Low vitamin D levels and prognosis in a COVID-19 pediatric population: a systematic review

Vitamin D Levels in COVID-19 and NonCOVID-19 Pediatric Patients and Its Relationship with Clinical and Laboratory Characteristics

25-hydroxyvitamin D [25(OH)D] is a marker with an important role in regulating the inflammatory response. Low concentrations of this vitamin are often found among the population, correlated with increased risk of respiratory tract infections. The aim of the study is to evaluate the relationship between vitamin D levels and clinical and laboratory markers in children and adolescents hospitalized with and without COVID-19. A retrospective study, including all patients tested for SARS-CoV-2 and having vitamin D measured, was performed. All included hospitalized cases, 78 COVID-19 patients and 162 NonCOVID-19 patients, were divided into subgroups according to their 25(OH)D serum levels (<20 ng/mL-deficiency, 20-30 ng/mL-insufficiency, ≥30 ng/mL-normal or <30 ng/mL, ≥30 ng/mL) and age (≤2 years, >2 years). Vitamin D deficiency and insufficiency increased with age, in both COVID-19 and NonCOVID-19 groups. All symptoms were encountered more frequently in cases of pediatric patients with COVID-19 in comparison with NonCOVID-19 cases. The most frequently encountered symptoms in the COVID-19 group were fever, loss of appetite, and nasal congestion. In the NonCOVID-19 group, serum 25(OH)D concentrations were positively correlated with leukocytes, lymphocytes, and LMR and negatively correlated with neutrophils, NLR, and PLR while no significant correlation was observed in the case of COVID-19 group. Differences between vitamin D status and clinical and laboratory parameters were observed, but their clinical significance should be interpreted with caution. The results of this study may offer further support for future studies exploring the mechanisms of the relationship between vitamin D and clinical and laboratory markers as well as for studies investigating the implications of vitamin D deficiency/supplementation on overall health/clinical outcomes of patients with/without COVID-19.

Vitamin D Supplementation in Neonatal and Infant MIS-C Following COVID-19 Infection

To date, the SARS-CoV-2 pandemic still represents a great clinical challenge worldwide, and effective anti-COVID-19 drugs are limited. For this reason, nutritional supplements have been investigated as adjuvant therapeutic approaches in disease management. Among such supplements, vitamin D has gained great interest, due to its immunomodulatory and anti-inflammatory actions both in adult and pediatric populations. Even if there is conflicting evidence about its prevention and/or mitigation effectiveness in SARS-CoV-2 infection, several studies demonstrated a strict correlation between hypovitaminosis D and disease severity in acute COVID-19 and MIS-C (multisystem inflammatory syndrome in children). This narrative review offers a resume of the state of the art about vitamin D's role in immunity and its clinical use in the context of the current pandemic, specially focusing on pediatric manifestations and MIS-C. It seems biologically reasonable that interventions aimed at normalizing circulating vitamin D levels could be beneficial. To help clinicians in establishing the correct prophylaxis and/or supportive therapy with vitamin D, well-designed and adequately statistically powered clinical trials involving both adult and pediatric populations are needed. Moreover, this review will also discuss the few other nutraceuticals evaluated in this context.

Evidence linking COVID-19 and the health/well-being of children and adolescents: an umbrella review

BACKGROUND

Experiences during childhood and adolescence have enduring impacts on physical and mental well-being, overall quality of life, and socioeconomic status throughout one's lifetime. This underscores the importance of prioritizing the health of children and adolescents to establish an impactful healthcare system that benefits both individuals and society. It is crucial for healthcare providers and policymakers to examine the relationship between COVID-19 and the health of children and adolescents, as this understanding will guide the creation of interventions and policies for the long-term management of the virus.

METHODS

In this umbrella review (PROSPERO ID: CRD42023401106), systematic reviews were identified from the Cochrane Database of Systematic Reviews; EMBASE (OvidSP); and MEDLINE (OvidSP) from December 2019 to February 2023. Pairwise and single-arm meta-analyses were extracted from the included systematic reviews. The methodological quality appraisal was completed using the AMSTAR-2 tool. Single-arm meta-analyses were re-presented under six domains associated with COVID-19 condition. Pairwise meta-analyses were classified into five domains according to the evidence classification criteria. Rosenberg's FSN was calculated for both binary and continuous measures.

