Vitamin D Supplementation in Infants, Children, and Adolescents

CATHERINE F. CASEY, MD; DAVID C. SLAWSON, Dr.; and LINDSEY R. NEAL, MD, Academy of Virginia Medical Center, Charlottesville, Virginia

Am Fam Doctor. 2010 Mar xv;81(6):745-748.

  Related Editorial

Patient information: See related handout on vitamin D in children, written by the authors of this commodity.

Commodity Sections

  • Abstract
  • Vitamin D in Health and Disease
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

Vitamin D deficiency in children can take adverse health consequences, such equally growth failure and rickets. In 2008, the American University of Pediatrics increased its recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU. Infants who are breastfed and children and adolescents who consume less than 1 Fifty of vitamin D–fortified milk per day will likely need supplementation to reach 400 IU of vitamin D per day. This recommendation is based on expert opinion and recent clinical trials measuring biomarkers of vitamin D status. It is also based on the precedent of preventing and treating rickets with 400 IU of vitamin D. In addition to dietary sources, exposure to ultraviolet B sunlight provides children and adults with additional vitamin D. Although the American Academy of Pediatrics recommends keeping infants out of straight sunlight, decreased sunlight exposure may increase children's risk of vitamin D deficiency. No randomized controlled trials assessing patient-oriented outcomes have been performed on universal vitamin D supplementation. Yet, vitamin D may reduce the risk of certain infections and chronic diseases. Physicians should assistance parents cull the appropriate vitamin D supplement for their child.

Vitamin D deficiency in children has been linked to adverse furnishings, such every bit growth failure and rickets. Although vitamin D is bachelor in several foods and drinks, recent estimates suggest the prevalence of vitamin D deficiency amidst infants, children, and adolescents is between 12 and 24 percent.one,2 Infants who are breastfed appear to be at college gamble of vitamin D deficiency. Family physicians should understand electric current recommendations for vitamin D supplementation, and be prepared to educate parents about breastfeeding, sun precautions, and nutrition throughout childhood and adolescence.

Vitamin D in Health and Disease

  • Abstruse
  • Vitamin D in Health and Illness
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

Vitamin D plays several of import roles in the metabolism and absorption of other minerals in the trunk. Vitamin D is essential for facilitating calcium metabolism and bone mineralization; is beneficial for phosphate and magnesium metabolism; and stimulates protein expression in the abdominal wall to promote calcium absorption. Depression levels of vitamin D atomic number 82 to the release of parathyroid hormone, which causes calcium mobilization from the bone. Over time, excessive bone resorption can lead to rickets.

Acceptable levels of vitamin D may besides help reduce the risk of autoimmune atmospheric condition,three,4 infection,5 and blazon 2 diabetes.6 Show from observational studies supports the role of vitamin D supplementation in reducing the risk of type 1 diabetes in infants and children.7 Although observational studies suggest that vitamin D may be protective against some cancers,eight a randomized controlled trial of calcium and vitamin D supplementation in 36,282 women did not find a protective effect against breast cancer.nine

Guidelines for Vitamin D Intake

  • Abstruse
  • Vitamin D in Health and Disease
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

In 2003, the American University of Pediatrics (AAP) published a guideline recommending that all children older than ii months receive 200 IU of supplemental vitamin D daily.10 This adept consensus statement was supported by studies of breastfed infants in the United states of america, Norway, and Mainland china and suggested that infants who ingest 100 or 200 IU of supplemental vitamin D daily were less likely to develop rickets.11 Since then, at that place have been concerns that these dosages may exist insufficient. These concerns are supported by studies showing that vitamin D deficiency can occur early in life12; that serum 25-hydroxyvitamin D concentrations tend to be lower in breastfed infants13; and that 400 IU of vitamin D supplementation in these infants maintains higher concentrations of 25-hydroxyvitamin D.14 In addition, studies take shown that adolescents eat insufficient levels of dietary vitamin D 15,16 and that supplementation increases 25-hydroxyvitamin D levels and bone mineral density.17

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Infants ingesting less than 1 L (33.8 fl oz) of formula per day, too as all breastfed or partially breastfed infants, should receive 400 IU of supplemental vitamin D daily.

C

13, xix, 20

Based on illness-oriented testify and practiced opinion

Children and adolescents consuming less than 1 L of vitamin D–fortified milk per day should receive 400 IU of supplemental vitamin D daily.

C

21, 22

Based on disease-oriented testify and case series

Limiting sunlight exposure may predispose children to vitamin D deficiency.

C

23, 25–27

Based on disease-oriented testify and skilful opinion

The best available biomarker of vitamin D status is serum 25-hydroxyvitamin D levels.

