Case-control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children

Assessment of serum vitamin D levels in children aged 0-17 years old in a Chinese population: a comprehensive study

Vitamin D deficiency and insufficiency pose global public health challenges, yet research on serum vitamin D levels in the 0-17-year-old age group in southeastern China remains limited. This study aimed to fill this gap by investigating serum 25(OH)D levels in children in the region aged 0-17 years, contributing crucial data for understanding vitamin D nutritional status. Liquid chromatography‒mass spectrometry/mass spectrometry (LC‒MS/MS) technology was used. Vitamin D testing was integrated into routine diagnostic procedures for 11,116 children in Wujiang District, Suzhou City. Among the 0-17-year age group, comprising 6348 boys and 4768 girls, the prevalence of serum 25(OH)D deficiency and insufficiency was 21.4% and 31.0%, respectively. The median serum 25(OH)D concentration was 29.72 ng/mL (21.84-39.84 ng/mL) in boys compared to 28.48 ng/mL (20.65-39.23 ng/mL) in girls. Seasonal variations were observed, with median serum 25(OH)D concentrations of 29.02 ng/mL (20.73-39.72 ng/mL) in spring, 28.79 ng/mL (21.53-39.37 ng/mL) in summer, 30.12 ng/mL (22.00-39.70 ng/mL) in autumn, and 28.58 ng/mL (19.97-39.46 ng/mL) in winter. Statistically significant differences were noted in the serum 25(OH)D levels during autumn and winter. In conclusion, the rate of adequate vitamin D levels in local children was 47.5%, revealing a relatively high prevalence of vitamin D deficiency (21.4%) and insufficiency (31.0%), especially during the post-preschool period. Advocating for vitamin D supplementation in children is crucial for ensuring adequate vitamin D support.

Epidemiological analysis to identify predictors of X-linked hypophosphatemia (XLH) diagnosis in an Italian pediatric population: the EPIX project

PURPOSE

X-linked hypophosphatemia (XLH) is a rare multi-systemic disease characterized by low plasma phosphate levels. The aim of this study was to investigate the annual XLH prevalence and internally evaluate predictive algorithms' application performance for the early diagnosis of XLH.

METHODS

The PediaNet database, containing data on more than 400,000 children aged up to 14 years, was used to identify a cohort of XLH patients, which were matched with up to 10 controls by date of birth and gender. The annual prevalence of XLH cases per 100,000 patients registered in PediaNet database was estimated. To identify possible predictors associated with XLH diagnosis, a logistic regression model and two machine learning algorithms were applied. Predictive analyses were separately carried out including patients with at least 1 or 2 years of database history in PediaNet.

RESULTS

Among 431,021 patients registered in the PediaNet database between 2007-2020, a total of 12 cases were identified with a mean annual prevalence of 1.78 cases per 100,000 patients registered in PediaNet database. Overall, 8 cases and 60 matched controls were included in the analysis. The random forest algorithm achieved the highest area under the receiver operating characteristic curve (AUC) value both in the one-year prior ID (AUC = 0.99, 95% CI = 0.99-1.00) and the two-year prior ID (AUC = 1.00, 95% CI = 1.00-1.00) analysis. Overall, the XLH predictors selected by the three predictive methods were: the number of vitamin D prescriptions, the number of recorded diagnoses of acute respiratory infections, the number of prescriptions of antihistamine for systemic use, the number of prescriptions of X-ray of the lower limbs and pelvis and the number of allergology visits.

CONCLUSION

Findings showed that data-driven machine learning models may play a prominent role for the prediction of the diagnosis of rare diseases such as XLH.

Treatment of vitamin D deficiency in children

INTRODUCTION

Vitamin D deficiency affects from 10% to 50% in various pediatric population groups and causes life-threatening hypocalcemia in infants, crippling rickets in infants and children, and increased risk of subsequent adult metabolic and neurologic problems.

AREAS COVERED

An English language literature search of PubMed was performed since 1940 as were the authors' personal literature collections. References identified in the reviewed literature are considered.

DIAGNOSIS

The diagnosis of vitamin D deficiency is based on serum 25-hydroxyvitamin D levels. Clinical features of rickets include bone deformities and elevated alkaline phosphatase. Most children and adolescents who are biochemically vitamin D deficient do not have specific symptoms or signs of deficiency.

PREVENTION

Prevention of vitamin D deficiency is via exposure to sunshine, food and beverage fortification, and dietary supplementation.

TREATMENT

Effective treatment of vitamin D deficiency is via oral or injectable administration of vitamin D. Dosing and duration of vitamin D therapy have been described for healthy children and for children with underlying medical conditions, but recommendations vary.

EXPERT OPINION

Further investigation is needed to determine long-term non-skeletal effects of childhood vitamin D deficiency, benefits of supplementation in asymptomatic individuals with biochemical vitamin D deficiency, and appropriate screening for vitamin D deficiency in asymptomatic children and adolescents.

Increased susceptibility to complicated pneumonia among egyptian children with FokI (rs2228570), not TaqI (rs731236), vitamin D receptor gene polymorphism in association with vitamin D deficiency: a case-control study

BACKGROUND

Determining a genetic contribution to the development of complicated community-acquired pneumonia in children may help understand underlying pathogenesis. We aimed to investigate the association between two vitamin D receptor (VDR) gene polymorphisms, FokI and TaqI, and susceptibility to complicated pneumonia in Egyptian children compared to uncomplicated pneumonia. Associations with 25 hydroxy-vitamin D serum level were studied.

METHODS

This was a case-control study that included 320 participants divided into 2 groups: patients and controls. The patients' group included 100 children hospitalized with complicated pneumonia and 100 with uncomplicated pneumonia. 120 age and sex-matched apparently healthy children served as controls. The VDR FokI and TaqI polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. 25 hydroxy-vitamin D level was estimated in serum using ELISA.

RESULTS

Regarding FokI, homozygous CC genotype was more common in complicated (52%) than uncomplicated pneumonia (28%) and controls (10%) (OR = 65; 95%CI (5.13-822.63), p < 0.001) and (OR = 4.3; 95%CI (0.7-27.16), p = 0.003), respectively. Children carrying C allele possessed 3 higher odds for complicated than uncomplicated pneumonia (OR = 3.08; 95%CI (1.33-7.14), p < 0.001). Heterozygous CT genotype increased susceptibility to complicated pneumonia (OR = 13.7; 95%CI (4.6-40.1), p < 0.001), not uncomplicated pneumonia (OR = 1.56; 95%CI (0.86-2.85), p = 0.145). Among complicated pneumonia, vitamin D level was lower in CC (6.92 ± 2.6ng/ml) than CT (9.55 ± 3.2 ng/ml) and TT genotype carriers (13.13 ± 3.6ng/ml) (p < 0.001). There was no significant difference between patients and controls as regards TaqI genotypes and alleles.

CONCLUSION

In association with vitamin D deficiency, VDR gene FokI polymorphism, not TaqI, is a genetic risk factor for complicated pneumonia in Egyptian children.

Association between Vitamin D Levels, Puberty Timing, and Age at Menarche

Pubertal development represents the process of physical maturation where an adolescent reaches sexual maturity and attains reproductive function. The effects of vitamin D are mainly mediated by the vitamin D receptor (VDR), which is expressed in almost all body cells, including the ovary and human pituitary gland and animal hypothalamus. Thus, vitamin D has gained great interest as pathogenic factor of pubertal disorders and fertility. This narrative review aimed to provide a broad overview of the available literature regarding the association between vitamin D levels, puberty timing, and age at menarche. A review of the data on the involvement of micronutrient deficiency, as a modifiable cause of pubertal disorders, is important for the prediction and prevention of deficiencies as well as for fertility protection and should be considered a public health priority. Reported data support that vitamin D is a regulator of neuroendocrine and ovarian physiology and, more in detail, a deficiency of vitamin D is involved in altered pubertal timing. Considering the long-term consequences of early pubertal development and early menarche, the detection of modifiable causes is crucial in preventive strategies. Future studies in humans and with an increased scale are needed to elucidate the vitamin D role in sexual maturation and puberty development.

