of this study was to examine whether daily vitamin D3 (25 μg/d or 10 μg/d) supplementation for 16 weeks would improve musculoskeletal pain or headache compared to placebo. This randomized, double-blind, placebo-controlled, parallel-group trial recruited 251 participants aged 18 to 50 years, and 215 (86%) attended the follow-up visit. The pain measures were occurrence, anatomical localization, and degree of musculoskeletal pain, as measured by visual analogue scale (VAS) score during the past 2 weeks. Headache was measured with VAS and the Headache Impact Test (HIT-6) questionnaire. At baseline, females reported more pain sites (4.7) than males (3.4), and only 7% reported no pain in the past 2 weeks. During the past 4 weeks, 63% reported headache with a high mean HIT-6 score of 60 (SD 7). At follow-up, vitamin D level, measured as serum 25(OH)D3, increased from 27 nmol/L to 52 nmol/L and from 27 nmol/L to 43 nmol/L in the 25-μg and 10-μg supplementation groups, respectively, whereas serum 25(OH)D3 did not change in the placebo group. Pain scores and headache scores were improved at follow-up compared with baseline. The use of vitamin D supplements, however, showed no significant effect on the occurrence, anatomical localization, and degree of pain or headache compared to placebo.
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Affiliation(s)
- Kirsten V Knutsen
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway Department of Community Medicine, Institute of Health and Society, University of Oslo, Norway Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
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Abstract
Epilepsy is one of the most common neurologic disorders in childhood that often requires long term treatment with antiepileptic drugs. Both antiepileptic treatment and the comorbidities associated with epilepsy have a negative impact on bone health in growing children. Given the fact that vitamin D deficiency is a major public health problem worldwide, clinicians caring for children with chronic diseases should be aware of effects of the medication on the bone metabolism. Yet, vitamin D deficiency due to antiepileptic treatment is an overlooked issue among neurologists. In this review, we briefly describe vitamin D metabolism and the effect of vitamin D in the brain. We also discuss the literature in terms of vitamin D deficiency and antiepileptic treatment in the pediatric population.
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Affiliation(s)
- Ayşe Nurcan Cebeci
- Derince Training and Research Hospital, Pediatric Endocrinology Clinic, Kocaeli, Turkey
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Abstract
AIMS To evaluate the association between vitamin D receptor (VDR) gene polymorphisms and the risk of rickets among Asians. METHODS Eligible studies were included in our meta-analysis by searching PubMed, Embase, Cochrane and China National Knowledge Infrastructure databases according to a predefined criteria. A random effects model was used to calculate the combined ORs and its corresponding 95% CI. RESULTS 16 studies were recruited for the analysis of the association between VDR BsmI (rs1544410), TaqI (rs731236), FokI (rs2228570) and ApaI (rs7975232) gene polymorphisms and the risk of rickets among Asians, most of whom were from China. B allele/BB genotype was associated with the susceptibility of rickets (p=0.017 and 0.044, respectively), and bb genotype was associated with lower risk of rickets (p=0.033). F allele/FF genotype was associated with the susceptibility of rickets (p<10(-4)), and ff genotype was associated with lower risk of rickets (p<10(-4)). AA genotype was associated with the onset of rickets (p=0.044). No significant association was observed between TaqI polymorphism the risk of rickets. A allele/aa genotype was not associated with the risk of rickets. No evidence of publication bias was observed. CONCLUSIONS B allele/BB genotype at the BsmI site, F allele/FF genotype at the FokI site and AA genotype at the ApaI site may be risk factors for the onset of rickets among Asians; bb genotype at the BsmI site and ff genotype at the FokI site may be protective factors against the risk of rickets among Asians.
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Affiliation(s)
- Song Mao
- Department of Nephrology, Nanjing Children's Hospital, Affiliated to Nanjing Medical University, , Nanjing, China
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Fluss J, Kern I, de Coulon G, Gonzalez E, Chehade H. Vitamin D deficiency: a forgotten treatable cause of motor delay and proximal myopathy. Brain Dev 2014; 36:84-7. [PMID: 23273989 DOI: 10.1016/j.braindev.2012.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 11/29/2012] [Accepted: 11/30/2012] [Indexed: 11/26/2022]
Abstract
We report a four-year-old African boy referred for proximal muscle weakness, fatigability and episodic limb pain. Classical causes of structural and metabolic myopathy were initially considered before clinical and biological features of vitamin D deficiency rickets were identified. Prompt treatment with vitamin D and calcium supplementation led to a complete reversal of the muscle symptoms. Rickets-associated myopathy should be included in the differential diagnosis of proximal myopathy, especially in at-risk individuals. Vitamin D deficiency and its prevention remain important health issues in industrialized countries.
