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Pieridou C, Uday S. Nutritional rickets presenting with developmental regression: a rare presentation of rickets. BMC Pediatr 2023; 23:330. [PMID: 37386483 PMCID: PMC10308663 DOI: 10.1186/s12887-023-04127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
Rickets is a disorder of defective mineralisation of the growth plate. Vitamin D deficiency remains the leading cause of nutritional rickets worldwide.We present the case of a 3.5-year-old breastfed boy who presented with dental abscess when a history of developmental regression was noted. Clinical assessment revealed hypotonia, poor growth and stunting. Biochemistry identified hypocalcaemia (1.63mmol/L, [normal range (NR) 2.2-2.7mmol/L]), severe vitamin D deficiency (25hydroxyvitamin D 5.3nmol/L, [NR > 50nmol/L]) with secondary hyperparathyroidism (Parathormone 159pmol/L, [NR 1.6-7.5pmol/L]) and rickets on radiographs. Growth failure screening suggested hypopituitarism with central hypothyroidism and low IGF1 at baseline, however, dynamic tests confirmed normal axis. Management included nasogastric nutritional rehabilitation, cholecalciferol and calcium supplementation and physiotherapy. A good biochemical response in all parameters was observed within 3 weeks and reversal of developmental regression by 3 months from treatment. Developmental regression as a presentation of nutritional rickets is rare and requires a high index of suspicion.
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Affiliation(s)
- Chariklia Pieridou
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, UK
| | - Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, UK.
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Lugg ST, Mackay WR, Faniyi AA, Faustini SE, Webster C, Duffy JE, Hewison M, Shields AM, Parekh D, Richter AG, Scott A, Thickett DR. Vitamin D status: a U-shaped relationship for SARS-CoV-2 seropositivity in UK healthcare workers. BMJ Open Respir Res 2022; 9:9/1/e001258. [PMID: 36167472 PMCID: PMC9515459 DOI: 10.1136/bmjresp-2022-001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/17/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is increasing evidence that vitamin D (VD) deficiency may increase individuals' risk of COVID-19 infection and susceptibility. We aimed to determine the relationship between VD deficiency and sufficiency and COVID-19 seropositivity within healthcare workers. METHODS The study included an observational cohort of healthcare workers who isolated due to COVID-19 symptoms from 12 May to 22 May 2020, from the University Hospitals Birmingham National Health Service Foundation Trust. Data collected included SARS-CoV-2 seroconversion status, serum 25(OH)D3 levels, age, body mass index (BMI), sex, ethnicity, job role and comorbidities. Participants were grouped into four VD categories: (1) Severe VD deficiency (VD<30 nmol/L); (2) VD deficiency (30 nmol/L ≤VD<50 nmol/L); (3) VD insufficiency (50 nmol/L ≤VD<75 nmol/L); (4) VD sufficiency (VD≥75 nmol/L). RESULTS When VD levels were compared against COVID-19 seropositivity rate, a U-shaped curve was identified. This trend repeated when participants were split into subgroups of age, sex, ethnicity, BMI and comorbidity status. Significant difference was identified in the COVID-19 seropositivity rate between VD groups in the total population and between groups of men and women; black, Asian and minority ethnic (BAME) group; BMI<30 (kg/m2); 0 and +1 comorbidities; the majority of which were differences when the severely VD deficient category were compared with the other groups. A larger proportion of those within the BAME group (vs white ethnicity) were severely VD deficient (p<0.00001). A larger proportion of the 0 comorbidity subgroup were VD deficient in comparison to the 1+ comorbidity subgroup (p=0.046). CONCLUSIONS Our study has shown a U-shaped relationship for COVID-19 seropositivity in UK healthcare workers. Further investigation is required to determine whether high VD levels can have a detrimental effect on susceptibility to COVID-19 infection. Future randomised clinical trials of VD supplementation could potentially identify 'optimal' VD levels, allowing for targeted therapeutic treatment for those at risk.
