Many healthcare professionals have vitamin
D on their minds at the moment and those that aren’t thinking about it may
need to in the near future. The fact that many people are vitamin D
insufficient has been highlighted by studies in populations from Western
Europe but also areas perceived to have sunnier climates such as North
America, Africa and Australia. Dark skin generates a fraction of the
amount of vitamin D generated by fair skin when exposed to sunlight and is
undoubtedly a risk factor for a low vitamin D status. Traditional dress,
time spent indoors rather than outdoors and a low dietary intake of foods
containing vitamin D has also been implicated. It is therefore important
to emphasize that people from broad sections of society may be at risk,
irrespective of skin color(1). With this background it is surprising that
the supplementation of at risk groups such as pregnant women and children
with vitamin D has not been given greater priority in many countries.
Obstetricians, midwifes, neonatologists and pediatricians have, it can be
argued, been a little slow to address the suboptimal vitamin D status of
many of our patients. The potential link between a low vitamin D status
and cardiovascular disease, diabetes and cancer means that other health
professionals may have to take note now as well(2-4).
The well-designed article by Mehrotra and colleagues
from Delhi(5) is yet another reminder of how important vitamin D status is
in determining the well-being of pregnant women and their offspring. The
fact that so many infants with a suboptimal vitamin D status develop
hypocalcemic seizures is quite alarming. Many health professionals know
about vitamin D insufficiency and skeletal deformity but seizures in the
first weeks of life must clearly result in an assessment of calcium
concentrations straight away. Seizures as a presentation of vitamin D
deficiency seems to be much more common than people previously thought.
Other notable aspects of Mehrotra and colleagues’ study include the close
relationship between vitamin D status in mother and child. Furthermore,
the difference in calcium intake between patients and controls suggests
that a low calcium intake might also contribute to risk of seizures(6). A
potential ‘catch’ for doctors investigating babies with vitamin D
deficiency is the fact that parathormone (PTH) levels are frequently not
elevated in contrast to older children.
What should we do? Well, the first issue is to target
high risk groups such as pregnant women and the rapidly growing child.
Vitamin D supplementation can be given relatively easily in the form of a
‘children’s multi-vitamin’ supplement. Vitamin D2 (ergocalciferol) or D3 (choleclalciferol)
should be provided to pregnant women. It is important to highlight the
fact that 1-alphacalcidol is not an effective therapy for vitamin D
deficiency and hence should not be used in this context. We should all be
made aware of the need for calcium containing foods and the beneficial
role of sunlight. Too much sun and associated skin erythema is not good
for health but some sun exposure is an effective way of enhancing vitamin
D status. Hence sunlight is like so many things in life – too much may not
be good for you but too little may not be good for you either. For people
who cannot easily increase sunlight exposure or increase their oral intake
of vitamin D with foods such as oily fish, long term vitamin D2 or D3
supplementation will be appropriate.
1. Beck-Nielsen SS, Jensen TK, Gram J, Brixen K,
Brock-Jacobsen B. Nutritional rickets in Denmark: A retrospective review
of children’s medical records from 1985 to 2005. Eur J Pediatr 2009; 168:
941-949.
2. Dobnig H, Pilz S, Scharnagl H, Renner W, Seelhorst
U, Wellnitz B, et al. Independent association of low serum
25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels with all-cause and
cardiovascular mortality. Arch Intern Med 2008; 168: 1340-1349.
3. Zipitis CS, Akobeng AK. Vitamin D supplementation in
early childhood and risk of type 1 diabetes: A systematic review and
meta-analysis. Arch Dis Child 2008; 93: 512-517.
4. Lappe JM, Travers-Gustafson D, Davies KM, Recker RR,
Heaney RP. Vitamin D and calcium supplementation reduces cancer risk:
Results of a randomized trial. Am J Clin Nutr 2007; 85: 1586-1591.
5. Mehrotra P, Marwaha RK, Aneja S, Seth A, Singla BM,
Ashraf G, et al. Hypovitaminosis D and hypocalcemic seizures in
infancy. Indian Pediatr 2010; 47: 581-586.
6. DeLucia MC, Mitnick ME, Carpenter TO. Nutritional
rickets with normal circulating 25-hydroxyvitamin D: A call for
re-examining the role of dietary calcium intake in North American infants.
J Clin Endocrinol Metab 2003; 88: 3539-3545.