Adipositas and metabolic bone disorder in a 16th century Upper Austrian infant crypt mummy—An interdisciplinary palaeopathological insight into historical aristocratic life

We describe here the results of a multidisciplinary study on an infant mummy from 16th century Upper Austria buried in the crypt of the family of the Counts of Starhemberg. The macroscopic-anthropological, radiological (whole-body CT scan), histological (skin tissue), and radiocarbon isotope investigations suggested a male infant of 10–18 months' age, most likely dying between 1550 and 1635 CE (probably Reichard Wilhelm, 1625–1626 CE), that presented with evidence of metabolic bone disease with significant bilateral flaring of costochondral joints resembling “rachitic rosary” of the ribs, along with straight long bones and lack of fractures or subperiosteal bleeding residues. Although incompletely developed, the osteopathology points toward rickets, without upper or lower extremities long bone deformation. The differential diagnosis is vitamin C deficiency (scurvy) (also with an incomplete presentation, although overlap between both disorders may be present). As additional pathology, there was significantly enlarged subcutaneous fat tissue (thickness more than 1 cm at the navel and thighs and longitudinal creases of the skin) along with a histologically enlarged subcutaneous fat layer consistent with infantile adipositas as a coincident disorder. Finally, remnants of lung tissue with pleural adhesion of the right lung indicate possibly lethal pneumonia, a disease with an increased prevalence in vitamin D deficient infants. Ultimately, the skull presented with extensive destruction of the bones of the base and dislocation of the bones of the skull squama. These changes, however, are most likely post-mortal pseudopathology, the result of a burial in a flat, narrow coffin because there were no bone fractures or residues of bleeding/tissue reaction that would have occurred whilst the patient was alive.

Role of Vitamin D Deficiency in Increased Susceptibility to Respiratory Infections Among Children: A Systematic Review

Vitamin D has several roles in the immune system besides its effects on bone metabolism. Acute respiratory infections are common infections in children. Severe lower respiratory tract infections (LRTIs) even cause death in children, especially in those less than five years of age. Our study aims to examine whether children with vitamin D deficiency are susceptible to respiratory infections and to study the association between vitamin D deficiency and the severity of respiratory infections. We comprehensively searched research articles in PubMed, ScienceDirect, and Cochrane library databases. The main keywords were vitamin D deficiency, respiratory infections, and children. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this systematic review. The initial search showed 16,120 papers. A meticulous screening of research articles using the eligibility criteria and quality appraisal tools was done. Finally, 10 research articles qualified for this systematic review, including eight case-control studies, one randomized controlled trial (RCT), and one cohort study. Seven of 10 research studies reviewed found that children with low vitamin D levels are susceptible to respiratory infections. Five studies discussed the severity of respiratory infections and low vitamin D levels. This systematic review concluded that children with low vitamin D levels are prone to developing respiratory infections. But we could not find a conclusive association between the severity of respiratory infections and low vitamin D levels.

A comprehensive look into the association of vitamin D levels and vitamin D receptor gene polymorphism with obesity in children

Childhood obesity accounts for several psychosocial and clinical consequences. Psychosocial consequences include lower self-esteem, social isolation, poor academic achievement, peer problems, and depression, whereas clinical consequences are cardiovascular diseases, type 2 diabetes, dyslipidemia, cancer, autoimmune diseases, girls early polycystic ovarian syndrome (PCOS), asthma, bone deformities, etc. A growing number of studies have uncovered the association of childhood obesity and its consequences with vitamin-D (vit-D) deficiency and vitamin-D receptor (VDR) gene polymorphisms such as single nucleotide polymorphisms (SNPs), e.g., TaqI, BsmI, ApaI, FokI, and Cdx2. Considering the impact of vit-D deficiency and VDR gene polymorphisms, identifying associated factors and risk groups linked to lower serum vit-D levels and prevention of obesity-related syndromes in children is of utmost importance. Previously published review articles mainly focused on the association of vit-D deficiency with obesity or other non-communicable diseases in children. The nature of the correlation between vit-D deficiency and VDR gene polymorphisms with obesity in children is yet to be clarified. Therefore, this review attempts to delineate the association of obesity with these two factors by identifying the molecular mechanism of the relationship.

Risk factors for childhood pneumonia: a case-control study in a high prevalence area in Indonesia

BACKGROUND

Acute respiratory infections (ARIs), especially pneumonia, remain a major cause of infant mortality worldwide. In Indonesia, pneumonia is the second most common cause of infant and toddler deaths. Exclusive breastfeeding and basic immunization can protect infants and children from contracting pneumonia.

PURPOSE

Our goal was to assess the risk factors for childhood pneumonia in regions with a high prevalence of pneumonia in Indonesia.

METHODS

This case-control study was conducted between March and April 2019. A total of 176 infants and toddlers aged 10-59 months were enrolled and selected from among patients who visited the community health center. Cases of pneumonia were diagnosed clinically based on the World Health Organization guidelines, and the control was nonpneumonia.

RESULTS

The risk factors for the diagnosis of pneumonia included no or nonexclusive breastfeeding (odds ratio [OR], 7.95; 95% confidence interval [CI], 3.52-17.94), incomplete basic immunizations (OR, 4.47; 95% CI, 2.22-8.99), indoor air pollution (OR, 7.12; 95% CI, 3.03-16.70), low birth weight (OR, 3.27; 95% CI, 1.19-8.92), and a high degree of wasting (OR, 2.77; 95% CI, 1.06-7.17). Other variables such as nutritional status (height-for-age z score), age, sex, and educational status of the mother were not risk factors for pneumonia.

CONCLUSION

No or nonexclusive breastfeeding, incomplete basic immunizations, indoor air pollution, a history of low birth weight, and severe malnutrition were risk factors for childhood pneumonia. Breastfeeding was the dominant factor, while sex modified the relationship between exclusive breastfeeding and the incidence of pneumonia.

Is the shielding effect of cholecalciferol in SARS CoV-2 infection dependable? An evidence based unraveling

Despite being announced as a global health concern and emergency in January by WHO, designing specific treatment for SARS-CoV-2 is still a summit yet to be conquered. Currently, many drugs are being tested in the clinical scenario and vitamins play a significant role in therapeutic management. Based on the available evidence, we postulate that maintaining normal vitamin D₃ levels may reduce severity, mortality risk of COVID-19. This review elucidates the alarming need for randomized clinical trials to determine the role of vitamin D in patient prognosis in COVID-19 infection and on latitude bases epidemiological outcome.

The effect of vitamin D administration on vitamin D status and respiratory morbidity in late premature infants

OBJECTIVE

To assess whether increment of vitamin D daily intake results in improved serum25(OH) vitamin D levels and reduced respiratory morbidity in premature infants.

METHODS

A randomized double-blind clinical pilot trial, including preterm infants born at 32 + 6 to 36 + 6 weeks of gestation. The control group received 400 international units (IU) of cholecalciferol daily compared to 800 IU daily in the intervention group. Levels of 25(OH) vitamin D were measured at birth and 6 and 12 months of age. Respiratory morbidity was followed until 1 year of age.

RESULTS

Fifty subjects were recruited during the study period; the median measured 25(OH) vitamin D levels in the control vs intervention groups were: 26.5 vs 34 nmol/L (P = .271) at birth, 99 vs 75.5 nmol/L (P = .008) at 6 months and 72.5 vs 75 nmol/L (P = .95) at 12 months of age. Infants with insufficient vitamin D (<75 nmol/L) levels had higher respiratory morbidity. Serum vitamin 25(OH) D is a fair predictor for respiratory symptoms (area under the curve [AUC], 0.697; 95% confidence interval [CI], 0.509-0.885; P = .047) and for recorded acute respiratory illnesses (AUC, 0.745; 95% CI, 0.569-0.922; P = .012).