C

28, 29

Based on consensus and disease-oriented bear witness

Children at increased risk of vitamin D deficiency may require higher dosages of supplemental vitamin D.

C

32–34

Based on disease-oriented evidence and expert opinion

Consequently, the AAP issued an updated recommendation in 2008 that all infants, children, and adolescents receive a minimum of 400 IU of vitamin D daily through diet or supplements.eighteen Infants who are formula-fed exclusively volition virtually likely have an adequate level of vitamin D. Infants who are breastfed or partially breastfed, too equally children and adolescents who consume less than ane L (33.8 fl oz) of vitamin D–fortified milk per day, should receive 400 IU of supplemental vitamin D daily.13,nineteen–22

Despite these recommendations, there are no studies showing that universal supplementation improves patient-oriented outcomes, such every bit the reversal of languor, irritability, and growth failure, attributed to vitamin D deficiency. Only indirect evidence supports the contention that 400 IU of supplemental vitamin D daily prevents and treats rickets.14 Prospective studies focusing on patient-oriented outcomes, rather than biomarkers, are needed earlier the actual clinical impact of supplemental vitamin D volition exist understood.

Vitamin D and Sunlight

  • Abstract
  • Vitamin D in Wellness and Affliction
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

In addition to dietary sources, children and adults obtain vitamin D through exposure to ultraviolet B sunlight. As niggling as 10 to 15 minutes of straight sunlight can generate x,000 to 20,000 IU of vitamin D. Many factors influence vitamin D synthesis, such equally skin pigmentation, latitude, and corporeality of skin exposed, making it difficult to assess how much vitamin D will be converted from sunlight exposure. Infants and children who have darker pigmentation require v to ten times the length of sunlight exposure to reach the same levels of 25-hydroxyvitamin D when compared with children who have lighter pigmentation.23 However, the AAP recommends that infants younger than six months exist kept out of direct sunlight.24 Although the goal of limiting sunlight exposure is to minimize the take chances of skin cancer, information technology may also predispose children to vitamin D deficiency.25–27 Because the condom level of sunlight exposure needed for vitamin D conversion is unknown, increasing vitamin D supplementation is a reasonable alternative.

Complications of Vitamin D Deficiency

  • Abstract
  • Vitamin D in Wellness and Disease
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

Risk factors for vitamin D deficiency are summarized in Table 1. Physicians should confirm suspicion of vitamin D deficiency by measuring levels of 25-hydroxyvitamin D, which is the best bachelor biomarker for checking vitamin D condition.28,29 Vitamin D deficiency in adults is defined equally 25-hydroxyvitamin D levels of less than twenty ng per mL (50 nmol per L), although this varies among studies.thirty There is no ready level of 25-hydroxyvitamin D to confirm vitamin D deficiency in infants, children, and adolescents. Although no prepare level has been established for children and adolescents, recent studies accept used less than 15 to twenty ng per mL (37.44 to 50 nmol per L) as a cutoff for vitamin D deficiency in these age groups.

Table 1.

Chance Factors for Vitamin D Deficiency in Children

Anticonvulsant medication therapy

Chronic diseases associated with fatty malabsorption

Darker skin pigmentation

Sectional breastfeeding without vitamin D supplementation

Insufficient sunlight exposure

Low maternal vitamin D levels (risk factor for infants)

Patients with severe cases of rickets may present with growth failure, hypocalcemic seizures, decreased bone mass, and characteristic bone changes or fractures (Effigy 1). Nonspecific symptoms, such as irritability, sluggishness, and developmental delay, may exist less obvious. In a instance-control study of children hospitalized for acute illnesses, investigators found an increased rate of admissions for lower respiratory tract infections among those with rickets.31

Figure 1.

Talocrural joint radiograph of a 17-month-old girl with healing rickets. Note the lateral bowing of the fibulas and the right tibia, as well equally the bandlike lucency in the metaphysis.

Supplementation Options

  • Abstruse
  • Vitamin D in Wellness and Affliction
  • Guidelines for Vitamin D Intake
  • Vitamin D and Sunlight
  • Complications of Vitamin D Deficiency
  • Supplementation Options
  • References

Vitamin D3, known every bit cholecalciferol, is the preferred grade of vitamin D for supplementation. Children with certain conditions, such as fatty malabsorption, and those who crave long-term apply of seizure medications may demand higher dosages of vitamin D considering of increased gamble of deficiency.32–34 Monitoring 25-hydroxyvitamin D levels every iii months, and parathyroid hormone levels and bone-mineral status every six months, is recommended for these children.