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Affiliation(s)
- Joel Fluss
- Pediatric Neurology, Pediatric Subspecialties Service, Geneva Children's Hospital, Switzerland.
| | - Ilse Kern
- Pediatric Nephrology and Metabolism Unit, Pediatric Subspecialties Service, Geneva Children's Hospital, Switzerland
| | - Geraldo de Coulon
- Pediatric Orthopaedic Service, Geneva Children's Hospital, Switzerland
| | - Elsa Gonzalez
- Pediatric Nephrology and Metabolism Unit, Pediatric Subspecialties Service, Geneva Children's Hospital, Switzerland
| | - Hassib Chehade
- Pediatric Nephrology and Metabolism Unit, Pediatric Subspecialties Service, Geneva Children's Hospital, Switzerland
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Tijhuis MJ, Doets EL, Vonk Noordegraaf‐Schouten M. Extensive literature search and review as preparatory work for the evaluation of the essential composition of infant and follow‐on formulae and growing‐up milk. ACTA ACUST UNITED AC 2014. [DOI: 10.2903/sp.efsa.2014.en-551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- MJ Tijhuis
- Pallas health research and consultancy the Netherlands
| | - EL Doets
- Pallas health research and consultancy the Netherlands
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32
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Wändell PE. Population groups in dietary transition. Food Nutr Res 2013; 57:21668. [PMID: 24106456 PMCID: PMC3790911 DOI: 10.3402/fnr.v57i0.21668] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 04/25/2013] [Accepted: 04/26/2013] [Indexed: 12/12/2022] Open
Abstract
Background Little is known about the effects of dietary acculturation in minority groups in the Nordic countries, including immigrants from non-Western societies. Methods A search was performed in Medlin33e/PubMed and SweMed+ for articles published in 1990–2011. Results A total of 840 articles were identified, with a final 32 articles used to tabulate results which were included in the primary analysis. High rates of vitamin D deficiency (23 articles) were found in immigrants of non-Western origin; deficiency rates were very high among both pregnant and non-pregnant women, and also among children, with young children of immigrant parents showing 50 times higher risk for rickets when compared to children of indigenous parents. The risk of iron deficiency (two articles) was high among immigrant women, while the results were inconclusive regarding children. High rates of dental caries (seven articles) were found among pre-school and younger school children of immigrant origin, while the risk of caries was not as evident among older children. In a secondary analysis, including 48 articles (results not tabulated), overweight and obesity (14 articles) were seen in many immigrant groups, resulting in a high prevalence of diabetes (2 review articles from a total of 14 original articles) and incidence of coronary heart disease (CHD; seven articles). For hypertension (three articles), dyslipidemia (four articles), and dietary patterns among immigrants (10 articles), the results were contradictory. Conclusions Risk of vitamin D deficiency is alarmingly high in the Nordic countries among immigrants of non-Western origin, especially among women. Dental caries is high among immigrant children aged 0–7 years due to a higher intake of sugary products. Overweight and obesity, associated with a higher risk of diabetes and CHD, are prevalent in many immigrant groups and need further attention.