CONCLUSION

Doubling the daily intake of vitamin D in premature infants did not increase serum 25(OH) vitamin D level, due to poor compliance in the intervention group. We found an inverse association between serum 25(OH) vitamin D and respiratory symptoms, indicating vitamin D deficiency is a fair predictor for respiratory morbidity.

The Role of Micronutrients in Support of the Immune Response against Viral Infections

Viral infections are a leading cause of morbidity and mortality worldwide, and the importance of public health practices including handwashing and vaccinations in reducing their spread is well established. Furthermore, it is well known that proper nutrition can help support optimal immune function, reducing the impact of infections. Several vitamins and trace elements play an important role in supporting the cells of the immune system, thus increasing the resistance to infections. Other nutrients, such as omega-3 fatty acids, help sustain optimal function of the immune system. The main aim of this manuscript is to discuss of the potential role of micronutrients supplementation in supporting immunity, particularly against respiratory virus infections. Literature analysis showed that in vitro and observational studies, and clinical trials, highlight the important role of vitamins A, C, and D, omega-3 fatty acids, and zinc in modulating the immune response. Supplementation with vitamins, omega 3 fatty acids and zinc appears to be a safe and low-cost way to support optimal function of the immune system, with the potential to reduce the risk and consequences of infection, including viral respiratory infections. Supplementation should be in addition to a healthy diet and fall within recommended upper safety limits set by scientific expert bodies. Therefore, implementing an optimal nutrition, with micronutrients and omega-3 fatty acids supplementation, might be a cost-effective, underestimated strategy to help reduce the burden of infectious diseases worldwide, including coronavirus disease 2019 (COVID-19).

Vitamin D deficiency as the risk of respiratory tract infections in the institutionalized elderly: A prospective 1-year cohort study

BACKGROUND & AIMS

Respiratory tract infections (RTIs) are one of the major causes of morbidity and mortality in the elderly. Since vitamin D is known to play important roles in immunity, and its deficiency has been reported to be prevalent in the elderly, we have studied the relationship between serum 25-hydroxyvitamin D [25(OH)D] level, which is the most reliable marker for vitamin D status, and the incidence of RTIs in the institutionalized elderly by a prospective observational study.

METHODS

From 208 Japanese subjects aged 60 and older fulfilling the inclusion criteria, 148 subjects remained after propensity score matching. Data were obtained from the medical records including their age, gender, histories of co-morbidities and medications, the incidence of acute RTIs including pneumonia. Measurement of serum 25(OH)D level and assessment of nutrients intake including vitamin D were done at baseline. Cox's proportional hazard analysis was performed to assess the significant predictors for RTIs during the follow-up period.

RESULTS

The median observation duration was 354.2 days, and the incidence of RTIs was 75.8 person-years. Subjects with RTIs had significantly lower serum 25(OH)D concentration, and a higher prevalence of vitamin D deficiency (25(OH)D < 10 ng/mL). Cox's proportional hazard analysis revealed that vitamin D deficiency was a significant predictor for RTIs.

CONCLUSIONS

Our results suggested that vitamin D deficiency was a significant predictor for an increased incidence of RTIs in institutionalized elderly, and the necessity of vitamin D supplementation for the prevention of RTIs was considered.

Risk Factors for Severe Pneumonia According to WHO 2005 Criteria Definition Among Children <5 Years of Age in Thai Binh, Vietnam: A Case-Control Study

Vietnam is one of the 15 countries where the prevalence of child pneumonia is highest. It is a major cause of admission in pediatric hospitals. However, little is known on the burden of severe pneumonia and their risk factors in children <5 years of age in Vietnam. A case–control study was conducted among children aged 2–59 months presenting with pneumonia at the Pediatric Provincial Hospital of Thai Binh. Cases were children with severe pneumonia while controls included those with non-severe pneumonia as defined by the World Health Organization (WHO) classification of 2005. Eighty-three cases and 83 controls were included. Sex ratio was 2.19. Children with severe pneumonia were significantly less likely to receive antibiotics preadmission compared to children with non-severe pneumonia [odds ratio (OR) = 0.16, 95% confidence interval (CI) = 0.06–0.42]. The main risk factors of severe pneumonia were a lack of immunization (OR = 4.77, 95% CI = 1.80–12.65), an exposure to cigarette smoke (OR = 3.87, 95% CI = 1.62–9.23), and having a mother with a low level of education. Children with severe pneumonia were 25 times more likely to present with associated measles with p < 0.0001 and five times more likely to present with diarrhea than children with non-severe pneumonia (p < 0.0001). Improving immunization coverage, educating parents about the risks of passive smoking and the recognition of respiratory distress signs, and facilitating early antibiotic access for infants with acute pulmonary disease should reduce the burden of such illnesses. To implement a national, multicenter study about pneumonia in children, more precise inclusion criteria should be chosen, including radiological and/or biological assessment.

Effect of Severe Vitamin D Deficiency at Admission on Shock Reversal in Children With Septic Shock: A Prospective Observational Study

OBJECTIVES:

To evaluate the association of severe vitamin D deficiency with clinically important outcomes in children with septic shock.

METHODS:

We enrolled children ≤17 years with septic shock prospectively over a period of 6 months. We estimated 25-hydroxyvitamin D [25 (OH) D] levels at admission and 72 hours. Severe deficiency was defined as serum 25 (OH) <10 ng/mL. We performed univariate and multivariate analysis to evaluate association with clinically important outcomes.

RESULTS:

Forty-three children were enrolled in the study. The prevalence of severe vitamin D deficiency was 72% and 69% at admission and 72 hours, respectively. On univariate analysis, severe vitamin D deficiency at admission was associated with lower rates of shock reversal, 74% (23) versus 25% (3); relative risk (95% confidence interval [CI]): 2.9 (1.09-8.08), at 24 hours and greater need for fluid boluses (75 vs 59 mL/kg). On multivariate analysis, nonresolution of shock at 24 hours was significantly associated with severe vitamin D deficiency after adjusting for other key baseline and clinical variables, adjusted odds ratio (95% CI): 12 (2.01-87.01); 0.01.

CONCLUSION:

The prevalence of severe vitamin D deficiency is high in children with septic shock admitted to pediatric intensive care unit. Severe vitamin D deficiency at admission seems to be associated with lower rates of shock reversal at 24 hours of ICU stay. Our study provides preliminary data for planning interventional studies in children with septic shock and severe vitamin D deficiency.

Vitamin D Deficiency is Associated with Increased Use of Antimicrobials among Preschool Girls in Ethiopia

Preschool children in Addis Ababa, Ethiopia, are highly exposed to influenza viruses. Factors related to infections, nutrition, and environmental conditions that might explain the burden of influenza among these children were investigated. Ninety-five preschool children, 48 girls and 47 boys, were followed clinically for 12 months. Illness and immune responses to influenza; three other respiratory viruses; five airway pathogenic bacteria; and levels of vitamins D, A, and B12 were assessed. Most of the children had antibodies to numerous respiratory viral and bacterial agents at study start, and many were infected during follow-up. Twenty-five girls and 25 boys fell ill during the study, and were treated with one or more courses of systemic antimicrobials. Ninety percent of both girls and boys had 25-hydroxyvitamin D [25(OH)D] levels below the recommended levels. While there was no overall difference in the levels of vitamins D, A, and B12 between girls and boys, treated girls had significantly lower 25(OH)D levels than non-treated girls and treated boys. There was a considerable number of short for age children, but only the short treated girls had significantly lower 25(OH)D levels than the non-treated children. Preschool girls with low 25(OH)D levels were more vulnerable to pathogenic microbes than boys.