RESULTS

We identified 1551 single-arm and 301 pairwise meta-analyses from 124 systematic reviews that met our predefined criteria for inclusion. The focus of the meta-analytical evidence was predominantly on the physical outcomes of COVID-19, encompassing both single-arm and pairwise study designs. However, the quality of evidence and methodological rigor were suboptimal. Based on the evidence gathered from single-arm meta-analyses, we constructed an illustrative representation of the disease severity, clinical manifestations, laboratory and radiological findings, treatments, and outcomes from 2020 to 2022. Additionally, we discovered 17 instances of strong or highly suggestive pairwise meta-analytical evidence concerning long-COVID, pediatric comorbidity, COVID-19 vaccines, mental health, and depression.

CONCLUSIONS

The findings of our study advocate for the implementation of surveillance systems to track health consequences associated with COVID-19 and the establishment of multidisciplinary collaborative rehabilitation programs for affected younger populations. In future research endeavors, it is important to prioritize the investigation of non-physical outcomes to bridge the gap between research findings and clinical application in this field.

The Association between Serum Vitamin D Levels and Urinary Tract Infection Risk in Children: A Systematic Review and Meta-Analysis

The association between serum vitamin D levels and urinary tract infection (UTI) in children is unclear. We undertook a systematic review and meta-analysis to evaluate the relationships between different vitamin D levels and the likelihood of UTI in children. Online databases, including Web of Science, PubMed, Embase, and Cochrane Library, were searched up to 6 February 2023 for studies based on the inclusion criteria. Weighted mean difference (WMD) and Odds Ratios (ORs), along with their 95% confidence intervals (CI), were calculated, and the random-effects model was used for analysis. Twelve case-control studies and one cross-sectional study (839 children with UTI and 929 controls) were included. We found that children with UTI had lower levels of serum vitamin D than healthy controls (WMD: -7.730, 95% CI: -11.57, -3.89; p < 0.001). Low vitamin D levels were significantly associated with UTI in children (OR: 2.80; 95% CI: 1.55, 5.05; p = 0.001). The likelihood of children having a UTI significantly increased when their serum vitamin D level was less than 20 ng/mL (OR: 5.49, 95% CI: 1.12, 27.04; p = 0.036). Therefore, vitamin D level, especially when less than 20 ng/mL, is a risk factor in UTI.

The role of free vitamin D and vitamin D binding protein in SARS-Cov-2 infection in children

BACKGROUND

Many studies have discussed the effects of serum vitamin D deficiency in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients. This study aimed to investigate the relationship between SARS-CoV-2 infection severity and free vitamin D (FVD) and bioavailable vitamin D (BAVD) levels in children.

METHODS

A prospective case-control study design was used. Participants were divided into three groups based on the World Health Organization COVID-19 Clinical Progression Scale. Serum 25-hydroxyvitamin D (ng/mL), albumin (g/L), and vitamin D binding protein (ng/mL) levels were evaluated to investigate the relationship between disease severity and FVD and BAVD levels.

RESULTS

In total, 82 participants were included in the study. Of those, 24.4% were uninfected (n = 20), 50% had a mild case of SARS-CoV-2 (n = 41), and 25.6% had a moderate case (n = 21). There was a statistically significant difference in FVD and BAVD levels between the groups (p = 0.026). Median FVD (p = 0.007, Cohen's d = 0.84) and BAVD (p = 0.007, Cohen's d = 0.86) levels were significantly higher in the mild group compared to the moderate group. FVD and BAVD metabolites were moderately positively correlated with lymphocyte counts (FVD: r = 0.437, p < 0.001; BAVD: r = 0.439, p < 0.001).

CONCLUSIONS

This is the first study to demonstrate a relationship between SARS-CoV-2 symptom severity and FVD and BAVD levels. The relationship between FVD and BAVD levels and lymphocyte counts could play an important role in symptom severity and should be evaluated in further studies.

