Effect of Vitamin D and Calcium Supplementation on Bone Mineral Content in Children with Thalassemia

Prevalence and Associated Factors of Zinc and Vitamin D Deficiencies in Pediatric and Young Adult Patients with Non-Transfusion-Dependent Thalassemia

Micronutrient deficiencies pose significant long-term risks in non-transfusion dependent thalassemia (NTDT) patients. Zinc deficiency can impair growth, cause atopic dermatitis, and increase susceptibility to respiratory infections, while vitamin D deficiency disrupts bone mineralization and metabolism. This study aimed to determine the prevalence of zinc and vitamin D deficiencies and investigate associated factors in pediatric to young adult NTDT patients. A cross-sectional study was conducted at Chiang Mai University Hospital, enrolling NTDT patients aged 5 to 25 years who received fewer than three transfusions annually. Serum zinc and vitamin D levels were measured. Patients and parents completed a 3-day food diary and a sun exposure questionnaire. Zinc deficiency was defined as levels below the reference level for age. Vitamin D deficiency was defined as levels <20 ng/mL. Clinical and hematologic parameters were compared between groups with and without deficiencies. Forty-five patients with NTDT were enrolled, including 23 males (51.1%) males, with a mean age of 12.8 ± 5.3 years. Zinc deficiency affected 13 patients (28.9%), while 23 patients (51.1%) had vitamin D deficiency. Thinness was observed more frequently in patients with zinc deficiency. However, this finding did not reach statistical significance. Older age and inadequate sun exposure were associated with vitamin D deficiency. This study underscores a high prevalence of zinc and vitamin D deficiencies in pediatric and young adult NTDT patients and identifies the associated factors. Addressing and monitoring these deficiencies are crucial for optimizing long-term health outcomes in this patient group.

Interventions to improve vitamin and mineral inadequacies among children in India: a scoping review

INTRODUCTION

Vitamin and mineral deficiencies are commonly seen in children, and they affect the physical, mental and cognitive development of a child.

OBJECTIVE

This study aimed to map interventions to improve vitamin and mineral inadequacies among children in India.

METHODS

A review was conducted using the PRISMA extension for scoping reviews (PRISMA-ScR) 2018 checklist. Based on the PICO framework, further steps were followed in conducting the review. Studies conducted on children and adolescents (ranging in age from 6 months to 19 years) in India were considered. A search was carried out in PubMed, CINAHL, ProQuest, Cochrane Library, Scopus and Web of Science. Interventions that focused on improving vitamin and mineral inadequacies were collated. Studies published in the English language between 1 January 2012, and 30 September 2023, were included. The data from the included studies were reported narratively.

RESULTS

The search yielded 1566 records through the databases. Finally, 18 studies were found to be eligible to be considered in this review. For improving vitamin and mineral deficiencies, different types of supplements like iron, vitamins A, C and D in different amounts; nutritional supplements like zinc-rich foods, whole-wheat recipes, milk, lipid-based vitamin B12 supplements, ragi, porridge and iron-fortified whole-wheat drinks; or nutritional counselling worked better in children.

CONCLUSION

Vitamin and mineral supplementation for children reduces anaemia among children. Policymakers need to develop a strategy to increase awareness among parents, AWWs, caregivers and schoolteachers to reduce further complications.

Clinical Profile and Vitamin D Status in Beta Thalassemia Major Children at a Tertiary Care Institute of Central India: A Cross-Sectional Study

BACKGROUND

In India, the prevalence of beta thalassemia is 3.74%, and sixty to eighty percent of thalassemic children have vitamin D deficiency syndrome.

AIM

To estimate the prevalence of vitamin D deficiency and parathyroid levels in thalassemic children of Central India.

METHODS

This cross-sectional study was conducted on 61 diagnosed beta thalassemic children of 2-12 years of age at the pediatric department of the tertiary care institute of Central India for six months by consecutive sampling method. Demographic, transfusion, and clinical data were collected. Serum Vitamin D levels were estimated by electrochemical-luminescence technology and serum parathyroid hormone was by immunoassay. Complete blood count, serum ferritin/calcium/phosphorous, and liver functions test were performed. Frequency, mean, standard deviation, and correlation of various variables were performed.

RESULTS

Three-fourths of the participants were above 5 years of age and male to female ratio was 1.5:1. Most (88.5%) cases required blood transfusion every 3-4 weeks duration and 80.3% were receiving chelation therapy and all of them were on oral Deferasirox. About half of the participants had serum ferritin levels 1000-3000 ng/dl, and 27 (44.3%) had levels more than 3000- 5000 ng/dl. The total mean vitamin D and parathyroid hormone were 18.4 ± 9.9 ng/ml, and 13.1 ± 15.4 pg/ml respectively. The prevalence of low vitamin D was 63.9% and low parathyroid level in 21.3% of participants. Serum vitamin D level was inversely related to age, serum ferritin level, and transfusion frequency while directly related to serum calcium level.

CONCLUSION

The prevalence of vitamin D deficiency is 63.9% and low parathyroid hormone is 21.3%. Serum vitamin D has a negative correlation with increased age and increased serum ferritin levels.

