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Presentation by Dr.Rajeev jain from Agra,India for pediatric group clinical meeting.

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  • Neuropediatrics. 2007 Aug;38(4):167-72. High-dose vitamin D supplementation in children with cerebral palsy or neuromuscular disorder. Kilpinen-Loisa P, Nenonen H, Pihko H, Mäkitie O. Päijät-Häme Central Hospital, Department of Pediatric Neurology, Lahti, Finland. paivi.kilpinen-loisa@phsotey.fiAbstractAdequate vitamin D levels are essential for normal skeletal development and mineralization. This is particularly important in children with cerebral palsy or other neuromuscular disorders who are at an increased risk of osteoporosis. The aim of this study was to evaluate the effect of high-dose vitamin D3 supplementation on vitamin D status in 44 disabled children. Vitamin D was administered during school days (1000 IU vitamin D3 per orally five days per week for 10 weeks) to half of the children (N=21) while the others (N=23) continued without supplementation. At baseline the median serum 25-hydroxyvitamin D was 44 nmol/L (range 26-82 nmol/L). The concentration increased significantly during the 10 weeks intervention in the supplemented group (median 56 nmol/L, range 39-88 nmol/L; p=0.012 for the difference from baseline) and decreased in the control group (median 37 nmol/L, range 24-74 nmol/L; p=0.038). No significant changes in any of the other measured parameters were observed. Hypovitaminosis D is prevalent in disabled children. Supplementation with 1000 IU vitamin D3 perorally five days per week results in a significant increase in vitamin D level and is not associated with hypercalcemia or other adverse effects. PMID: 18058622   
  • Am J Clin Nutr. 2010 May;91(5):1255-60. Epub 2010 Mar 10. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Urashima M, Segawa T, Okazaki M, Kurihara M, Wada Y, Ida H.SourceDivision of Molecular Epidemiology, Jikei University School of Medicine, Nishi-shimbashi 3-25-8, Minato-ku, Tokyo 105-8461, Japan. urashima@jikei.ac.jpAbstractBACKGROUND: To our knowledge, no rigorously designed clinical trials have evaluated the relation between vitamin D and physician-diagnosed seasonal influenza.OBJECTIVE: We investigated the effect of vitamin D supplements on the incidence of seasonal influenza A in schoolchildren.DESIGN: From December 2008 through March 2009, we conducted a randomized, double-blind, placebo-controlled trial comparing vitamin D(3) supplements (1200 IU/d) with placebo in schoolchildren. The primary outcome was the incidence of influenza A, diagnosed with influenza antigen testing with a nasopharyngeal swab specimen.RESULTS: Influenza A occurred in 18 of 167 (10.8%) children in the vitamin D(3) group compared with 31 of 167 (18.6%) children in the placebo group [relative risk (RR), 0.58; 95% CI: 0.34, 0.99; P = 0.04]. The reduction in influenza A was more prominent in children who had not been taking other vitamin D supplements (RR: 0.36; 95% CI: 0.17, 0.79; P = 0.006) and who started nursery school after age 3 y (RR: 0.36; 95% CI: 0.17, 0.78; P = 0.005). In children with a previous diagnosis of asthma, asthma attacks as a secondary outcome occurred in 2 children receiving vitamin D(3) compared with 12 children receiving placebo (RR: 0.17; 95% CI: 0.04, 0.73; P = 0.006).CONCLUSION: This study suggests that vitamin D(3) supplementation during the winter may reduce the incidence of influenza A, especially in specific subgroups of schoolchildren.  This trial was registered at https://center.umin.ac.jp as UMIN000001373. PMID:20219962 
  • Rajeev slides

    1. 1. Nutritional Deficiency of Vitamin D in children
    2. 2. Background: In the later part of 19th century estimated that nearly 80-90% of children who lived in industrialized cities of Europe and North America had rickets. J Clin Invest. 2006;116(8):2062-2072
    3. 3. Definition:Rickets :It is caused by failure of osteiod to calcify in growingperson.Failure of osteiod to calcify in adults is calledOsteomalacia.
    4. 4. Severe chronic vitamin D deficiency [25(OH)D level>15 ng/ml] leads to overt skeletal abnormalities inchildren that is typically defined as rickets.
    5. 5. “Vitamin D is critical for skeletal development andcellular function because of its effect on calciumhomeostasis by promoting intestinal calciumabsorption”Vitamin D deficiency rickets occurs when themetabolites of vitamin D are deficient.