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Affiliation(s)
- Sebastian T Lugg
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - William R Mackay
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Aduragbemi A Faniyi
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Sian E Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Craig Webster
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanne E Duffy
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Hewison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Adrian M Shields
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Dhruv Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Alex G Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Aaron Scott
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - David R Thickett
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Wille K, Richard A, Nieters A, Rohrmann S, Quack Lötscher K. Vitamin D and parathyroid hormone in the umbilical cord blood - Correlation with light and dark maternal skin color. Food Sci Nutr 2022; 10:4201-4208. [PMID: 36514767 PMCID: PMC9731526 DOI: 10.1002/fsn3.3013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 12/16/2022] Open
Abstract
During pregnancy, vitamin D deficiency is associated with negative health consequences for mother and child. Furthermore, dark skin color is associated with lower vitamin D levels. We investigated 25-hydroxy-vitamin D (25(OH)D) and parathyroid hormone (PTH) levels in mothers and in cord blood of their newborns depending on maternal skin color. We recruited 202 mother and child pairs at the University Hospital Zurich and measured 25(OH)D and PTH concentrations in maternal and postpartum umbilical cord blood. Skin type was self-reported based on the Fitzpatrick Scale (type I to V). Uni- and multivariate methods were used to compare the maternal and neonatal 25(OH)D and PTH levels by skin type (light: I-III vs. dark: IV-V). As many as 54.5% of all mothers and 41.1% of the neonates were 25(OH)D deficient. This was higher in the neonates of dark-skinned (55.9%) than in the neonates of light-skinned mothers (38.1%; p = .06). The correlation of 25(OH)D in the maternal with umbilical cord blood was high (light: r = 0.85, dark: r = 0.87), with higher concentrations of 25(OH) vitamin D in the umbilical cord than in maternal blood. Regression analysis revealed that country of origin and maternal 25(OH)D concentration were the only statistically significant determinants for umbilical cord blood 25(OH)D. We observed no correlation of maternal with umbilical cord PTH concentrations; median PTH concentrations in the umbilical cord (5.6 pg/ml) were significantly lower than in maternal blood (25.7 pg/ml). The recommendation of vitamin D supplementation in newborns in their first 3 years of life should be particularly emphasized to dark-skinned mothers.
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Affiliation(s)
- Klara Wille
- Department of ObstetricsUniversity Hospital ZurichZurichSwitzerland
| | - Aline Richard
- EpidemiologyBiostatistics and Prevention Institute, University of ZurichZurichSwitzerland
| | - Alexandra Nieters
- FREEZE‐Biobank, Center for Chronic Immunodeficiency, Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Sabine Rohrmann
- EpidemiologyBiostatistics and Prevention Institute, University of ZurichZurichSwitzerland
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Tamblyn JA, Pilarski NS, Markland AD, Marson EJ, Devall A, Hewison M, Morris RK, Coomarasamy A. Vitamin D and miscarriage: a systematic review and meta-analysis. Fertil Steril 2022; 118:111-122. [DOI: 10.1016/j.fertnstert.2022.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 12/13/2022]
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Kurnaz E, Çetinkaya S, Elmaoğulları S, Araslı Yılmaz A, Muratoğlu Şahin N, Keskin M, Savaş Erdeve Ş. A major health problem facing immigrant children: nutritional rickets. J Pediatr Endocrinol Metab 2022; 35:223-229. [PMID: 34610231 DOI: 10.1515/jpem-2021-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nutritional rickets (NR) is still an important problem and one which increasing influxes of immigrants are further exacerbating. This study evaluated cases of mostly immigrant children followed up with diagnoses of NR in our pediatric endocrinology clinic. METHODS Details of 20 cases diagnosed with NR between 2017 and 2020 were retrieved from file records. RESULTS Twenty (11 male) cases were included in the study. Three (15%) were Turkish nationals and the others (85%) were immigrants. Hypocalcemia and hypophosphatemia were detected in 17 and 13, respectively. Alkaline phosphatase (ALP) values were normal in two cases, while ALP and parathyroid hormone (PTH) values were elevated in all other cases, and PTH levels were very high (473.64 ± 197.05 pg/mL). 25-hydroxyvitamin D levels were below 20 ng/mL in all cases. Patients with NR received high-dose long-term vitamin D or stoss therapy. Six patients failed to attend long-term follow-up, while PTH and ALP levels and clinical findings improved at long-term follow-up in the other 14 cases. CONCLUSIONS The elevated PTH levels suggest only the most severe cases of NR presented to our clinic. Clinically evident NR is therefore only the tip of the iceberg, and the true burden of subclinical rickets and osteomalacia remains unidentified. Public health policies should therefore focus on universal vitamin D supplementation and adequate dietary calcium provision, their integration into child surveillance programs, adequate advice and support to ensure normal nutrition, exposure to sunlight, and informing families of the increased risk not only for resident populations but also for refugee and immigrant children.