Alterations in trace elements and cation profiles in transfusion-dependent thalassemia patients

BACKGROUND

Transfusion-dependent thalassemia (TDT) is a severe form of beta-thalassemia, characterized by defective-globin production, resulting in a buildup of unpaired alpha globin chains. Patients with TDT can only survive if they receive safe blood transfusions regularly, which causes iron overload in their blood, which causes a variety of disorders. Cations and trace elements in TDT patients as a drug target deserve more studies.

OBJECTIVES

In the present study, the cations and some trace elements were studied in TDT patients as a tool to adjust their level in the case of any disturbances.

METHODS

Serum calcium, magnesium, zinc, copper, and iron were measured spectrophotometrically while manganese and cobalt were measured by flameless atomic absorption spectroscopy in 100 TDT patients and compared with 35 healthy control children.

RESULTS

Patients with TDT exhibit a notable elevation in blood levels of iron, copper, copper/zinc ratio, and manganese, with a substantial reduction in serum levels of zinc, magnesium, calcium, and cobalt, as compared to the control group. These minerals have diverse associations with clinical data and transfusion frequencies. The receiver operating characteristic (ROC) analysis revealed that the elevated levels of iron, manganese, and calcium exhibit the greatest diagnostic capability, with a sensitivity and specificity of over 80 %, and a Youdin's J value of more than 0.6.

CONCLUSION

The levels of cations and trace elements are disturbed in TDT patients. Hence, the monitoring and adjustment of the level of these minerals are important to prevent further consequences.

Bone Mineral Density, Serum Calcium, and Vitamin D Levels in Adult Thalassemia Major Patients: Experience From a Single Center in Eastern India

Background and objective Patients suffering from thalassemia major are at higher risk of osteoporosis. Due to their decreased life expectancy, the number of adult patients is low. However, their bone health is rarely checked in developing countries like India. There is no data available in the literature on the bone mineral density (BMD) of adult (aged ≥18 years) thalassemia major patients in eastern India. In this study, we aimed to measure the BMD and serum calcium and vitamin D levels in adult thalassemia major patients and to compare them with healthy controls. Materials and methods We conducted this cross-sectional observational study at a tertiary care hospital in eastern India. We recruited adult thalassemia major patients who were not on calcium or vitamin D supplements. Their BMD was measured by dual-energy X-ray absorptiometry (DXA) on the lumbar spine (L1-L4). Venous blood was tested for serum calcium and vitamin D levels. We compared the parameters between the cases and controls by using the Mann-Whitney U test. Results A total of 31 (male = 19, female = 12) patients with a median age of 28 years comprised the case group. Age- and sex-matched controls showed similar height but higher weight and BMI. The serum calcium level was similar (p = 0.43) in the case and control groups but T-score (p = 0.0003) and vitamin D levels (p: <0.0001) were significantly lower in thalassemia major patients. Conclusion Based on our findings, adult thalassemia major patients have lower BMD and vitamin D levels. Although the serum calcium may be normal in these patients, they should still be screened both for BMD and vitamin D for prompt and early detection of risks and complications so that a proper management strategy can be implemented.

Drug Treatment of Low Bone Mass and Other Bone Conditions in Pediatric Patients

Osteoporosis may affect young individuals, albeit infrequently. In childhood, bone mass increases, reaching its peak between the second and third decades; then, after a period of stability, it gradually declines. Several conditions, including genetic disorders, chronic diseases, and some medications, can have an impact on bone homeostasis. Diagnosis in young patients is based on the criteria defined by the International Society for Clinical Densitometry (ISCD), published in 2013. High risk factors should be identified and monitored. Often simple interventions aimed to eliminate the underlying cause, to minimize the negative bone effects linked to drugs, or to increase calcium and vitamin D intake can protect bone mass. However, in selected cases, pharmacological treatment should be considered. Bisphosphonates remain the main therapeutic agent for children with significant skeletal fragility and are also useful in a large number of other bone conditions. Denosumab, an anti-RANKL antibody, could become a potential alternative treatment. Clinical trials to evaluate the long-term effects and safety of denosumab in children are ongoing.

Nutrition in Thalassemia: A Systematic Review of Deficiency, Relations to Morbidity, and Supplementation Recommendations

BACKGROUND

Reports of nutritional deficiencies in patients with thalassemia (Thal) are common. Despite its importance, however, nutritionally focused research in Thal has been limited by inadequate sample size, inconsistent methodology, a lack of control comparisons, and few interventional trials. Due to these limitations, clinicians lack evidence-based nutrition recommendations to support clinical decision-making. This systematic review summarizes observed relationships between nutrition and morbidity in Thal published in the last 3 decades.

METHODS

PubMed, Web of Science, and Embase were screened for articles pertaining to nutrition in Thal using comprehensive search terms. Studies performed in humans, written in English, and published between 1990 and 2020 were included. Over 2100 manuscripts were identified, from which 97 were included.

RESULTS

Patients with Thal were most often deficient in vitamins A, C, D, selenium, and zinc. Prevalence of nutritional deficiency was positively correlated with age and iron overload. Evidence to support the role of vitamin D and zinc for bone health was observed; zinc was also found to improve glucose metabolism.