Vitamin D deficiency during pregnancy may increase the risk of aberrant fetal growth and bone development, but further studies are needed before loftier-dose supplementation in pregnant women can be universally recommended.35

No testify suggests that daily supplementation of 400 IU of vitamin D is toxic. Physicians should provide patients with detailed assistants instructions to avert adventitious overdose. Vitamin D3 drops, which are preferable for infants, are bachelor in formulations of 400, 1,000, and 2,000 IU per drop. Varying amounts of vitamin D3 are available within formulations of the same brand. Chewable and sticky vitamins for older children contain 200 or 400 IU of vitamin D, just may vary by formulation from the same manufacturer. Physicians may prefer to recommend one brand and formulation for each historic period group to ensure that patients accomplish a daily dosage of 400 IU (Tables 2 and 3).

Table 2.

Vitamin D Liquid Supplements for Infants and Children Younger than Two Years

Make Vitamin D per serving (IU) Serving size

Carlson Baby D Drops

400

1 drop

Enfamil Poly-Half dozen-Sol Multivitamin Supplement Drops

400

1 mL

Enfamil Tri-Vi-Sol Vitamins A, C & D with Fe

400

1 mL

Sunlight Vitamins Just D infant vitamin drops

400

1 mL

Twinlab Infant Care Multivitamin Drops with DHA

400

i mL

Table 3.

Multivitamins Containing Vitamin D for Children and Adolescents

Brand Vitamin D per serving (IU) Serving size

Centrum Kids Complete Multivitamins, chewable tablets

400

One tablet for children four years and older (1/2 tablet for children two and 3 years of historic period)

Disney Gummies Children's Multivitamin

200

Ii gummies for children two years and older

Flintstones Children's Complete Multivitamin, chewable tablets

400

One tablet for children four years and older (ane/two tablet for children two and three years of age)

Flintstones Gummies with Calcium & Vitamin D, multivitamin

400

Two gummies for children 4 years and older (one viscous for children 2 and iii years of age)

Li'50 Critters Viscid Vites Kids Multivitamin

240

Two gummies for children two years and older

Sundown Spider-man Complete Children'south Gummies

200

Two gummies for children two years and older

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The Authors

testify all author info

CATHERINE F. CASEY, MD, is an banana professor of family medicine at the University of Virginia Medical Center in Charlottesville....

DAVID C. SLAWSON, MD, is the B. Lewis Barnett, Jr., Professor of Family Medicine at the University of Virginia Medical Heart.

LINDSEY R. NEAL, Doctor, is a family unit medicine resident at the University of Virginia Medical Eye.

Address correspondence to Catherine F. Casey, MD, University of Virginia Medical Center, 375 Four Leaf Lane, Ste. 103, Charlottesville, VA 22903 (e-mail: cc5ds@virginia.edu). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

show all references

1. Gordon CM, Feldman HA, Sinclair L, et al. Prevalence of vitamin D deficiency among healthy infants and toddlers. Curvation Pediatr Adolesc Med. 2008;162(6):505–512. ...

2. Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency amidst healthy adolescents. Curvation Pediatr Adolesc Med. 2004;158(6):531–537.

3. Munger KL, Zhang SM, O'Reilly E, et al. Vitamin D intake and incidence of multiple sclerosis. Neurology. 2004;62(1):lx–65.

4. Merlino LA, Curtis J, Mikuls TR, Cerhan JR, Criswell LA, Saag KG, for the Iowa Women's Health Written report. Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women'southward Health Study. Arthritis Rheum. 2004;50(i):72–77.

v. Liu PT, Stenger S, Li H, et al. Toll-similar receptor triggering of a vitamin D-mediated human being antimicrobial response. Science. 2006;311(5768):1770–1773.

6. Chiu KC, Chu A, Go VL, Saad MF. Hypovitaminosis D is associated with insulin resistance and beta prison cell dysfunction. Am J Clin Nutr. 2004;79(v):820–825.

vii. Hyppönen E, Läärä E, Reunanen A, Järvelin MR, Virtanen SM. Intake of vitamin D and chance of type 1 diabetes: a nascence-cohort study. Lancet. 2001;358(9292):1500–1503.

viii. Tuohimaa P, Tenkanen L, Ahonen M, et al. Both high and low levels of blood vitamin D are associated with a college prostate cancer chance: a longitudinal, nested case-control study in the Nordic countries. Int J Cancer. 2004;108(1):104–108.

9. Chlebowski RT, Johnson KC, Kooperberg C, et al., for the Women'south Health Initiative Investigators. Calcium plus vitamin D supplementation and the chance of breast cancer. J Natl Cancer Inst. 2008;100(22):1581–1591.

