VITAMIN –D DIFICIENCY IN CHILDREN DR. PRADEEP DUBEY MD(PED). DCH. CONSULTANT PEDITRICIAN. “AADIGURU” NEURO PEDITRIC CENTRE PREM MANDIR CHOWK, WRIGHT TOWN , JABALPUR.

20th century witnessed - Discovery of Vit D Rickets is a nutritional disorder cured with cod liver oil, & the necessary curing factor may be vit A. – The Hypothesis Later, an antirachitic factor distinct from vitamin A was demonstrated & subsequently called vit D. rickets appeared to have been conquered, many health care professionals thought the major health problems resulting from vitamin D deficiency had been resolved. Nutrition Research, Vol. 19, No. 11, pp. 1683-1718, 1999

E N R O V Vitamin D O I When it comes to vitamins, most of us know our ABCs. It's when we hit D that we seem to falter. Vitamin Acarrots and spinach, check. Vitamin Beggs. Vitamin Coranges. You load up on them through the day. But Vitamin D, the sunshine vitamin, despite being around us all day, is often forgotten. L T U

Bone health Vitamin Miracle Drug The Evolution of Vit D For strong bones Bone health Vitamin Miracle Drug

Vitamin D & Cancer People living in northern latitudes of USA more likely to die of cancer than those in southern states. – Apperley 1941 USA In 1941, Apperley (57) reported a curious observation, i.e., that people who lived in northern latitudes in the United States, including Massachusetts, Vermont, and New Hampshire, were more likely to die of cancer than adults living in Texas, South Carolina, and other southern states. He noted that although people living in southern states were more likely to develop nonlife-threatening skin cancer, he suggested that this provided an immunity for the more serious cancers of breast, colon, and prostate that were lethal. J. Nutr. 135: 2739S–2748S, 2005.

First evidence for anticancer effects of Vit D = The first real evidence for the anticancer properties of vit d emerged in the early 1980s, when researchers found that if they added calcitriol to the immature malignant leukemia cells, the cells would stop growing. They could only guess why this was, but scientists have since shown that Vit D interacts with an unusually large number of genes and has the apparent ability to turn them on and off. + Calcitriol Biochem Biophys Res Commun. 1981 Oct 15;102(3):937-43.

Clinical trials - Vit D & Cancer ~3,000 studies published 275 epidemiological studies. 4 RCTs Most epidemiological studies report higher vit D levels associated with lower incidence of various cancers. Ann Epidemiol 2009;19:468–483.

Infections TB Epidemic influenza HIV Vaginal infections

NOBEL PRIZE CERTIFICATE Nobel Prize in Physiology or Medicine, 1903 Dr.Niels Ryberg Finsen “In recognition of his contribution to the treatment of diseases, especially lupus vulgaris, with artificial UV radiation, whereby he has opened a new avenue for medical science". 1903 Nobel Prize in Medicine o Physiology was awarded to Dr Niels Finsen for his discovery that artificial UV radiation cured tuberculosis of the skin (lupus vulgaris) [15]. It is commonly assumed that Finsen’s discovery was due to direct UV effects on the skin and thus only relevant to skin infections.

Finsen extended his work to all forms of internal TB The benefit derived by patients suffering from TB of bones, articulations, peritoneum, intestine, larynx & lymph nodes when exposed to natural sunlight or rays emitted by certain artificial sources cannot be doubted … -AMA 1925 In fact, Finsen and others extended his work to all forms of internal tuberculosis. By 1925, the American Medical Association was comfortable enough with the scientific evidence to issue the following statement.

Sputum Conversion Rate RCT Sputum conversion rates from AFB positive to negative- Vit D 0.25 mg/day supplemented patients -100% Non-supplemented patients- 77% South Med J. Author manuscript; available in PMC 2010 November 1.

Refractory case of PTB- Improvement with Vit D

Vitamin D & Autoimmune diseases You look delicious! Who are you? Where am I?

T1DM IBD RA Multiple sclerosis 400 IU Vit D decreased RA risk by 40% Vit D>400 IU daily reduces MS risk by 42%. RA Multiple sclerosis N Engl J Med 2007;357:266-81. J. Nutr. 135: 2739S–2748S, 2005.

An Important, Common, & Easily Treatable Cardiovascular Risk Factor? Vit D deficiency- An Important, Common, & Easily Treatable Cardiovascular Risk Factor?

Vit D deficiency Atherosclerosis PTH IR & Pancreatic cell dysfunction RAAS IR & Pancreatic cell dysfunction Inflammation Diabetes & Metabolic Syndrome Hypertension & Hypertrophy Atherosclerosis Adverse CV events J Am Coll Cardiol 2008;52:1949–56

Vitamin D deficiency in healthy South Indians Deficient (<20 ng/mL) Insufficient (20–30 ng/mL) Sufficient (30 ng/mL) Am J Clin Nutr 2007; 85: 1062-7

Vitamin D deficiency in healthy South Indians Deficient (<20 ng/mL) Insufficient (20–30 ng/mL) Sufficient (30 ng/mL) Am J Clin Nutr 2007; 85: 1062-7

Groups at Risk of Vitamin D Inadequacy Breastfed infants AAP recommends that exclusively and partially breastfed infants be supplemented with 400 IU of vitamin D per day Older adults Older adults are at increased risk of developing vitamin D insufficiency People with limited sun exposure Homebound individuals, people who wear long robes and head coverings, & people with occupations that limit sun exposure People with dark skin People with fat malabsorption People who are obese or who have undergone gastric bypass surgery

Cause of Rickets – The First Insight “Thus, strong & obvious is influence of sun on cure of the English disease & frequent occurrence of it in densely populated towns where streets are narrow & dwellings of the working class are poorly lit” -Sniadecki 1822

Vit D physiology Sunscreen & Vit D synthesis SPF 8 by 92.5%, SPF 15 by 99% UVB rays 10 am – 3 pm 290 to 315 nm 7- dehydrocholesterol Cholecalciferol (Vitamin D3) Vit D 25-Hydroxylase This step is said to occur only in the kidneys, so if you have only a small amount of vit D in the body it will all be used by the kidneys to produce calcitriol. And maintain blood calcium levels. But when there is more Vit D available, something very different happens. As scientists have discovered in recent decades, it’s not only the kidneys that can make calcitriol from the calcidiol produced in the liver. Many tissues throughout the body can as well. These tissues use the hormone locally, within the cells, to regulate their behaviour. This was the finding that kind of kicked of or paved way for further research in Vit D. 25 (OH)D3 (Calcidiol) 1-Hydroxylase 1,25 (OH)D3 (Calcitriol) N Engl J Med 2007;357:266-81.

RICKETS ROSARY

SKELETAL CHANGES

HEALING RICKETS

LINE OF CALCIFICATION

NORMAL PELVIS

DEFORMED PELVIS

Dose of Vitamin D Loading dose 60,000 IU/Week for 8 weeks Blood test For treatment of Vitamin D Deficiency Loading dose 60,000 IU/Week for 8 weeks Blood test Maintenance dose 60,000 IU/ Month

Recommended Vitamin D Intake by Endo. Society Guidelines, 2011 Reasonable daily allowance (IU/ day) Reasonable allowance (IU/ month) 0-6 months 400-1000 12000-30000 6-12 months Children (1-18 yrs) 1000-2000 30,000-60,000 Adults (19-50 yrs) 1500-2000 45,000-60,000 Elderly (51-70 yrs) Elderly (71 yrs) Pregnancy Lactation

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