Vitamin D status and vitamin D receptor gene polymorphism in Saudi children with acute lower respiratory tract infection

There is a significant association exists between vitamin D deficiencies, low respiratory tract infections, and certain types of VDR gene polymorphism. Various studies are being conducted to prove any such link between the different clinical conditions due to disturbed vitamin D regulation and VDR gene polymorphisms. The present study analyzed the presence of vitamin D receptor (VDR) gene polymorphisms (ApaI and TaqI) in Saudi pediatric patient suffering from acute lower respiratory tract infection (ALRTI) cases. Fifty children (50) with ALRTI admitted at King Saud University Medical City, Riyadh/Saudi Arabia were included in addition to seventy-three (73) apparently healthy children who were considered as the control group. Genomic DNA from whole blood was extracted and subjected to polymerase chain reaction (PCR) targeting TaqI and ApaI VDR polymorphisms. RFLP-PCR genotyping was performed to determine the allelic frequency within the VDR gene. In the whole sample, the allelic frequency of ApaI polymorphism in the VDR gene was 58.5%, 17.9%, and 23.6% for AA, Aa, and aa respectively (p = 0.11), while it was 48%, 19%, and 33% for TT, Tt, and tt respectively (p = 0.33) with regards to the frequency of TaqI polymorphism in the VDR gene. VDR ApaI Aa and aa genotypes and VDR TaqI Tt and tt genotypes were not associated with increased risk of ALRTI in children (OR 0.87, 95% CI 0.33-2.28, p = 0.77; OR 0.56, 95% CI 0.23-1.4, p = 0.21; OR 1.15, 95% CI 0.44-2.99, p = 0.77; OR 0.73, 95% CI 0.32-1.68, p = 0.46 respectively). To conclude, neither vitamin D status nor VDR gene polymorphisms such as ApaI and TaqI is associated with increased susceptibility to ALRTI. Linkage disequilibrium was not detected between ApaI and TaqI VDR gene polymorphisms as in the case of serum vitamin D status in ALRTI patients versus apparent healthy children.

Comorbidity of Vitamin A and Vitamin D Deficiency Exacerbates the Severity of Atopic Dermatitis in Children

<b><i>Background:</i></b> Several studies have suggested that vitamin D (VD) deficiency (VDD) is associated with atopic dermatitis (AD). However, little is known about the relationship between AD and vitamin A (VA). The interaction between VA and VD on AD requires further study. <b><i>Objective:</i></b> We detected serum levels of VA and VD in children with AD to explore how VA deficiency (VAD) and VDD affect AD severity. <b><i>Methods:</i></b> We assessed the SCORing Atopic Dermatitis (SCORAD) index, total immunoglobin E levels and peripheral blood eosinophil counts. VA and VD levels were determined with high-performance liquid chromatography. Correlations among variables were investigated with Pearson’s correlation analysis. <b><i>Results:</i></b> The VD and VA levels were significantly lower in children with AD than in normal children (p &#x3c; 0.001, p = 0.0423). Both VD and VA levels were negatively correlated with SCORAD scores. The SCORAD scores were significantly higher in AD patients with both VDD and VAD (co-deficiency) than in other AD patients. Significant inverse correlations were observed between peripheral blood eosinophil counts and serum VA and VD levels. <b><i>Conclusions:</i></b> VA and VD co-deficiency may exacerbate AD symptoms in children, but the specific mechanism underlying this relationship requires further study. These findings may indicate the need for studies evaluating the use of VD and VA as potential treatments for AD patients.

Association of vitamin D receptor gene FokI polymorphism and susceptibility to CAP in Egyptian children: a multicenter study

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of child deaths around the world. Recently, the vitamin D receptor (VDR) gene has emerged as a susceptibility gene for CAP.

OBJECTIVES

To evaluate the association of the VDR gene Fok I polymorphism with susceptibility to CAP in Egyptian children.

METHODS

This was a multicenter case-control study of 300 patients diagnosed with CAP, and 300 well-matched healthy control children. The VDR Fok I (rs2228570) polymorphism was genotyped by PCR-restriction fragment length polymorphism (RFLP), meanwhile serum 25-hydroxy vitamin D (25D) level was assessed using ELISA method.

RESULTS

The frequencies of the VDR FF genotype and F allele were more common in patients with CAP than in our control group (OR = 3.6; (95% CI: 1.9-6.7) for the FF genotype; P = 0.001) and (OR: 1.8; (95% CI: 1.4-2.3) for the F allele; P = 0.01). Patients carrying the VDR FF genotype had lower serum (25D) level (mean; 14.8 ± 3.6 ng/ml) than Ff genotype (20.6 ± 4.5 ng/ml) and the ff genotype (24.5 ± 3.7 ng/ml); P < 0.01.

CONCLUSION

The VDR gene Fok I (rs2228570) polymorphism confers susceptibility to CAP in Egyptian children.

Nutritional rickets among children admitted with severe pneumonia at Mulago hospital, Uganda: a cross-sectional study

BACKGROUND

There's abundant sunshine in the tropics but severe rickets is still observed. Nutritional rickets is associated with an increased risk of acute lower respiratory infections. Pneumonia is the leading cause of death in the under 5 -year old children with the highest burden in developing countries. Both Pneumonia and rickets are common in the developing countries and may affect clinical presentation and outcome. This study aimed to determine the prevalence and associated factors of nutritional rickets in children admitted with severe pneumonia.

METHODS

This was a cross-sectional study of children aged 2-59 months presenting with severe pneumonia at an emergency unit. We enrolled 221 children between February and June 2012 after consent. A pre-coded questionnaire was used to collect data on socio-demographic, nutritional and past medical history. Physical exam was done for signs of rickets and anthropometric measurements. Serum calcium, phosphorus, and alkaline phosphatase (ALP) were assessed. Children with any physical signs of rickets or biochemical rickets (ALP > 400 IU); had a wrist x-ray done. Nutritional rickets was defined as the presence of radiological changes of cupping or fraying and/ or metaphyseal thickening. Severe pneumonia was defined using the WHO criteria. Statistical analysis was performed using the Stata 10 statistical package. P- value < 0.05 was significant.

RESULTS

The prevalence of nutritional rickets among children with severe pneumonia is 9.5%. However, 14.5% had raised ALP (biochemical rickets). The factors independently associated with rickets was an elevated alkaline phosphatase; p-value < 0.001, or 32.95 95% CI (10.54-102.93). Other factors like breastfeeding, big family size, birth order were not significantly associated with rickets. Low serum calcium was detected in 22 (9.9%) of the 221 participants. Overall few children with rickets had typical clinical features of rickets on physical examination.

CONCLUSION

Rickets is a common problem in our setting despite ample sunshine. Clinicians should actively assess children for rickets in this setting and screen for rickets in those children at high risk even without clinical features.

Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia

BACKGROUND

Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases the risk of developing pneumonia in children. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited.

OBJECTIVES

To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia.