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Affiliation(s)
- Per E Wändell
- Centre for Family Medicine, Karolinska Institutet, Huddinge, Sweden
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Hammar M, Östgren CJ. Healthy aging and age-adjusted nutrition and physical fitness. Best Pract Res Clin Obstet Gynaecol 2013; 27:741-52. [DOI: 10.1016/j.bpobgyn.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/09/2013] [Accepted: 01/19/2013] [Indexed: 12/12/2022]
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Abstract
In recent years, reports suggesting a resurgence of vitamin D deficiency in the Western world, combined with various proposed health benefits for vitamin D supplementation, have resulted in increased interest from health care professionals, the media, and the public. The aim of this position paper is to summarise the published data on vitamin D intake and prevalence of vitamin D deficiency in the healthy European paediatric population, to discuss the health benefits of vitamin D and to provide recommendations for the prevention of vitamin D deficiency in this population. Vitamin D plays a key role in calcium and phosphate metabolism and is essential for bone health. There is insufficient evidence from interventional studies to support vitamin D supplementation for other health benefits in infants, children, and adolescents. The pragmatic use of a serum concentration >50 nmol/L to indicate sufficiency and a serum concentration <25 nmol/L to indicate severe deficiency is recommended. Vitamin D deficiency occurs commonly among healthy European infants, children, and adolescents, especially in certain risk groups, including breast-fed infants, not adhering to the present recommendation for vitamin D supplementation, children and adolescents with dark skin living in northern countries, children and adolescents without adequate sun exposure, and obese children. Infants should receive an oral supplementation of 400 IU/day of vitamin D. The implementation should be promoted and supervised by paediatricians and other health care professionals. Healthy children and adolescents should be encouraged to follow a healthy lifestyle associated with a normal body mass index, including a varied diet with vitamin D-containing foods (fish, eggs, dairy products) and adequate outdoor activities with associated sun exposure. For children in risk groups identified above, an oral supplementation of vitamin D must be considered beyond 1 year of age. National authorities should adopt policies aimed at improving vitamin D status using measures such as dietary recommendations, food fortification, vitamin D supplementation, and judicious sun exposure, depending on local circumstances.
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Seizures as initial manifestation of vitamin D-deficiency rickets in a 5-month-old exclusively breastfed infant. Pediatr Neonatol 2012; 53:384-6. [PMID: 23276445 DOI: 10.1016/j.pedneo.2012.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 03/29/2012] [Accepted: 05/22/2012] [Indexed: 01/25/2023] Open
Abstract
Despite the fact that sunlight-dependent skin synthesis is the major mechanism for vitamin D synthesis in vivo, vitamin D-deficiency rickets continues to occur in exclusively breastfed infants in Greece. We present such a case in a 5-month-old infant who presented with afebrile seizures and whose mother was underexposed to sunlight due to veiling for religious reasons. Additionally, we briefly but thoroughly review the relevant medical literature. A high index of suspicion is required for nutritional rickets, when seizures occur in exclusively breastfed infants whose mothers have inadequate exposure to sunlight.
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The association between childhood rickets and nonaffective psychosis: a Danish record-linkage study. Schizophr Res 2012; 137:256-7. [PMID: 22445669 DOI: 10.1016/j.schres.2012.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 03/01/2012] [Indexed: 11/20/2022]
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Abstract
Neonatologists and paediatricians have a crucial role working with mothers at the most nutritionally challenged point in their lives and that of their infants. This position of responsibility is particularly important in tackling the re-emerging problem of hypovitaminosis D. In this overview the role of vitamin D, its contribution to pathology in those to whom we provide a service and possible actions will be considered.
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Affiliation(s)
- Colin A Michie
- Department of Paediatrics, Ealing Hospital, Uxbridge Road, Middlesex, United Kingdom.
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Sinha A, Avery P, Turner S, Bailey S, Cheetham T. Vitamin D status in paediatric patients with cancer. Pediatr Blood Cancer 2011; 57:594-8. [PMID: 21294242 DOI: 10.1002/pbc.22963] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 11/12/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Children with malignant disease are at increased risk of bone disorders and cardiovascular disease. Vitamin D status may influence this risk and so we assessed vitamin D levels in children with malignant disease undergoing active treatment or surveillance post-therapy. PROCEDURE This was an outpatient-based cross-sectional study of 61 children with a history of malignancy (median age 11.1 years; range 1.5-24.4 years) and 60 control subjects (median age 8.4 years; range 0.2-18.0 years) attending hospital for the management of non-malignant disorders. Serum vitamin D (25-OH-D), parathormone levels and bone biochemistry were determined. Vitamin D status and its relationship to age, sex, ethnicity, time of sampling and presence of malignant disease was determined. RESULTS Vitamin D status was suboptimal in 62% of cases (25-OH-D < 50 nmol/L [20 ng/ml]). Vitamin D deficiency (25-OH-D < 25 nmol/L [10 ng/ml]) was more common in children with malignant disease than controls (21.3% vs. 3.3%; P = 0.013). Month of sampling (P < 0.001), ethnicity (P < 0.001), older age (P = 0.011), and history of malignancy (P = 0.012) were associated with a poorer vitamin D status. CONCLUSIONS Vitamin D levels [25-OH-D] are lower in survivors of childhood cancer in comparison to control children with the majority either insufficient or deficient. Assessment and adequate replacement of vitamin D status may be of particular value in this group of children.