CONCLUSIONS

Due to the risk for multinutrient deficiency, nutritional status should be assessed annually in patients with Thal with prompt nutrient replacement when deficiency is detected. Routine supplementation with vitamin D and zinc is recommended.

Vitamin D and bone health status in beta thalassemia patients-systematic review

Thalassemia is a chronic congenital disease characterized by a combination of endocrine and metabolic disorders. Bone disease is a very common complication related to the poor absorption of calcium, the secondary chronic renal disease with low vitamin D, as well as multiple endocrine risk factors. The aim of this systematic review was to estimate the prevalence of vitamin D deficiency in thalassemia, as well as its association with osteoporosis/low bone mass. A systematic review was carried out using PubMed/Medline, Cochrane, and EBSCO databases. The methodological quality of the included studies was assessed with the validated Newcastle-Ottawa Quality Assessment Scale adapted for cross-sectional studies and cohort studies respectfully and the Cochrane Collaboration for clinical trials. After application of predetermined exclusion criteria compatible with the PICOS process, a total of 12 suitable articles were identified. The prevalence of vitamin D deficiency varied considerably. Only five of the reviewed studies examined the correlation between vitamin D levels and BMD of which just three showed a statistically significant positive association of mild/moderate grade. Vitamin D deficiency is a common comorbidity in patients with thalassemia. However, both its prevalence and its severity vary considerably in different populations, and existing evidence is insufficient to conclude whether vitamin D supplementation is also associated with BMD improvement in this special population group.

Increased prevalence of fractures in inadequately transfused and chelated Indian children and young adults with beta thalassemia major

INTRODUCTION

In patients with beta thalassemia major, inadequate transfusion and chelation may compromise bone health and increase risk of fractures. The objective of this study was to describe the prevalence of fractures in Indian inadequately transfused and chelated children, adolescents and young adults with beta thalassemia major.

METHODS

We studied 179 patients with beta thalassemia (3.6-28.3 years; 105 boys). Medical, transfusion, chelation and fracture history were recorded. Vertebral fracture assessment (VFA) was performed using lateral spine images acquired using the GE Lunar iDXA (Wisconsin, MD). Fractures were classified according to an adapted semi-quantitative method.

RESULTS

History of non-traumatic long bone fractures was observed in 21% patients (n = 37); there were significantly greater (p < 0.05) number of males (n = 30) than females (n = 15). The 21% fracture prevalence in the present study is higher than the reported fractures of 9% in healthy Indian children and adolescents. The prevalence of vertebral fractures was 4.5% (n = 8) in the study group. Of those with fractures, four patients had both long bone and vertebral fractures, and (any, long bone or vertebral fractures) sixteen patients had more than 1 fracture; eleven patients had 2 fractures, four patients had 3 fractures and one patient had 5 fractures. Thus, in 179 patients, there were a total of 68 single fractures which translates to 307 fractures per 10,000 patient years.

CONCLUSION

This study found increased prevalence of non-traumatic long bone and vertebral fractures in children and adolescents with thalassemia major.

Vitamin D status in an Australian patient population: a large retrospective case series focusing on factors associated with variations in serum 25(OH)D

OBJECTIVES

To investigate whether sex, age, medical specialty and seasonal variations in serum concentration of 25-hydroxy vitamin D (25(OH)D) are evident among an Australian patient population.

DESIGN

Retrospective study analysing the results of serum 25(OH)D lab tests and vitamin D supplementation from Royal Melbourne Hospital (RMH) between 2014 and 2017.

SETTING

Tertiary healthcare centre in Victoria, Australia.

PARTICIPANTS

30 023 patients (inpatient and outpatient) who had their serum 25(OH)D levels measured at RMH between 2014 and 2017.

MAIN OUTCOME MEASURES

Serum 25(OH)D levels stratified according to patients' sex, age and medical specialty admitted to, as well as the season and year (2014 to 2017) 25(OH)D level was measured.

RESULTS

Mean serum 25(OH)D level of study population was 69.9 nmol/L (95% CI 69.5 to 70.2). Only 40.2% patients in this cohort were sufficient in vitamin D (>75 nmol/L). On average, 25(OH)D levels in male patients were 6.1 units (95% CI 5.4 to 6.9) lower than in females. Linear regression analysis found that 25(OH)D levels increased by 0.16 unit (95% CI 0.14 to 0.18) for every year increase in age. One-way analysis of variance showed patients from neurology had the highest average 25(OH)D level, 76.8 nmol/L (95% CI 74.2 to 79.3) compared with other medical specialties. Mean 25(OH)D level during winter, 64.9 nmol/L (95% CI 64.2 to 65.6) was significantly lower compared with other seasons despite supplementation. Average 25(OH)D level measured in 2014, 71.5 nmol/L (95 CI% 70.8 to 72.2) was significantly higher than levels measured in 2016-2017.

CONCLUSIONS

There is a sex, age, medical specialty, seasonal and yearly variation in vitamin D status in an Australian patient population. The association between low vitamin D status and winter despite supplementation suggests other interventions are required to boost serum 25(OH)D levels.