SEARCH METHODS

We searched CENTRAL (2017, Issue 7), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; Ovid MEDLINE Epub Ahead of Print; In-Process & Other Non-Indexed Citations; Ovid MEDLINE Daily and Ovid MEDLINE (1946 to July Week 4, 2017); and Embase (2010 to 28 July 2017). We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 28 July 2017. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including children (aged over one month and up to five years) hospitalised with acute community-acquired pneumonia, as defined by the WHO acute respiratory infection guidelines, that compared vitamin D supplementation with control.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with numbers of participants in each group. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven RCTs conducted in low-income countries that involved 1529 children (780 with pneumonia and 749 with severe or very severe pneumonia). Four studies used a single 100,000 IU dose of vitamin D₃ at the onset of illness or within 24 hours of hospital admission; two used a daily dose of oral vitamin D₃ (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used a daily dose of oral vitamin D₃ (50,000 IU) for two days. One study reported microbiological and radiological diagnosis of pneumonia.The effects of vitamin D on outcomes were inconclusive when compared with control: time to resolution of acute illness (hours) (mean difference (MD) -0.95, 95% confidence interval (CI) -6.14 to 4.24; 3 studies; 935 children; low-quality evidence) mortality rate (risk ratio (RR) 0.97, 95% CI 0.06 to 15.28; 1 study; 193 children; very low-quality evidence); duration of hospitalisation (MD 0.49, 95% CI -8.41 to 9.4; 4 studies; 835 children; very low-quality evidence) and time to resolution of fever (MD 1.66, 95% CI -2.44 to 5.76; 4 studies; 584 children; very low-quality evidence).No major adverse events were reported.The GRADE assessment found very low-quality evidence (due to serious study limitations, inconsistencies, indirectness, and imprecision) for all outcomes except time to resolution of acute illness.One study was funded by the New Zealand Aid Corporation; one study was funded by an institutional grant; and five studies were unfunded.

AUTHORS' CONCLUSIONS

We are uncertain as to whether vitamin D has an important effect on outcomes because the results were imprecise. No major adverse events were reported. We assessed the quality of the evidence as very low to low. Several trials are ongoing and may provide additional information.

Vitamin D in pediatric age: consensus of the Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Federation of Pediatricians

Vitamin D plays a pivotal role in the regulation of calcium-phosphorus metabolism, particularly during pediatric age when nutritional rickets and impaired bone mass acquisition may occur.Besides its historical skeletal functions, in the last years it has been demonstrated that vitamin D directly or indirectly regulates up to 1250 genes, playing so-called extraskeletal actions. Indeed, recent data suggest a possible role of vitamin D in the pathogenesis of several pathological conditions, including infectious, allergic and autoimmune diseases. Thus, vitamin D deficiency may affect not only musculoskeletal health but also a potentially wide range of acute and chronic conditions. At present, the prevalence of vitamin D deficiency is high in Italian children and adolescents, and national recommendations on vitamin D supplementation during pediatric age are lacking. An expert panel of the Italian Society of Preventive and Social Pediatrics reviewed available literature focusing on randomized controlled trials of vitamin D supplementation to provide a practical approach to vitamin D supplementation for infants, children and adolescents.

Association between vitamin D and urinary tract infection in children

Purpose

The present study aimed to determine the relationship between serum 25-hydroxyvitamin D (25(OH)D) level and Urinary tract infections (UTIs) in children.

Methods

In this case-control study, 70 children with UTI (case group) were compared with 70 healthy children (control group) in terms of serum 25(OH)D levels. The children were between 1 month and 12 years of age. Serum 25(OH)D levels were measured using enzyme-linked immunosorbent assay (ELISA). The results were analyzed and compared between both groups.

Results

Among 70 children with UTI (case group), 5 children (7.2%) were male and 65 (92.8%) were female. Among the healthy children (control group), 9 (12.8%) and 61 children (87.2%) were male and female, respectively (P=0.39). The mean±standard deviation of age in the case and control groups were 53.2±35.6 and 36.1±60.2 months, respectively (P=0.24). The mean level of serum 25(OH)D in the case group was significantly higher than that of the control group (20.4±8.6 ng/mL vs. 16.9±7.4 ng/mL, P=0.01).

Conclusion

This study showed that there was a relationship between serum 25(OH)D levels and UTI in children. It seems that 25(OH)D plays a role in the pathogenesis of UTI.

Vitamin D deficiency in children with recurrent respiratory infections, with or without immunoglobulin deficiency

PURPOSE

The objective of this study was to evaluate thevitamin D concentration in patients with recurrent respiratory infections with or without immunoglobulin G, A or M (IgG, IgA, IgM) deficiency, and to find a correlation between the vitamin D concentration and the response to hepatitis B vaccination.

MATERIALS AND METHOD

The study involved 730 patients with recurrent respiratory infections. The concentration of 25-hydroxyvitamin D (25(OH)D), immunoglobulins G, A and M, anti-HBs was determined.

RESULTS

The tests showed that 11% of patients presented IgG levels below the age related reference values. Children with reduced IgG concentration were also found to have significantly lower vitamin D concentrations in comparison to children with normal IgG. Vitamin D deficiency was observed in schoolchildren between 7 and 18 years of age. No correlation was found between 25(OH)D concentration and Hbs antibody levels.

CONCLUSIONS

An investigation of a large group of patients who have recurrent infection found patients with IgG deficiency to whom special proceeding have to be performed: 1. Significantly lower vitamin D concentration observed in the group of children with IgG deficiency implicated in long-lasting monitoring of vitamin D level require adding to the practice guidelines for Central Europe 2013. 2. Intervention treatment with suitable doses of vitamin D to clarified metabolism of vitamin D has to be plan for children with IgG deficiency and significant lower vitamin D concentration.

Evaluation of serum 25-hidroxy vitamin D and zinc levels in asthmatic patients

Introduction:

We aimed to investigate the impact of serum zinc, and vitamin D levels on the development of asthma, and its clinical characteristics.

Methods:

In our cross-sectional study; 50 patients who were diagnosed as atopic asthma and 70 healthy children consisted the control group. In both groups levels of vitamin D, and zinc were analyzed.

Results:

A statistically significant intergroup difference was not detected as for age, gender, body height (percentile), and weight (percentile) of the patients (p>0.05). Mean vitamin D levels in the asthmatic patient, and control groups were 32.61±9.48 nmol/L, and 42.55±15.42 nmol/L, respectively. Between two groups a statistically significant difference was found (p=0.001). Zinc levels were higher in the control group without any statistically significant difference between groups (p=0.25). A statistically significant negative correlation (−0.635) was found between vitamin D levels, and severity of asthma in the patient group. As the level of vitamin D increased, a decrease in severity of asthma was seen (p=0.04).

Conclusion:

Though larger series are needed to arrive at definitive conclusions, we think that vitamin D deficiency rather than zinc deficiency, might convey importance in the emergence, and exacerbation of asthma.

Association Between Vitamin D Levels and Treatment Response to Direct-Acting Antivirals in Chronic Hepatitis C: A Real-World Study

Background

Low serum vitamin D levels in chronic hepatitis C (CHC) is associated with advanced liver fibrosis; and there remains an imprecise relationship with the treatment response based on the vitamin D levels. Previous studies have shown conflicting results on the vitamin D levels, and association with treatment response in CHC treated with interferon-based regimens.

Methods

Patients with CHC treated with direct-acting antivirals (DAAs) between January 2016 and December 2017 in the community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks post-treatment (SVR 12) were assessed in CHC patients with deficient, insufficient, and normal levels of vitamin D measured before the initiation of DAA therapy.

Results

Two hundred and ninety-one patients were included in the study. Direct-acting antivirals included in the study were ledipasvir/sofosbuvir ± ribavirin, ombitasvir + paritaprevir + ritonavir + dasabuvir ± ribavirin, and sofosbuvir/velpatasvir. An overall sustained virologic response was achieved in 95% (n = 276) of patients. SVR 12 rates among patients with vitamin D deficiency, vitamin D insufficiency and normal vitamin D levels were 92%, 96.2%, and 97.2% respectively and was not statically significant (P = 0.214). A total of 71 patients were cirrhotic. The prevalence of vitamin D insufficiency (20 - 29.9 ng/mL) and deficiency (< 20 ng/mL) was significantly higher in cirrhotic patients (P = 0.01). Despite this, pretreatment vitamin D levels did not show any impact on the virologic response. The most common adverse effect observed was fatigue. None of the patients had to discontinue the treatment due to adverse events.