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Affiliation(s)
- Erdal Kurnaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Semra Çetinkaya
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Selin Elmaoğulları
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Aslıhan Araslı Yılmaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Nursel Muratoğlu Şahin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Melikşah Keskin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Şenay Savaş Erdeve
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
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Högler W, Tischlinger K, Fraser WD, Tang JCY, Uday S. Influence of maternal socioeconomic deprivation and living environment on newborn bloodspot 25-hydroxyvitamin D levels. Front Endocrinol (Lausanne) 2022; 13:978580. [PMID: 37091212 PMCID: PMC10116494 DOI: 10.3389/fendo.2022.978580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/24/2022] [Indexed: 04/25/2023] Open
Abstract
Objectives Vitamin D deficiency in neonates can have life-threatening consequences, hence the knowledge of risk factors is essential. This study aimed to explore the effect of maternal socioeconomic status (SES) on newborn 25-hydroxyvitamin D (25OHD) concentrations. Design Over two 1-week periods (winter and summer of 2019), 3000 newborn heel prick dried blood spots (DBS) and additional data of newborns, from a regional newborn screening laboratory (52° N) in the West Midlands, UK, were gathered. Post code was replaced with lower layer super output area (LSOA). Index of Multiple Deprivation (IMD) quintiles for the corresponding LSOA was used to assess SES [quintile one (Q1): most deprived 20%, quintile five (Q5): least deprived 20%]. Each of the seven domains of deprivation were examined (income, employment, education, health, barriers to housing and services, crime and living environment). 25OHD was measured on 6mm sub-punch from DBS using quantitative liquid chromatography tandem mass spectrometry and equivalent plasma values were derived. Results In total 2999 (1500 summer-born, 1499 winter-born) newborn DBS (1580 males) were analysed. Summer-born newborns had significantly higher 25OHD (IQR) concentrations [49.2 (34.3; 64.8) nmol/l] than winter-born newborns [29.1 (19.8; 40.6) nmol/l, p<0.001].25OHD levels varied significantly between the different IMD quintiles in the whole (p<0.001) and summer-born cohort (p<0.001), but not in the winter-born cohort (p=0.26), whereby Q1 had the lowest 25OHD concentrations. Among the domains of deprivation, living environment had a significant influence on 25OHD levels (β=0.07, p=0.002). In this subdomain, 25OHD levels varied significantly between quintiles in the whole (p<0.001) and summer-born cohort (mean 25OHD Q1 46.45 nmol/l, Q5 54.54 nmol/l; p<0.001) but not in the winter-born cohort (mean 25OHD Q1 31.57 nmol/l, Q5 31.72 nmol/l; p=0.16). In a regression model, living environment was still significant (p=0.018), albeit less than season of birth and ethnicity. Conclusion Among the seven domains of deprivation, maternal living environment had the greatest effect on newborn 25OHD levels. Whilst improved living environment positively influenced vitamin D status in the summer-born babies, winter-born had low 25OHD levels irrespective of the environment. Strategies such as enhanced supplementation and food fortification with vitamin D should be considered to overcome the non-modifiable main risk factors for vitamin D deficiency.
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Affiliation(s)
- Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
- *Correspondence: Wolfgang Högler,
| | - Katharina Tischlinger
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - William D. Fraser
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
- Departments of Diabetes and Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Jonathan C. Y. Tang
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
- Clinical Biochemistry, Departments of Laboratory Medicine, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - Suma Uday
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
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Uday S, Högler W. The burden of vitamin D deficiency in household members of children presenting with symptomatic vitamin D deficiency. Front Endocrinol (Lausanne) 2022; 13:958422. [PMID: 36111298 PMCID: PMC9468761 DOI: 10.3389/fendo.2022.958422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Micronutrient deficiencies are common among household/family members due to shared lifestyle and dietary habits. The extent of biochemical abnormalities in household members of children presenting with symptomatic vitamin D deficiency remains unknown. AIM Investigate the prevalence of vitamin D deficiency and biochemical osteomalacia in the mothers and siblings of children presenting with symptomatic vitamin D deficiency. METHODS All mothers and sibling of children referred to a single tertiary endocrine centre between January 2018 and December 2021, with symptomatic vitamin D deficiency were investigated prospectively for vitamin D deficiency [defined as 25 hydroxyvitamin D (25OHD) < 30nmol/L] and biochemical osteomalacia [vitamin D deficiency and elevated alkaline phosphatase (ALP) and/or parathormone (PTH)] as per clinical guidelines. REULTS Ninety-seven family members (68 siblings and 29 mothers) of 29 index cases (median age 1.7 years, 55.5% male) were investigated. The majority (65.5%, n=19) were of Asian ethnic background. The mean (SD) 25OHD levels of the index, maternal and sibling cohorts were 15 (10), 15 (7) and 20 (10) nmol/L respectively. Vitamin D deficiency was noted in 93% of the maternal and 79% of the sibling cohorts. Biochemical osteomalacia was present in 72% of the maternal and 79% of the sibling cohorts. Mothers of infants had significantly lower mean 25OHD levels compared to mothers of older children [11 (n=12) vs 18 nmol/L (n=17) respectively, p=0.006)], most of whom were symptomatic (66.6%, n=8/12). None of the mothers had hypocalcaemia. Among the 10% (n=7) of the siblings with hypocalcaemia, 86% (n=6/7) had concurrent dietary calcium deficiency and 71.4% (n= 5/7) reported symptoms in retrospect. Hypocalcaemic siblings had significantly lower 25OHD (7 vs 15 nmol/L, p<0.001), higher PTH (175 vs 58 ng/L, p<0.001) and ALP (846 vs 318 IU/L, p<0.001), respectively compared to normocalcaemic siblings. CONCLUSIONS In view of the substantial morbidity uncovered in household/family members of children diagnosed with symptomatic vitamin D deficiency, we recommend universal supplementation of all risk groups. Biochemical testing and treatment is indicated to replenish stores only in those at highest risk such as mothers of infants, individuals with concurrent dietary calcium deficiency and those with clinical symptoms.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Suma Uday,
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
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