Addressing the supplementation needs of the under 5s Vitamin D Briefing 19 March 2012 Royal National Orthopaedic Hospital Dr Robert Moy Retired Senior Lecturer in Child Health College of Medical and Dental Sciences University of Birmingham

National Diet and Nutrition Survey 1995 Blood level of 25 hydroxyvitamin D <25 nmol/l White children 1% Bangladeshi children 20% Indian children 25% Pakistani children 34% Lawson M. BMJ 1998;317:10-11 High prevalence of vitamin D deficiency in children 1.5 to 2.5 years

Low Vitamin D status in pregnant women National Diet and Nutrition Survey 1995 –28% females years 25(OH)D < 25 nmol/l –50% ethnic minorities 160 non white pregnant women in South Wales 2002 –50% 25(OH)D level < 20 nmol/l 198 white pregnant women in Southampton 2008 –18% 25(OH)D level < 27.5 nmol/l pregnant Asian women in Birmingham % 25(OH)D level < 15 nmol/l Datta S et al. Brit J Obstetrics 2002;109:905-8 Gale C et al. Eur J Clin Nutr 2008;62:68-77

Caused by: 1. Limited sunlight exposure >90% of vitamin D derived from UVB light through photosynthesis of 7 dehydrocholesterol in the skin Fair skinned persons: minutes on face/forearms at midday in summer 2-3 times per week Pigmented skin persons: 2-10 times exposure or frequency required Oct to April inadequate UVB at UK latitude º north SF15 blocks 99% of skin synthesis Pearce S Cheetham T. Diagnosis and management of vitamin D deficiency. BMJ 2010;340:142-7

2. UK diet profoundly lacking in vitamin D Oily fish (trout, salmon, mackerel, herring, sardine, anchovy, tuna) and fish oils (5-10 µg/100g) Egg yolk (5µg/100g) Red meat (1µg/100g) Breast milk (0.07µg/100ml) Fortified sources Fortified breakfast cereals (3-8µg/100g) Margarine (7.5µg/100g) Formula (1.2µg/100ml) SACN Update on Vitamin D 2007

Recent dietary evidence: NDNS Reference Nutrient Intake children 1.5 to 3 years 7 µg/day Average daily intake of vitamin D 1.9 µg/day (27% of RNI) Only 7% toddlers taking any vitamin supplement Mean dietary intake of all other vitamins above RNI Bates B et al. National Diet and Nutrition Survey 2008/ /10

Bridging the gap by vitamin D supplementation “ vitamin D intake cannot be met from the diet alone (or usual sunlight exposure) and can only be guaranteed by supplementation” BUT “there is concern that supplementation is being overlooked or not implemented by health professionals and the general public” SACN Update on vitamin D 2007

Supplementation through welfare schemes 1940 Welfare Food Scheme Dried milk Cod liver oil Orange juice Dried eggs 1970 Welfare Food Scheme Vitamin drops Targeted programme Families in special circumstances 1988 Welfare Food Scheme Targeted to families in receipt of income support and Job seekers allowance Milk tokens: Cow’s milk or infant formula Vitamin supplements for pregnant women and children under 5 years 2006 Launch of Healthy Start Targeted to pregnant women and families in receipt of benefits or pregnant women under the age of 18 Free milk fruit, vegetables and vitamins for women and children under 5

Vitamin D supplementation in 1950s

Vitamin D supplementation campaign

Promotion of vitamin D drops to the Asian community posters and leaflets radio and TV video tapes Asian newspapers places of worship Asian GPs Community leaders

COMA recommendations for vitamin D supplementation 1998 ALL pregnant women and breast feeding mothers should take a vitamin D supplement ALL infants should receive vitamin supplements unless they are having > 500 ml of fortified infant formula daily Breast fed babies may delay supplements until 6 months if there mother was in “good vitamin status” during pregnancy Children over 1 year should have vitamins unless their diet is “diverse and plentiful” and have exposure to sunlight Children at high risk should take supplements until age 5 years eg living in north of UK, from Asian/Islamic families, poor eaters, restricted or exclusion diets, born with poor vitamin stores Department of Health: Nutrition and Bone Health 1998

NICE guidance PH 11: Maternal and Child Nutrition 2008 Recommends Healthy Start vitamins for all children 6 months to 4 years and for all pregnant women eligible for the Healthy Start scheme Recommends health professionals should promote vitamin D supplements for all those not eligible for Healthy Start, especially for pregnant women with limited sun exposure, of south Asian, African, Caribbean or Middle Eastern descent NICE PH Improving the nutrition of pregnant and breastfeeding mothers and children in low income households

Chief Medical Officers’ letter 2 Feb 2012 ALL pregnant and breastfeeding women require 10µg vitamin D daily ALL infants and children aged 6 months to 5 years need 7-8.5µg daily Breast fed infants whose mothers did not take vitamin D in pregnancy require vitamin D drops from age one month Infants receiving > 500ml formula do NOT require additional vitamin D 65 years+ not exposed to much sun should take 10µg daily

Bridging the Gap by vitamin D supplementation

Current UK vitamin supplements for children A D CB Minerals IU µg mg Healthy Start Abidec Dalivit Haliborange Well Kid µg vitamin D equivalent to 40 International Units