    6. 6. Pathophysiology:
    7. 7. Vitamin D content of common foods Clinical Signs and Symptoms of vitamin D deficiency: Craniotabes Hair loss or alopecia Genu varum or valgum Delayed dentintion Costchondral swellings Refusal to walk Growth delay Fracture Muscle weakness Seizure Harrison’s grooves Tetany Micheal F. Holick. Vitamin D –Physiology, Molecular Biology, and Clinical Applications. 2nd Edition. Humana Press.
    8. 8. Clinical Presentation:
    9. 9. Radiological Image:Radiograph in a 4-year-old girl with rickets depicts bowing ofthe legs caused by loading. http://emedicine.medscape.com/article/985510-overview
    10. 10. Clinical Investigations:Serum measurement of  Calcium  Phosphorous  Alkaline phosphatase  Parathyroid Hormone  25-hydroxy vitamin D  1,25 –dihydroxy vitamin D http://emedicine.medscape.com/article/985510-overview
    11. 11. Vitamin D – An Introduction: The sunshine vitamin The primary source – exposure to ultraviolet B sunlight. Secondary sources- Fatty fish, fish oil, eggs, from products (such as milk and orange juice and vitamin D supplements.
    12. 12. Content of Vitamin D in Foods: Food items Cow’s milk 3-40 IU/L Butter (100gm) 35 IU/L Egg yolk 20-25 IU/L Fish (100gm) 44-624 IU Yoghurt (100gm) 89 IU Cheese (100gm) 12-44 IU Ind J Endo Metab. 2012; 16(2): 164–176.
    13. 13. Factors associated with deficiency: • Religious customs • Atmospheric pollution • Skin pigmentation • Vegetarian diets • Maternal vitamin D deficiency Ind J Med Res.2008;127 (): 245-249
    14. 14. FACT: The high prevalence of hypovitaminosis D in a number of developing countries exists despite the fact that a large number of these countries lie in zones that have sufficient sunlight for vitamin D synthesis for most if not all of the year. Vitamin D deficiency is now recognized as a pandemic. Am J Clin Nutr. 2008;87(4):1080S-6S.
    15. 15. Vitamin D status: 25(OH)D Level 25(OH)D Level Health Implications (ng/mL) (nmol/L) <20 <50 Deficiency 20-32 50-80 Insufficiency 32-100 80-250 Sufficiency 54-90 135-225 Normal in sunny countries >100 >250 Excess >150 >325 Intoxication Alternative Medicine Review.2008;13(1):1-20 , Alternative Medicine Review.2005;10(2):94-111
    16. 16. Recommendations: Daily intake American Academy of Pediatrics 400 IU Canadian Pediatric Society 400 IU Health Canada 400 IU Health policy in North America 400 IU Institute of Medicine , Food & Nutrition Board 0-12 months 400 IU 1-3years 600 IU The Endocrine Society 0-12 months 400-1000 IU 1-3 years 600-1000 IU Appl Physiol Nutr Metab. 2010;35(3):303-9, Am Fam Physician.2010;81(6):745-8. Pediatrics 2008;122;398 Institute of Medicine. Nov 2010. The Endocrine Society. 2011.
    17. 17. FACT: Vitamin D deficiency in pediatric patients has serious implications. Several recent studies have demonstrated an alarming prevalence of medical conditions related to this nutritionall problem, ranging from severe nutritional rickets to sub-clinical vitamin D deficiency even within industrialized societies.
    18. 18. It is estimated that children need at least 400-1000 IU ofvitamin D a daywhile teenagers and adults need at least 2000 IU ofvitamin D a day to satisfy their bodys vitamin Drequirement. Curr Drug Targets. 2011 Jan;12(1):4-18.
    19. 19. Neuromuscular DisorderSubjects: 44 disabled children with cerebral palsyTreatment: Oral vitamin D 1000 IU five days per weekTreatment Duration :10 weeks 25.00 20.00 25(OH)D ng/mL 22.4 15.00 14.8 17.60 10.00 5.00 0.00 Baseline Control At End of Group Therapy vitamin D(3) supplementation resulted in significant increase in vitamin D level and was not associated with hypecalcemia or other adverse effect. Neuropediatrics. 2007;38(4):167-72.
    20. 20. Seasonal Influenza ASubjects: School children (6-15yrs)Primary outcome: Incidence of seasonal influenza ATreatment: Oral vitamin D 1200 IUTreatment Duration :4 months Incidence of Influenza A (%) 20 15 18.6 10 10.8 5 0 Vit D Group Placebo Group vitamin D(3) supplementation during the winter may reduce the incidence of influenza A, especially in specific subgroups of schoolchildren. Am J Clin Nutr. 2010;91(5):1255-60.
    21. 21. Essential. Simple. Safe