Journal of Rawalpindi Medical College (JRMC); 2014;18(1):52-54
Original Article
Vitamin D Deficiency Among Healthy Infants
Muhammad Waqas Ashfaq*, Rai Muhammad Asghar *, Saba Naim Khan**
* Department of Pediatrics, Benazir Bhutto Hospital Rawalpindi;**Department of Pediatrics, Holy Family Hospital
Rawalpindi.
Abstract
skin synthesis, decreased bioavailability, increased
catabolism, exclusive breast feeding, decreased
synthesis, increased urinary loss.Without sufficient
vitamin D bones can become thin, brittle or misshapen.
It leads to bone softening diseases, rickets in children
and osteomalacia in adults.1
Rickets is a childhood disease characterized by
impeded growth and deformity of long bones which
can be caused by calcium or phosphorous deficiency
as well as lack of vitamin D. Today it is largely found
in low income countries in Africa, Asia and Middle
East.1 Rickets is among five most prevalent diseases of
infants and toddlers.3
Vitamin D deficiency prevents the efficient
absorption of dietary calcium and phosphorus.4 Only
10–15% of dietary calcium and 50–60% of dietary
phosphorus is absorbed when Vitamin D is deficient.
In a vitamin D deficient infant or child, serum calcium
level is usually normal, serum phosphorus level is
usually low, and there is inadequate calcium
phosphorus ratio which is necessary to mineralize the
osteoid by osteoblasts, elevated alkaline phosphatase
levels, and low 25(OH)D levels.
There is lack of consensus on optimal levels of
serum 25-hydroxyvitamin D.Lower limit of 30 ng/mL
is increasingly acknowledged as the lower limit of
normal for 25(OH)-D levels in adults as well as
children. Vitamin D insufficiency for children is
labeled when serum 25(OH)-D level is below 30ng/ml
however clinical signs and symptoms appear even at
higher levels in some infants and children.5
Recommended serum 25(OH)-D level of less than 20
ng/mL is considered as indicative of deficiency.6
Severe deficiency is defined as serum 25(OH)-D level
of less than 8ng/mL.7 According to American
Association of Paediatrics a minimum of 400 IU/day
vitamin D supplementation is required to prevent
Vitamin D Deficiency and rickets in healthy infants,
children and adolescents.8
Background:
To determine the frequency of
Vitamin D deficiency in healthy infants in order to
prevent Rickets and other conditions associated with
it.
Methods: In this Cross Sectional Study, total 72
healthy infants of age 09 months to 12 months were
selected .Blood sample (3ml) was also collected for
quantitative determination of 25-hydroxy vitamin D
level,by Enzyme immunoassay. X-ray wrists were
done of Vitamin D deficient infants.
Results: 25-hydroxy vitamin D level were found
suboptimal in 50%,deficient in 15.3 and deverly
deficient in 2.8%.Radiological studies of the wrists
were conducted in infants having below suboptimal
serum 25-hydroxy vitamin D level which showed
that 53.8% of the patients had radiological findings
suggestive of Rickets and 46.2% were normal.
Conclusion:Serum 25-hydroxy Vitamin D
concentration was low in otherwise healthy
infants. Vitamin D supplementation should be
started early in infancy.
Key Words: Vitamin D, Rickets, Infancy
Introduction
Vitamin D is a steroid vitamin, group of fat soluble
prohormones, the two major forms of which are
ergocalciferol or vitamin D2 and cholecalciferol or
vitamin D3. Vitamin D2 comes from plant sources
while Vitamin D3 is mainly manufactured in the skin
when skin is exposed to ultraviolet rays in natural
sunlight and the dietary sources of Vitamin D3 include
fatty fish, whole egg, beef liver, mushrooms and
supplements. As few foods contain vitamin D
precursors sunlight exposure is primary determinant
of vitamin D status in human.Calcitriol (1,25Dihyroxycholecalciferol) is the active form of vitamin
D and it plays an important role in the maintenance of
several organ systems. However its major role is to
increase the flow of calcium into the blood stream. It is
also necessary for bone growth and bone remodeling
by osteoblasts and osteoclasts.
