Home            Past Issues            About IP            About IAP           Author Information            Subscription            Advertisement              Search  

   
editorial

Indian Pediatr 2012;49: 439-440

Vitamin D for Childhood Pneumonia


Semira Manaseki-Holland

School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham,
Rm 112, 90 Vincent Drive, Edgbaston, Birmingham B15 2TT, United Kingdom.
Email: [email protected]
 


The immunoregulatory functions of Vitamin D have become prominent in the current medical literature. With respect to infectious diseases, there is growing evidence for vitamin D enhancing innate immunity [1,2]. In vitro studies have shown that 1,25-dihydroxyvitamine D
3, the active metabolite of vitamin D, is important for promoting and regulating immune responses [3,4], induces expression of the TLR co-receptor CD14 [5] and antimicrobial gene expression (CAMP and defensin B2 expression). The increased expression of anti-microbial cathelicidin by macrophages and epithelial cells in response to exposure to microbes depends upon the presence of vitamin D [1,2]. However, there is no clinical trial evidence for the effectiveness of vitamin D supplementation for improving treatment outcomes during infectious disease episodes. Observational studies have demonstrated important links between rickets or vitamin D deficiency and higher rates of infectious diseases that have significant burden of disease, such as pneumonia and tuberculosis. In pediatrics, two hospital-based case-control studies from Ethiopia [6] and India [7] suggest that vitamin D deficiency may substantially increase the risk of severe pneumonia among children. Only one other published study, prior to Choudhary and Gupta [8] in this volume of Indian Pediatrics, investigated the effect of vitamin D supplementation upon the treatment of pneumonia in children. A randomized placebo controlled trial of Cholecalciferol (Vitamin D3) (100,000 IU) supplementation along with antibiotic treatment to 1-3 year old children with clinically diagnosed pneumonia found no difference in the time to recovery between the vitamin D and placebo groups [9]. The study in this issue resembles the 2006 study [9]. However, due to the totally different dosage regime of vitamin D, comparison of results becomes difficult. The trial by Choudhary and Gupta has strengths such as effective randomisation and looking at the most vulnerable category of pneumonia patients with more reliable clinical diagnosis, namely severe pneumonia patients. However, as acknowledged by the authors, its major weakness is the low dosage which together with no blood levels of vitamin D, makes adequate supplementation questionable and the study difficult to interpret. It is not clear if the lack of positive effect of supplementation was due to inadequate dosage or actual no effect from adequate supplementation.

An optimal vitamin D supplementation regime, for skeletal or immunological functions of vitamin D remains controversial, as does the fully sufficient serum levels for immunological function [10]. Nevertheless, it is important that numerous researchers in a range of settings investigate the effect of vitamin D supplementation upon pneumonia. Other infectious diseases should be explored, too. For example, in vitro studies indicate that diarrhea infections could be affected by vitamin D deficiency through the role of vitamin D on cethelicidin and a-defensin in gastrointestinal defence and IgA in adaptive immunity. As yet, this area remains unexplored.

Importance of further research is due to the public health significance of the topic. Vitamin D supplementation is affordable and pragmatic from the programmatic point of view. There is widespread evidence for vitamin D deficiency in low, middle and high income countries, and diarrhea and pneumonia are responsible for the highest burden of childhood mortality and morbidity, globally. Therefore, if alleviating deficiency is possible with supplementation and has an effect upon pneumonia or diarrhea rates or prognosis, this could be linked with significant reductions in childhood mortality. More research is needed in a range of settings, using different dosing regimes in order to establish whether and how any benefit can be demonstrated from vitamin D supplementation.

Competing interest: None stated; Funding: None.

References

1. Bikle DD. Vitamin D and the immune system: role in protection against bacterial infection. Curr Opin Nephrol Hypertens. 2008;17:348-52.

2. White HJ. Vitamin D Signaling, infectious diseases and regulation of innate immunity. Infect Immun. 2008;76:3837.

3. Cantorna MT. Vitamin D and autoimmunity: is vitamin D status an environmental factor affecting autoimmune disease prevalence? Proc Soc Exp Biol Med. 2000;223:230-3.

4. Pichler J, Gerstmayr M, Szeepfalusi Z, Urbanek R, Peterlik M, Willheim M. 1-alpha, 25(OH)2D3 inhibits not only Th1 but also Th2 differentiation in human cord blood Tcells. Pediatr Res.2002; 52: 12-8.

5. Liu PT, Stenger S, Li H, Wenzel L, Tan BH, Krutzik SR, et al. Toll-like receptor triggering of a vitamin D - mediated human antimicrobial response. Science. 2006;311:1770-3.

6. Muhe L, Lulseged S, Mason KE, Simoes EA. Case-control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children. Lancet. 1997;349:1801-4.

7. Wayse V, Yousafzai A, Mogale K, Filteau S. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 y. Eur J Clin Nutr. 2004;58:563-7.

8. Choudhary N, Gupta P. Vitamin D supplementation for severe pneumonia: A randomized controlled trial. Indian Pediatr. 2012;49:449-54.

9. Manaseki-Holland S, Qader G, Isaq Masher M, Bruce J, Zulf Mughal M, Chandramohan D, et al. Effects of vitamin D supplementation to children diagnosed with pneumonia in Kabul: a randomised controlled trial. Trop Med Int Health. 2010;15:1148-55.

10. Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122:398-417.
 

 

Copyright © 1999-2012 Indian Pediatrics