Vitamin D status can affect COVID-19 outcomes also in pediatric population

Background

vitamin D influences the immune system and the inflammatory response. It is known that vitamin D supplementation reduces the risk of acute respiratory tract infection. In the last two years, many researchers have investigated vitamin D's role in the pathophysiology of COVID-19 disease.

Results

the findings obtained from clinical trials and systematic reviews highlight that most patients with COVID-19 have decreased vitamin D levels and low levels of vitamin D increase the risk of severe disease. This evidence seems to be also confirmed in the pediatric population.

Conclusions

further studies (systematic review and meta-analysis) conducted on children are needed to confirm that vitamin D affects COVID-19 outcomes and to determine the effectiveness of supplementation and the appropriate dose, duration and mode of administration.

Severity of Pediatric COVID-19: Role of Vitamin D

Objective Vitamin D has many immune benefits and because its deficiency impacts most age groups, it became a nutrient of interest in the coronavirus disease 2019 (COVID-19) era. The objective of this study was to highlight the contribution of vitamin D status to the disease severity of hospitalized pediatric patients suffering from COVID-19 infection.

Methods This was a cross-sectional study that was conducted on 42 children with documented positive polymerase chain reaction for COVID-19 infection. Detailed history taking and thorough clinical examination were done for each recruited patient. Besides the laboratory and radiological assessment done for COVID-19 patients, 25 hydroxy vitamin D levels [25(OH) D] in the serum were estimated using enzyme linked immunosorbent assay.

Results Using the cutoff level of 10 ng/mL, only 40% of the patients were below this level and 60% had their vitamin D level more than or equal to 10 ng/mL. Significantly more patients of the first group needed oxygen support (denoting more severe COVID-19 infection and lung involvement). The older the patients, the more evident was vitamin D deficiency among them, and 25(OH) D values were not correlated to weight for length nor weight categories in the studied series of patients suffering from COVID-19.

Conclusion Vitamin D deficiency affects the severity of pediatric COVID-19 infection in hospitalized patients. It is prudent to advise vitamin D level assessment in such cases and promptly manage the patients accordingly. We recommend further studies to assess the effect of vitamin D supplementation on the clinical outcome of COVID-19 in the pediatric population and other vulnerable groups.

Prognostic and Therapeutic Role of Vitamin D in COVID-19: Systematic Review and Meta-analysis

PURPOSE

Vitamin D deficiency/insufficiency may increase the susceptibility to coronavirus disease 2019 (COVID-19). We aimed to determine the association between vitamin D deficiency/insufficiency and susceptibility to COVID-19, its severity, mortality, and role of vitamin D in its treatment.

METHODS

We searched CINAHL, Cochrane library, EMBASE, PubMED, Scopus, and Web of Science up to May 30, 2021, for observational studies on association between vitamin D deficiency/insufficiency and susceptibility to COVID-19, severe disease, and death among adults, and, randomized controlled trials (RCTs) comparing vitamin D treatment against standard care or placebo, in improving severity or mortality among adults with COVID-19. Risk of bias was assessed using Newcastle-Ottawa scale for observational studies and AUB-KQ1 Cochrane tool for RCTs. Study-level data were analyzed using RevMan 5.3 and R (v4.1.0). Heterogeneity was determined by I2 and sources were explored through prespecified sensitivity analyses, subgroup analyses, and meta-regressions.

RESULTS

Of 1877 search results, 76 studies satisfying eligibility criteria were included. Seventy-two observational studies were included in the meta-analysis (n = 1 976 099). Vitamin D deficiency/insufficiency increased the odds of developing COVID-19 (odds ratio [OR] 1.46; 95% CI, 1.28-1.65; P < 0.0001; I2 = 92%), severe disease (OR 1.90; 95% CI, 1.52-2.38; P < 0.0001; I2 = 81%), and death (OR 2.07; 95% CI, 1.28-3.35; P = 0.003; I2 = 73%). The 25-hydroxy vitamin D concentrations were lower in individuals with COVID-19 compared with controls (mean difference [MD] -3.85 ng/mL; 95% CI, -5.44 to -2.26; P ≤ 0.0001), in patients with severe COVID-19 compared with controls with nonsevere COVID-19 (MD -4.84 ng/mL; 95% CI, -7.32 to -2.35; P = 0.0001) and in nonsurvivors compared with survivors (MD -4.80 ng/mL; 95% CI, -7.89 to -1.71; P = 0.002). The association between vitamin D deficiency/insufficiency and death was insignificant when studies with high risk of bias or studies reporting unadjusted effect estimates were excluded. Risk of bias and heterogeneity were high across all analyses. Discrepancies in timing of vitamin D testing, definitions of severe COVID-19, and vitamin D deficiency/insufficiency partly explained the heterogeneity. Four RCTs were widely heterogeneous precluding meta-analysis.