Lack of moderate sun exposure is the major cause of
vitamin D deficiency. Other causes include reduced
Patients and Methods
This cross sectional study was done at outpatient
Department of Paediatric Medicine, Benazir Bhutto
Hospital, Rawalpindi in six months from 1st March
52
Journal of Rawalpindi Medical College (JRMC); 2014;18(1):52-54
Discussion
2011 to 31st August 2011.Total 72 patients were
selected who presented to OPD in the department of
Pediatrics for Vaccination with age 09 to 12 months of
both Sex and all Socio-Economic Groups. Those with
acute or chronic illness or using medication known to
affect the vitamin D metabolism during the previous
three months, like Isoniazid, Phenobarbital, Antacids,
Thiazide Diuretics etc or who received vitamin D
supplementations within three months were
excluded.The sampling technique was convenience
sampling. A single blood sample, 3ml of free flow
blood was drawn and quantitative determination of
25-hydroxy vitamin D level was done by Enzyme
immunoassay. X-ray wrists were also done of those
infants whose Vitamin D levels were deficient or
severely deficient.
Rickets is among five most common diseases of
children and undiagnosed vitamin D deficiency is also
not uncommon.9,10 Over the last few years, a number
of studies have been conducted to find out prevalence
of Vitamin D deficiency around the world.10 Studies
revealed that two third of healthy infants were having
Vitamin D levels below normal. Prevalence of clinical
vitamin D deficiency (rickets and osteomalacia) is high
in many parts of the world and it is a worldwide
epidemic.10,11 Recent estimates indicates greater than
50% of the global population is at risk.13
Schwalfenberg et al found a high prevalence of
vitamin D deficiency in all age groups and all
populations studied in countries around the world,
even those who are otherwise healthy are not immune
to deficiency.14 Madar et al studied Vitamin D status
among immigrant mothers from Pakistan, Turkey and
Somalia and their infants attending child health clinics
in Norway and found that 50% of the mothers and
65% of the infants had 25(OH)D levels below 12
ng/ml.15 A study from China16 found a 65.3%
prevalence of vitamin D deficiency among 12- to 24month-old infants.16
This study implies the importance of vitamin D for
the prevention of nutritional rickets which is much
more common in our country. Being a part of third
world, one of the major problems is maternal and child
health and the burning issue of child health include
nutrition and nutritional rickets. Vitamin D deficiency
can develop early in infancy and initially without
clinical symptoms and its supplements may offer
promising results in reducing its deficiency and
associated morbidity, without risk of any serious
adverse effects. Breast-feeding does not prevent
rickets, particularly when the lactating mother is
vitamin D deficient, therefore, all pregnant and
lactating mothers should be supplemented.
American Academy of Pediatrics recommends that
all infants, including those who are exclusively breastfed,should have a minimum intake of 400IU vitamin D
per day beginning as early as the first two months of
life.17 There are few studies suggesting that 400 IU is
inadequate. 18
Results
Seventy two healthy children with mean age of 9.56
months (34 males and 38 female) were included in our
study and serum 25-hydroxy vitamin D level was
measured. Mean serum 25-hydroxy vitamin D level
was 26.1 ng/ml with standard deviation of 7.5
According to our study results, more than 68% healthy
infants had below normal Vitamin D levels, and about
18% were deficient in Vitamin D (Table 1).Radiological
studies of the wrists were also conducted in 18% of
infants having below suboptimal serum 25-hydroxy
vitamin D level in the study population (n=13) which
showed that among them 53.8% (n=7) of the patients
had radiological findings suggestive of Rickets and
46.2% (n= 6) were normal. So, among healthy infants
having deficient serum Vitamin D level, more than
half were having radiological evidence of Rickets
(Table 2).
Table 1: Frequency of Vitamin D status in
healthy infants of study population
Normal
Suboptimal
Deficient
Severe deficient
Frequency
23
36
11
2
Percent
31.9
50.0
15.3
2.8
Table 2: Radiological changes in healthy infants
with decreased serum Vitamin D level.
Suggestive
Non sugestive
Total
Missing system
Frequency
7
6
13
59
Conclusion
1.Frequency of vitamin D deficiency and insufficiency
is quite common even in healthy infants and
radiological rickets is likely to develop when serum
25(OH)D is less than 20 ng/ml.
2.Most of the infants require oral vitamin D
supplement daily, beginning from early infancy and
Percent
9.7
8.3
18.1
81.9
53
Journal of Rawalpindi Medical College (JRMC); 2014;18(1):52-54
must be continued
adolescence.
throughout
childhood
and
9.
10.
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