Conclusions

DAAs are safe and effective with a high overall SVR 12 in CHC and treatment response does not depend on the pretreatment vitamin D levels. The prevalence of both vitamin D insufficiency and deficiency was observed to be higher in cirrhotic cohorts compared to non-cirrhotic counterparts.

Vitamin D status is associated with treatment failure and duration of illness in Nepalese children with severe pneumonia

BackgroundThere is no consensus on optimal Vitamin D status. The objective of this study was to estimate the extent to which vitamin D status predicts illness duration and treatment failure in children with severe pneumonia by using different cutoffs for vitamin D concentration.MethodsWe measured the plasma concentration of 25(OH)D in 568 children hospitalized with World Health Organization-defined severe pneumonia. The associations between vitamin D status, using the most frequently used cutoffs for vitamin D insufficiency (25(OH)D<50 and <75 nmol/l), and risk for treatment failure and time until recovery were analyzed in multiple logistic regression and Cox proportional hazards models, respectively.ResultsOf the 568 children, 322 (56.7%) had plasma 25(OH)D levels ≥75 nmol/l, 179 (31.5%) had levels of 50-74.9 nmol/l, and 67 (%) had levels <50 nmol/l. Plasma 25(OH)D <50 nmol/l was associated with increased risk for treatment failure and longer time until recovery.ConclusionOur findings indicate that low vitamin D status (25(OH)D<50 nmol/l) is an independent risk factor for treatment failure and delayed recovery from severe lower respiratory infections in children.

Serum 25-hydroxyvitamin D levels in patients with Granulomatosis with Polyangiitis: association with respiratory infection

OBJECTIVES

To determine the possible association of serum 25-hydroxyvitamin D (25OHD) levels with disease activity and respiratory infection in granulomatosis with polyangiitis patients during two different periods: winter/spring and summer/autumn.

METHODS

Thirty-two granulomatosis with polyangiitis patients were evaluated in the winter/spring, and the same patients (except 5) were evaluated in summer/autumn (n=27). The 25OHD levels were measured by radioimmunoassay. Disease activity was assessed by the Birmingham Vasculitis Activity Score Modified for Wegener's Granulomatosis (BVAS/WG) and antineutrophil cytoplasmic antibody (ANCA) positivity. Respiratory infection was defined according the Centers for Disease Control and Prevention criteria.

RESULTS

25OHD levels were lower among patients in winter/spring than in summer/autumn (32.31±13.10 vs. 38.98±10.97 ng/mL, p=0.04). Seven patients met the criteria for respiratory infection: 5 in winter/spring and 2 in summer/autumn. Patients with respiratory infection presented lower 25OHD levels than those without infection (25.15±11.70 vs. 36.73±12.08 ng/mL, p=0.02). A higher frequency of low vitamin D levels (25OHD<20 ng/mL) was observed in patients with respiratory infection (37.5% vs. 7.8, p=0.04). Serum 25OHD levels were comparable between patients with (BVAS/WG≥1 plus positive ANCA) and without disease activity (BVAS/WG=0 plus negative ANCA) (35.40±11.48 vs. 35.34±13.13 ng/mL, p=0.98).

CONCLUSIONS

Lower 25OHD levels were associated with respiratory infection but not disease activity in granulomatosis with polyangiitis patients. Our data suggest that hypovitaminosis D could be an important risk factor for respiratory infection in granulomatosis with polyangiitis patients.

The impact of rickets on growth and morbidity during recovery among children with complicated severe acute malnutrition in Kenya: A cohort study

The effects of rickets on children recovery from severe acute malnutrition (SAM) are unknown. Rickets may affect both growth and susceptibility to infectious diseases. We investigated the associations of clinically diagnosed rickets with life‐threatening events and anthropometric recovery during 1 year following inpatient treatment for complicated SAM. This was a secondary analysis of clinical trial data among non‐human immunodeficiency virus‐infected Kenyan children with complicated SAM (2–59 months) followed for 1 year posthospital discharge (ClinicalTrials.gov ID NCT00934492). The outcomes were mortality, hospital readmissions, and growth during 12 months. The main exposure was clinically diagnosed rickets at baseline. Of 1,778 children recruited, 230 (12.9%, 95% CI [11.4, 14 .6]) had clinical signs of rickets at baseline. Enrolment at an urban site, height‐for‐age and head circumference‐for‐age z scores were associated with rickets. Rickets at study enrolment was associated with increased mortality (adjusted Hazard Ratio [aHR] 1.61, 95% CI [1.14, 2.27]), any readmission (aHR 1.37, 95% CI [1.09, 1.72]), readmission for severe pneumonia (aHR 1.37, 95% CI [1.05, 1.79]), but not readmission with diarrhoea (aHR 1.05, 95% CI [0.73, 1.51]). Rickets was associated with increased height gain (centimetres), adjusted regression coefficient 0.19 (95% CI [0.10, 0.28]), but not changes in head circumference, mid‐upper arm circumference, or weight. Rickets was common among children with SAM at urban sites and associated with increased risks of severe pneumonia and death. Increased height gain may have resulted from vitamin D and calcium treatment. Future work should explore possibility of other concurrent micronutrient deficiencies and optimal treatment of rickets in this high‐risk population.

Spatial variation of pneumonia hospitalization risk in Twin Cities metro area, Minnesota

Fine resolution spatial variability in pneumonia hospitalization may identify correlates with socioeconomic, demographic and environmental factors. We performed a retrospective study within the Fairview Health System network of Minnesota. Patients 2 months of age and older hospitalized with pneumonia between 2011 and 2015 were geocoded to their census block group, and pneumonia hospitalization risk was analyzed in relation to socioeconomic, demographic and environmental factors. Spatial analyses were performed using Esri's ArcGIS software, and multivariate Poisson regression was used. Hospital encounters of 17 840 patients were included in the analysis. Multivariate Poisson regression identified several significant associations, including a 40% increased risk of pneumonia hospitalization among census block groups with large, compared with small, populations of ⩾65 years, a 56% increased risk among census block groups in the bottom (first) quartile of median household income compared to the top (fourth) quartile, a 44% higher risk in the fourth quartile of average nitrogen dioxide emissions compared with the first quartile, and a 47% higher risk in the fourth quartile of average annual solar insolation compared to the first quartile. After adjusting for income, moving from the first to the second quartile of the race/ethnic diversity index resulted in a 21% significantly increased risk of pneumonia hospitalization. In conclusion, the risk of pneumonia hospitalization at the census-block level is associated with age, income, race/ethnic diversity index, air quality, and solar insolation, and varies by region-specific factors. Identifying correlates using fine spatial analysis provides opportunities for targeted prevention and control.

Measurement of serum 3-epi-25-hydroxyvitamin D3, 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 in infant, paediatric and adolescent populations of Korea using ultra-performance liquid chromatography-tandem mass spectrometry

Background We evaluated the performance of ultra-performance liquid chromatography-tandem mass spectrometry to measure serum 3-epi-25-hydroxyvitamin D₃, 25-hydroxyvitamin D₃ and 25-hydroxyvitamin D₂ concentrations in 519 infant, paediatric and adolescent serum samples in Korea. Methods We used a Kinetex XB-C18 column and isocratic methanol/water (77.5/22.5, v/v) with 0.025% (v/v) high-performance liquid chromatography solvent additive flowing at 0.25 mL/min, yielding an 11 min/sample run time. A TQD triple quadrupole mass spectrometer in electrospray ionization positive ion mode with multiple reaction monitoring transition via an MSMS vitamin D kit was used to evaluate precision, carryover, ion suppression and linearity. Samples were prepared using the 4-phenyl-1,2,4-triazoline-3,5-dione derivatization method. Results Intra- and inter-run precisions were 1.23-13.28% and 1.02-10.08%, respectively. Group carryovers were -0.27% and 0.10%, respectively. There was no ion suppression. The calibration curve showed good linearity from calibrator Level 1 (11.75 nmol/L) to 6 (375 nmol/L) with R²> 0.9999. The 3-epi-25-hydroxyvitamin D₃ and 25-hydroxyvitamin D₃ peaks were clearly separated in the extracted ion chromatogram. Infant serum samples 3-epi-25-hydroxyvitamin D₃ concentrations were significantly higher than paediatric and adolescent concentrations. Conclusions The ultra-performance liquid chromatography-tandem mass spectrometry assay performed acceptably, clearly separating 3-epi-25-hydroxyvitamin D₃ from 25-hydroxyvitamin D₃. High 3-epi-25-hydroxyvitamin D₃ concentrations were observed in infant but not in paediatric and adolescent serum samples.