CONCLUSION

Multiple observational studies involving nearly 2 million adults suggest vitamin D deficiency/insufficiency increases susceptibility to COVID-19 and severe COVID-19, although with a high risk of bias and heterogeneity. Association with mortality was less robust. Heterogeneity in RCTs precluded their meta-analysis.

Association of vitamin D status with COVID‐19 disease severity in pediatric patients: A retrospective observational study

Background and Aims

Methods

Results

Conclusion

Exclusive Breastfeeding and Vitamin D Supplementation: A Positive Synergistic Effect on Prevention of Childhood Infections?

Human milk is the best food for infants. Breastfeeding has been associated with a reduced risk of viral and bacterial infections. Breast milk contains the perfect amount of nutrients needed to promote infant growth, except for vitamin D. Vitamin D is crucial for calcium metabolism and bone health, and it also has extra-skeletal actions, involving innate and adaptive immunity. As exclusive breastfeeding is a risk factor for vitamin D deficiency, infants should be supplemented with vitamin D at least during the first year. The promotion of breastfeeding and vitamin D supplementation represents an important objective of public health.

Efficacy and safety of vitamin D supplementation in hospitalized COVID-19 pediatric patients: A randomized controlled trial

BACKGROUND

Some studies suggested that adequate levels of vitamin D (VD) decrease the risk of severe COVID-19. Information about the effectiveness of VD supplementation in children is scarce.

OBJECTIVE

To assess the efficacy and safety of VD supplementation compared to the standard of care in hospitalized children with COVID-19.

PATIENTS AND METHODS

An open-label randomized controlled single-blind clinical trial was carried out. We included patients from 1 month to 17 years, with moderate COVID-19, who required hospitalization and supplemental oxygen. They were randomized into two groups: the VD group, which received doses of 1,000 (children < 1 year) or 2,000 IU/day (from 1 to 17 years) and the group without VD (control). The outcome variables were the progression of oxygen requirement, the development of complications, and death.

STATISTICAL ANALYSIS

For comparison between groups, we used the chi-squared test or Fisher's exact test and the Mann-Whitney U test. Absolute risk reduction (ARR) and the number needed to treat (NNT) were calculated. p ≤ 0.05 was considered statistically significant.

RESULTS

From 24 March 2020 to 31 March 2021, 87 patients were eligible to participate in the trial; 45 patients were randomized: 20 to the VD group and 25 to the control group. There was no difference in general characteristics at baseline, including serum VD levels (median 13.8 ng/ml in the VD group and 11.4 ng/ml in the control group).

OUTCOMES

2/20 (10%) in the VD group vs. 9/25 (36%) in the control group progressed to a superior ventilation modality (p = 0.10); one patient in the VD group died (5%) compared to 6 (24%) patients in the control group (p = 0.23). ARR was 26% (95% CI 8.8 to 60.2%) and NNT was 3 (2 to 11) for progression and ARR was 19% (95% CI -3.9 to 42.8%) and NNT was 6 (2 to 26) for death. None of the patients receiving VD had adverse effects. The trial was stopped for ethical reasons; since after receiving the results of the basal VD values, none of the patients had normal levels.

CONCLUSION

In this trial, VD supplementation in pediatric patients seems to decrease the risk of COVID-19 progression and death. More studies are needed to confirm these findings.

CLINICAL TRIAL REGISTRATION

This protocol was registered on ClinicalTrials.gov with the registration number NCT04502667.