What is optimal vitamin D supplementation for young children ? UK Reference Nutrient Intake: µg/day up to 3 years USA: doubled recommended minimum intake from 5 to 10µg from soon after birth (based on prevention of deficient blood level <50 nmol/l) Canada: recommends 20µg north of latitude 55º October-April (3 times vitamin D content of Healthy Start drops) Wagner C. Pediatrics 2008;122:

Importance of maternal vitamin D status Maternal vitamin D status determines neonatal vitamin D status Poor maternal vitamin D status adversely affects fetal and infant skeletal growth and bone ossification and tooth enamel formation Inadequate vitamin D in breast milk to meet infant’s needs unless mother and infant are exposed to sunlight Emphasises need for supplementation for pregnant and lactating women Specker BL. Am J Clin Nutr 1994;59:S Thomas S. BMJ Open 2011;1:e UNICEF UK Baby Friendly Initiative 21/12/2011

Vitamin supplements for pregnant and lactating women C D Folic acid Healthy Start 70mg 10µg 400µg Pregnacare 70mg 10µg 400µg

Is the current vitamin D supplementation dosage in pregnancy and lactation adequate ? 1. Conclusion of RCT of 10µg, 50µg or 100µg vitamin D supplementation from first trimester of pregnancy 100µg vitamin D is safe and most effective in achieving vitamin D sufficiency in all women (defined as 25(OH)D >80nmol/l) (ie 10 times USA/UK recommended dose) 2. Conclusion of RCT of 50µg or 100µg vitamin D supplementation of lactating women 100µg is safe and ensures adequate vitamin D status of mother and nursing infant Current recommendations for vitamin D supplementation with 10µg: “irrelevant”, “inconsequential” “ useless” ! Hollis B Wagner C. Am J Clin Nutr 2004;80:S175-8 Hollis B et al. J Bone and Mineral Research 2011;26:

Launched 2006 Department of Health: Scientific Review of the Welfare Food Scheme 2002

Is the Healthy Start vitamin supplementation programme working? Only those on benefits are eligible Many families at risk not covered by Healthy Start Estimated uptake of scheme: 80% of those eligible Uptake of vitamins very low: 2.7% children 4.0% women Significant problems with supplement supply and availability Department of Health Healthy Start unit statistics available to PCTs

51% are either not sure or are unaware of the UK Health Departments’ supplementation recommendations 46% of those who are aware of the recommendations don’t know which vitamins are recommended daily 56% don’t discuss the importance of vitamin supplementation with all parents The Feeding for Life Foundation survey was carried out by Opinion Health between 3 rd to 13 th October 2011, completed online with a sample of 155 healthcare professionals and 1001 parents Feeding for Life Foundation survey of HCPs

74% are not aware of the UK Health Department recommendations 65 % of those aware of the recommendation do not know which vitamins are recommended daily The Feeding for Life Foundation survey was carried out by Opinion Health between 3 rd to 13 th October 2011, completed online with a sample of 155 healthcare professionals and 1001 parents Feeding for Life Foundation survey of parents

Vitamin D deficiency in Heart of Birmingham PCT 20% Healthy Start eligibility of pregnant women 75% of births to ethnic minority women with dark skin increasing use of modest Islamic dress no UV light at latitude 52 degrees in winter frequent cases of rickets and neonatal hypocalcaemic seizures

HoB PCT vitamin D supplementation FREE Healthy Start Vitamin D tablets for ALL pregnant women 2 nd and 3 rd trimesters FREE Healthy Start Vitamin D tablets for one year for ALL post natal women (breast feeding or not) FREE Healthy Start Vitamin drops for ALL children from 2 weeks up to 4 years First bottle of Healthy Start drops provided by Health Visitors at Primary (New Baby) visit Subsequent supplies from Health Centres, Sure Start, pharmacists Universal untargeted approach

HoB public awareness about vitamin D Posters and leaflets in languages Community radio Shopkeepers Logo on shopping bags, trolley discs Baby T shirts, sun hats

HoB vitamin D programme outcomes Increased public awareness: heard of vitamin D 61% to 89% specific knowledge 21% to 79% Increased professional awareness: Increased uptake of supplements: children: 7% to 17% women: 4% to 17 % Decreased cases: 2006: 29 cases (incidence: 120/100,000) 2010: 12 cases (49/100,000)

What are the issues ? In general vitamin deficiency is not really a problem for the majority of children in UK EXCEPT for vitamin D especially in ethnic minority families Lack of Health Care Professional awareness about supplementation Poor awareness about vitamin D among parents Healthy Start not covering all at risk families Very limited uptake of Healthy Start vitamin supplements Overly cautious approach to sunlight exposure Limited vitamin D food fortification

Bridging the gap in vitamin D status Advocacy for a new integrated public health policy aimed at the elimination of rickets through: Supplementation of pregnant and lactating women and young children with an adequate dosage of vitamin D Enhanced food fortification eg milk Improved awareness of Health Care Professionals Increased parental awareness

Acknowledgement: Feeding for Life Foundation An education initiative that aims to enhance knowledge and expertise in early nutrition through training, research, raising awareness and collaborative working It’s education programme is led by a group of experts in child health and is aimed at supporting health professionals and early-years practitioners working with infants and toddlers The Feeding for Life Foundation is supported by Cow & Gate but is a non- promotion initiative which reflects and complements their continued commitment to improving early nutrition as a way of influencing future health outcomes.