Role of vitamin D in cystic fibrosis and non-cystic fibrosis bronchiectasis

Bronchiectasis is usually classified as cystic fibrosis (CF) related or CF unrelated (non-CF); the latter is not considered an orphan disease any more, even in developed countries. Irrespective of the underlying etiology, bronchiectasis is the result of interaction between host, pathogens, and environment. Vitamin D is known to be involved in a wide spectrum of significant immunomodulatory effects such as down-regulation of pro-inflammatory cytokines and chemokines. Respiratory epithelial cells constitutively express 1α-hydroxylase leading to the local transformation of the inactive 25(OH)-vitamin D to the active 1,25(OH)₂-vitamin D. The latter through its autocrine and paracrine functions up-regulates vitamin D dependent genes with important consequences in the local immunity of lungs. Despite the scarcity of direct evidence on the involvement of vitamin D deficiency states in the development of bronchiectasis in either CF or non-CF patients, it is reasonable to postulate that vitamin D may play some role in the pathogenesis of lung diseases and especially bronchiectasis. The potential contribution of vitamin D deficiency in the process of bronchiectasis is of particular clinical importance, taking into consideration the increasing prevalence of vitamin D deficiency worldwide and the significant morbidity of bronchiectasis. Given the well-established association of vitamin D deficiency with increased inflammation, and the indicative evidence for harmful consequences in lungs, it is intriguing to speculate that the administration of vitamin D supplementation could be a reasonable and cost effective supplementary therapeutic approach for children with non-CF bronchiectasis. Regarding CF patients, maybe in the future as more data become available, we have to re-evaluate our policy on the most appropriate dosage scheme for vitamin D.

Evaluation of vitamin D prophylaxis in 3-36-month-old infants and children

BACKGROUND

Vitamin D (VD) deficiency (VDD) is still a population-based health problem that affects people at different ages. The aim of this study was to evaluate VD prophylaxis for the prevention of VDD in (3-36)-month-old infants and children.

METHODS

Infants and children aged between 3 and 36 months, with different etiologies, admitted to outpatient and inpatient clinics from October 2010 to October 2011 at the Children's Hospital of Erciyes University, were enrolled for the study. Their VD intake (if used; time of initiation, dosage and compliance) and nutritional status (breast-fed, formula or complementary fed) were noted. In order to study seasonal VD changes, the levels of serum calcium, phosphorus and magnesium, alkaline phosphatase activity (PLA), plasma parathyroid hormone (PTH) and 25 hydroxyvitamin 25(OH)D levels were measured at the beginning of VD supplementation during the four seasons.

RESULTS

A total of 316 subjects were enrolled in the study, consisting of 202 (63.9%) outpatient and 114 (26.1%) inpatient groups. From these subjects, 304 (96.2%) were supplemented with VD; whereas 12 (3.8%) were not. Out of the subjects supplemented with VD, 237 (75%) initiated VD after the second week of life, 267 (87.8%) were given three drops of VD daily and 209 (66.1%) had taken VD regularly. The plasma 25(OH)D levels were found to be lower in the inpatient group than the outpatient group (29.35 ng/mL and 34.35 ng/mL, respectively). The plasma 25(OH)D levels were lower during the spring and winter. VDD and VD insufficiency (VDI) was found in 31 (9.8%) and 30 (9.5%) subjects, respectively.

CONCLUSIONS

The plasma 25(OH)D levels were lower in inpatient and breast-fed only subjects and in winter and spring. The national VD augmentation program seems to be beneficial for the prevention of VDD, but VDD/VDI seems to still be an important health problem.

Nutrient Status of Vitamin D among Chinese Children

Background: Vitamin D deficiency is considered to be a public health problem. However, the nutrient status of vitamin D in Chinese children is unclear. The aim of this study was to describe the vitamin D status among children aged under 18 years in southeast China. Methods: Children who visited the Huzhou Maternal and Child Care Hospital from January 2012 to August 2015 were included in this large cross-sectional study. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were measured by electrochemiluminescence immunoassay. Vitamin D status was defined as deficiency (25(OH)D < 20 ng/mL), insufficiency (25(OH)D: 20–29 ng/mL) and sufficiency (25(OH)D ≥ 30 ng/mL). The association between relevant variables and vitamin D status was analyzed by a using generalized estimated equation model and a multivariate regression model. Results: 13,997 children aged under 18 years were included. Of these, 23.3% children suffered from low vitamin D status (deficiency and insufficiency), while 76.7% had a sufficient vitamin D status. The prevalence of low vitamin D status was 29.7% in winter and 23.4% in spring, which was higher than that in summer (21.4%) and autumn (19.9%). Clinical visiting children (32.1%) suffered more from low vitamin D than health examination children (17.6%). Additionally, age and season were independently and significantly associated with 25(OH)D concentrations, respectively. Conclusions: The deficiency and insufficiency status of vitamin D was very common among newborns and children aged one to 17 years. This indicates that more sunshine and vitamin D–fortified foods are necessary among Chinese children.

Vitamin-D deficiency predicts infections in young north Indian children: A secondary data analysis

Background

Recent studies have demonstrated a relationship between poor vitamin D status and respiratory infections and diarrhea among young children. Acute lower respiratory infections (ALRI) and diarrhea are among the two most important causes of death in under-5 children. In this paper, we examined the extent to which vitamin-D deficiency (<10 ng/ml) predicts ALRI, clinical pneumonia and diarrhea among 6 to 30 months old children.

Methods

We used data from a randomized controlled trial (RCT) of daily folic acid and/or vitamin B12 supplementation for six months in 6 to 30 months old children conducted in Delhi, India. Generalized estimating equations (GEE) were used to examine the associations between vitamin-D deficiency and episodes of ALRI, clinical pneumonia and diarrhea.

Results

Of the 960 subjects who had vitamin-D concentrations measured, 331(34.5%) were vitamin-D deficient. We found, after controlling for relevant potential confounders (age, sex, breastfeeding status, wasting, stunting, underweight, anemia status and season), that the risk of ALRI was significantly higher among vitamin-D deficient (OR 1.26; 95% CI: 1.03 to 1.55) compared to vitamin-D-replete children in the six months follow-up period. Vitamin-D status was not associated with episodes of diarrhea or clinical pneumonia.

Conclusion

Vitamin-D deficiency is common in young children in New Delhi and is associated with a higher risk of ALRI. The role of vitamin D in Indian children needs to be elucidated in further studies.

Interventions to prevent respiratory diseases - Nutrition and the developing world

Malnutrition is a major cause of morbidity and mortality in developing countries and nutrition plays a critical role in both acute and chronic respiratory conditions. Inadequacies in the nutritional requirements of a developing lung in utero and in early life can compromise the respiratory system integrity and result in poor lung function, reduced protection against infections, greater likelihood of acute illnesses in childhood and chronic illness in adulthood. Nutritional interventions harness great potential in reducing respiratory illness related morbidity and mortality in the developing world. In this review we have summarized the findings from published systematic reviews/meta-analysis, experimental and observational studies that looked into different nutritional interventions for preventing respiratory diseases in developing countries.