10. Gartner LM, Greer FR, for the Department on Breastfeeding and Committee on Nutrition. American Academy of Pediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics. 2003;111(4 pt 1):908–910.

11. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board, Establish of Medicine Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academies Press; 1997:250–287.

12. Hollis BW, Wagner CL. Cess of dietary vitamin D requirements during pregnancy and lactation. Am J Clin Nutr. 2004;79(v):717–726.

13. Greer FR, Marshall S. Bone mineral content, serum vitamin D metabolite concentrations, and ultraviolet B low-cal exposure in infants fed man milk with and without vitamin D2 supplements. J Pediatr. 1989;114(ii):204–212.

xiv. Rajakumar Thousand, Thomas SB. Reemerging nutritional rickets: a historical perspective. Arch Pediatr Adolesc Med. 2005;159(iv):335–341.

15. Greer FR, Krebs NF, for the American Academy of Pediatrics Commission on Nutrition. Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics. 2006;117(2):578–585.

16. Bowman SA. Potable choices of immature females: changes and impact on nutrient intakes. J Am Diet Assoc. 2002;102(nine):1234–1239.

17. Viljakainen HT, Natri AM, Kärkkäinen MM, et al. A positive dose-response effect of vitamin D supplementation on site-specific bone mineral augmentation in adolescent girls: a double-blinded randomized placebo-controlled 1-year intervention. J Bone Miner Res. 2006;21(6):836–844.

18. Wagner CL, Greer FR, for the American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics. 2009;123(1):197]. Pediatrics. 2008;122(v):1142–1152.

19. American University of Pediatrics Commission on Nutrition. The prophylactic requirement and the toxicity of vitamin D. Pediatrics. 1963;31(3):512–525.

xx. Greer FR. Problems in establishing vitamin D recommendations for infants and children. Am J Clin Nutr. 2004;80(6 suppl):1759S–1762S.

21. Schnadower D, Agarwal C, Oberfield SE, Fennoy I, Pusic M. Hypocalcemic seizures and secondary bilateral femoral fractures in an boyish with master vitamin D deficiency. Pediatrics. 2006;118(5):2226–2230.

22. Bouillon R, Norman AW, Lips P. Vitamin D deficiency [letter of the alphabet]. N Engl J Med. 2007;357(19):1980–1981.

23. Clemens TL, Adams JS, Henderson SL, Holick MF. Increased skin pigment reduces the capacity of skin to synthesise vitamin D3. Lancet. 1982;i(8263):74–76.

24. Ultraviolet light: a hazard to children. American Academy of Pediatrics Committee on Environmental Health. Pediatrics. 1999;104(2 pt 1):328–333.

25. Reichrath J. The challenge resulting from positive and negative effects of sunlight: how much solar UV exposure is appropriate to rest between risks of vitamin D deficiency and skin cancer? Prog Biophys Mol Biol. 2006;92(i):ix–16.

26. Lucas RM, Ponsonby AL. Because the potential benefits likewise as adverse effects of sun exposure: can all the potential benefits exist provided past oral vitamin D supplementation? Prog Biophys Mol Biol. 2006;92(one):140–149.

27. Matsuoka LY, Wortsman J, Hanifan Northward, Holick MF. Chronic sunscreen use decreases circulating concentrations of 25-hydroxyvitamin D. A preliminary written report. Arch Dermatol. 1988;124(12):1802–1804.

28. Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: an important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol. 2007;103(iii–v):631–634.

29. Wolpowitz D, Gilchrest BA. The vitamin D questions: how much do you lot need and how should you go it? J Am Acad Dermatol. 2006;54(two):301–317.

thirty. Hollis BW, Wagner CL. Normal serum vitamin D levels [alphabetic character]. N Engl J Med. 2005;352(5):515–516.

31. Najada AS, Habashneh MS, Khader K. The frequency of nutritional rickets amid hospitalized infants and its relation to respiratory diseases. J Trop Pediatr. 2004;fifty(half-dozen):364–368.

32. Aris RM, Merkel PA, Bachrach LK, et al. Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab. 2005;90(3):1888–1896.

33. Mikati MA, Dib L, Yamout B, Sawaya R, Rahi AC, Fuleihan Gel-H. Two randomized vitamin D trials in ambulatory patients on anticonvulsants: impact on os. Neurology. 2006;67(11):2005–2014.

34. Valsamis HA, Arora SK, Labban B, McFarlane SI. Antiepileptic drugs and bone metabolism Nutr Metab (Lond). 2006;3:36.

35. Mahomed K, Gulmezoglu AM. Vitamin D supplementation in pregnancy. Cochrane Database Syst Rev. 2000;(2):CD000228.

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