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Affiliation(s)
- Akash Sinha
- Department of Paediatric Endocrinology, Great North Children's Hospital, Newcastle upon Tyne, UK
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The ambiguity of ethnicity as risk factor of vitamin D deficiency – A case study of Danish vitamin D policy documents. Health Policy 2011; 102:56-63. [DOI: 10.1016/j.healthpol.2011.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 05/17/2011] [Accepted: 05/24/2011] [Indexed: 01/08/2023]
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Østergård M, Arnberg K, Michaelsen KF, Madsen AL, Krarup H, Trolle E, Mølgaard C. Vitamin D status in infants: relation to nutrition and season. Eur J Clin Nutr 2011; 65:657-60. [PMID: 21245885 DOI: 10.1038/ejcn.2010.285] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In a cross-sectional study, the primary objective was to assess the plasma concentration of 25-hydroxyvitamin D (25(OH)D) in healthy 9-month-old infants (n=255). The secondary objective was to evaluate nutritional variables and season in relation to 25(OH)D. The concentration of 25(OH)D was 77.2 ± 22.7 nmol/l (mean ± s.d.), ranging from 12 to 151 nmol/l. During the first 9 months, 97% received vitamin D supplementation (10 μg/day) and 89% had sufficient levels of 25(OH)D (50-250 nmol/l). In multiple regression analysis, controlled for body mass index (BMI) and intake of infant formula, a longer period of exclusive breastfeeding (P=0.026) and breastfeeding at 9 months (P=0.001) were both associated with lower levels. Dietary vitamin D intake was 4.4 ± 3.1 μg/day and in multiple regression analysis, controlled for BMI, intake of infant formula and mean energy intake, it was positively associated with 25(OH)D (P=0.001). There was a significant seasonal difference in 25(OH)D, with higher levels during summer-autumn compared with winter-spring (P=0.021) after control for BMI.
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Affiliation(s)
- M Østergård
- Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Denmark
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Cesur Y, Doğan M, Ariyuca S, Basaranoglu M, Bektas MS, Peker E, Akbayram S, Caksen H. Evaluation of children with nutritional rickets. J Pediatr Endocrinol Metab 2011; 24:35-43. [PMID: 21528813 DOI: 10.1515/jpem.2011.108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To evaluate the clinical findings, risk factors, therapy and outcome in 946 children with nutritional rickets. PATIENTS AND METHODS This retrospective study included a review of medical records of patients with nutritional rickets between March 2004 and 2009. Patients who displayed both the biochemical inclusion criteria and the clinical signs/symptoms or radiological signs of rickets were included in the study. RESULTS The present study included 946 patients aged between 4 months and 15 years. Distribution of the cases showed a density between December and May. The age at diagnosis, showed two peaks and most of the patients were in the age range 0-23 months and 12.0-15 years. In infants and young children, most of the patients had been admitted to the hospital due to infectious diseases. In older children, short stature and obesity were the most common complaints. CONCLUSION Children aged between 0-23 months and 12.0-15 years were under most risk for nutritional rickets, especially in winter and spring and vitamin D should be given to them as supplementation dose.
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Affiliation(s)
- Yasar Cesur
- Department of Pediatrics, School of Medicine, Yuzuncu Yil University, Van, Turkey
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Melamed ML, Kumar J. Low levels of 25-hydroxyvitamin D in the pediatric populations: prevalence and clinical outcomes. ACTA ACUST UNITED AC 2010; 4:89-97. [PMID: 20490283 DOI: 10.2217/phe.09.72] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Vitamin D deficiency is becoming increasingly common in the USA. In this review we provide estimates of the prevalence of deficiency, and review the risk factors and the evidence of clinical consequences of vitamin D deficiency. Vitamin D deficiency causes the pediatric disease rickets. In addition, there is some evidence that vitamin D deficiency may lead to other diseases including diabetes mellitus, hypertension, infections, asthma and dyslipidemia.
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Affiliation(s)
- Michal L Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Ullman 615/Belfer 1008, Bronx, NY 10461, USA, Tel.: +1 718 430 2304, ,
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Moan J, Lagunova Z, Cicarma E, Aksnes L, Dahlback A, Grant WB, Porojnicu AC. Sunbeds as Vitamin D Sources. Photochem Photobiol 2009; 85:1474-9. [DOI: 10.1111/j.1751-1097.2009.00607.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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