Vitamin D supplementation for preventing infections in children under five years of age

BACKGROUND

Vitamin D is a micronutrient important for bone growth and immune function. Deficiency can lead to rickets and has been linked to various infections, including respiratory infections. The evidence on the effects of supplementation on infections in children has not been assessed systematically.

OBJECTIVES

To evaluate the role of vitamin D supplementation in preventing pneumonia, tuberculosis (TB), diarrhoea, and malaria in children under five years of age. This includes high-, middle-, and low-income countries.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library, MEDLINE, EMBASE, LILACS, the WHO International Clinical Trials Registry Platform (ICTRP; http://www.who.int/ictrp/en/) , ClinicalTrials.gov and the ISRCTN registry (http://www.isrctn.com/) up to 16 June 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated preventive supplementation of vitamin D (versus placebo or no intervention) in children under five years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts, extracted the data, and assessed the risk of bias of included trials.

MAIN RESULTS

Four trials met the inclusion criteria, with a total of 3198 children under five years of age, and were conducted in Afghanistan, Spain, and the USA. Prevalence of vitamin D deficiency varied widely in these populations (range: 73.1% in Afghanistan, 10 to 12% in USA, and 6.2% in Spain). The included trials evaluated mortality (two trials), pneumonia incidence (two trials), diarrhoea incidence (two trials), hospitalization (two trials), and mean serum vitamin D concentrations (four trials).We do not know whether vitamin D supplementation impacts on all-cause mortality because this outcome was underpowered due to few events (risk ratio (RR) 1.43, 95% confidence interval (CI) 0.54 to 3.74; one trial, 3046 participants, low quality evidence).For pneumonia, episodes of 'radiologically confirmed' first or only episode of pneumonia were little different in the supplemented and unsupplemented group (Rate Ratio: 1.06, 95% confidence interval (CI) 0.89 to 1.26; two trials, 3134 participants, moderate quality evidence), and similarly for children with confirmed or unconfirmed pneumonia (RR 0.95, 95% CI 0.87 to 1.04; one trial, 3046 participants). In these two trials there were no obvious differences between supplemented and unsupplemented children regarding episodes of diarrhoea.In the single large trial from Afghanistan, the trial authors reported that vitamin D supplementation was associated with an increase in repeat episodes of pneumonia confirmed by chest radiograph (RR 1.69, 95% CI 1.28 to 2.21; one trial, 3046 participants), but not reflected in the outcome of confirmed or unconfirmed pneumonia (RR 1.06, 95% CI 1.00 to 1.13; one trial, 3046 participants).For hospital admission measured in one small trial, there was no difference detected (RR 0.86, 95% CI 0.20 to 3.62; one trial, 88 participants; very low quality evidence).The mean serum vitamin D concentrations were higher in supplemented compared to unsupplemented children at the end of supplementation (MD 7.72 ng/mL, 95% CI 0.50 to 14.93; four trials, 266 participants, low quality evidence). These results were driven primarily by two smaller trials with large magnitudes of effect. In the other two bigger trials, serum vitamin D concentrations were elevated in the intervention group for most of the trial duration but not at the end of supplementation. This may be due to time elapsed at measurement from the last dose, incomplete compliance, or increased need of vitamin D with infant age.We did not find any trial that reported on the incidence of TB, malaria or febrile illness, duration of pneumonia, duration of diarrhoea, severity of infection, and cause-specific mortality (due to TB, diarrhoea, or malaria).

AUTHORS' CONCLUSIONS

Evidence from one large trial did not demonstrate benefit of vitamin D supplementation on the incidence of pneumonia or diarrhoea in children under five years. To our knowledge, trials that evaluated supplementation for preventing other infections, including TB and malaria, have not been performed.

Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

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.

Maternal vitamin D supplementation during pregnancy and lactation to prevent acute respiratory infections in infancy in Dhaka, Bangladesh (MDARI trial): protocol for a prospective cohort study nested within a randomized controlled trial

Background

Early infancy is a high-risk period for severe acute respiratory infection (ARI), particularly in low-income countries with resource-limited health systems. Lower respiratory tract infection (LRTI) is commonly preceded by upper respiratory infection (URTI), and often caused by respiratory syncytial virus (RSV), influenza and other common community-acquired viral pathogens. Vitamin D status is a candidate modifiable early-life determinant of the host antiviral immune response and thus may influence the risk of ARI-associated morbidity in high-risk populations.

Methods/Design

In the Maternal Vitamin D for Infant Growth (MDIG) study in Dhaka, Bangladesh (NCT01924013), 1300 pregnant women are randomized to one of five groups: placebo, 4200 IU/week, 16,800 IU/week, or 28,000 IU/week from 2^nd trimester to delivery plus placebo from 0–6 months postpartum; or, 28,000 IU/week prenatal and until 6-months postpartum. In the Maternal Vitamin D for ARI in Infancy (MDARI) sub-study nested within the MDIG trial, trained personnel conduct weekly postnatal home visits to inquire about ARI symptoms and conduct a standardized clinical assessment. Supplementary home visits between surveillance visits are conducted when caregivers make phone notifications of new infant symptoms. Mid-turbinate nasal swab samples are obtained from infants who meet standardized clinical ARI criteria. Specimens are tested by polymerase chain reaction (PCR) for 8 viruses (influenza A/B, parainfluenza 1/2/3, RSV, adenovirus, and human metapneumovirus), and nasal carriage density of Streptococcus pneumoniae. The primary outcome is the incidence rate of microbiologically-positive viral ARI, using incidence rate ratios to estimate between-group differences. We hypothesize that among infants 0–6 months of age, the incidence of microbiologically-confirmed viral ARI will be significantly lower in infants whose mothers received high-dose prenatal/postpartum vitamin D supplements versus placebo. Secondary outcomes include incidence of ARI associated with specific pathogens (influenza A or B, RSV), clinical ARI, and density of pneumococcal carriage.

Discussion

If shown to reduce the risk of viral ARI in infancy, integration of maternal prenatal/postpartum vitamin D supplementation into antenatal care programs in South Asia may be a feasible primary preventive strategy to reduce the burden of ARI-associated morbidity and mortality in young infants.

Trial registration

NCT02388516, registered March 9, 2015.

Preventing Rickets in Locally Appropriate Ways: A Case Report from North China

A rickets prevention program was carried out in Shanxi Province, China using locally appropriate methods. At the end of two and one-half years, the prevalence of rickets was 18% lower in program townships (56%) than in a control township that had no rickets prevention program (74%). Maternal awareness of how to prevent rickets was higher in program townships (43%) than in the control township (28%). However, the actual effect of maternal awareness on the prevention of rickets was negligible. In conclusion, this rickets prevention program was effective at reducing the prevalence of rickets. It appears the program was effective because of the presence of concerned program workers regularly visiting mothers and their infants, and using locally appropriate methods, but neither the vitamin supplements used nor the kind of rickets prevention education provided the mothers was shown to be positively correlated.

Nutritional rickets in immigrant and refugee children

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.

Vitamin D deficiency and lower respiratory tract infections in children: a systematic review and meta-analysis of observational studies

Studies related to vitamin D deficiency and lower respiratory tract infections (LRTI) in children have inconsistent findings. The objective of this systematic review was to assess the prevalence of vitamin D deficiency in children with LRTI, and to evaluate the correlation between vitamin D levels and the incidence and severity of LRTI. A total of 12 studies enrolling 2279 participants were included in our analysis. Children with LRTI were found to have significantly lower mean vitamin D levels as compared to controls There was likewise a correlation between vitamin D levels and incidence and severity of LRTI. Large randomised controlled trials are needed to evaluate effect of vitamin D supplementation for LRTI.