Vitamin D is a media darling. In addition to its
essential role in bone health, it has been touted to
cure or prevent ailments as wide-ranging as depres-
sion, infectious diseases, cancer and diabetes.
It is easy for pediatricians to be swept up in the
whirlwind of vitamin D enthusiasm, particularly
when encouraged by well-read parents bearing the
newest articles on their smartphones. It is critical
that providers be equally well-read.
Recently, international experts in pediatric endocrinology, nutrition and public health representing
10 pediatric societies released the Global Consensus
Recommendations on Prevention and Management of
Nutritional Rickets (Munns CF, et al. J Clin Endocri-nol Metab. 2016;101:394-415, 10.1210/jc.2015-
2175). Some key points from the recommendations and the most recent AAP rickets guidelines
(Wagner CL, Greer FR. Pediatrics. 2008;122:1142-
1152, http://bit.ly/2kkdsjZ) are outlined below.
Ensuring adequate intake
Vitamin D is both a nutrient and a hormone.
Infants up to age 12 months require 400 interna-
tional units (IU) daily of vitamin D; children and
adolescents require 600 IU daily.
In the U.S., many foods are fortified with vitamin
D, including milk, orange juice, cereals and yogurt.
One cup of vitamin D fortified milk provides 100-
125 IU. Oily fish also are a good source; 3 ounces of
salmon provide 447 IU, according to the National
Institutes of Health, http://bit.ly/2kGWLgq.
Infants who are exclusively breastfed or receive
less than 1 liter of formula daily should be supplemented with 400 IU of vitamin D daily, starting in
the first few days of life and continuing until they
are 12 months of age. Older children often are notoriously unpredictable eaters and also may require
supplemental vitamin D. Most multivitamins provide 300-600 IU per serving.
Vitamin D also can be synthesized by the skin
through ultraviolet (UV) light exposure. However,
multiple factors affect the magnitude of UV rays
that actually reach the skin, including latitude, time
of day, season, cloudiness and air pollution. Due
to the unpredictability of sun exposure, as well as
the increased risk of skin cancer with UV exposure,
consumption of vitamin D through diet is the most
dependable way to ensure adequate intake.
Vitamin D status is best assessed by measuring
serum concentrations of 25-hydroxyvitamin D
(25OHD). The Global Consensus Recommendations define vitamin D deficiency as a serum
25OHD concentration less than 12 nanograms/
milliliter (ng/mL) ( 30 nanomoles/liter [nmol/L]),
and insufficiency as 12-20 ng/mL (30-50 nmol/L).
Although routine 25OHD screening is not rec-
Consequences of deficiency
ommended for healthy children, those with bone
disease or certain other chronic diseases (especially
those involving malabsorption or use of medications
that interfere with vitamin D synthesis, such
as antiseizure medications) can benefit from
monitoring. Some of these children also may
benefit from chronic supplementation and
require higher daily vitamin D doses.
In growing children, vitamin D deficiency can result in rickets, defined as defective
growth plate mineralization, and osteomalacia, defined as abnormal matrix mineralization of established bone. The U.S. incidence
of nutritional rickets (NR) is 24 cases per
100,000, greater than in other developed
countries ( 2. 9 and 7. 5 per 100,000 in Canada and the United Kingdom, respectively).
Rickets can result in limb deformity and
scoliosis, and can be associated with fracture.
Other health complications include seizures,
Specific groups at higher risk for NR include infants who are exclusively breastfed without vitamin
D supplementation, those whose mothers had vitamin D deficiency, those with dark skin pigmentation
or reduced sun exposure, and those who consume
diets consistently low in vitamin D and calcium.
Treating, preventing rickets
The Global Consensus Recommendations state
that children with NR due to vitamin D deficiency
should receive at least 2000 IU of vitamin D daily for
three months, after which a 25OHD concentration
should be repeated to determine whether supplementation should be continued. When treating NR
with vitamin D, providers also should ensure the
child is consuming at least 500 milligrams of calcium
daily through diet or supplementation.
As the world becomes increasingly more global and
families from Africa, Asia and the Middle East are immigrating to far northern and southern countries, NR
is making a comeback. NR is a serious but preventable
disease; therefore, public health systems and providers must collaborate to develop prevention strategies.
Potential interventions include supplementing all infants with vitamin D, developing and implementing
rickets prevention and detection protocols in high-risk populations, and fortifying commonly consumed
foods with vitamin D and calcium.
Although a sprinkling of vitamin D might not
cure everything that ails you, it is absolutely essential
for bone health in growing children.
Dr. Folsom is a mem-
ber of the AAP Section
on Endocrinology. Dr.
DiMeglio is a co-author
of the Global Consensus
Recommendations and a
member of the AAP Section on Endocrinology Executive Committee.
Recommendations released on prevention, management of rickets
Infants who are exclusively breastfed or receive less than 1 liter
of formula daily should be supplemented with 400 IU of vitamin
D daily, starting in the first few days of life and continuing until
they are 12 months of age.
‘Vaccines save lives’: 350 groups sign letter to President Trump
by Alyson Sulaski Wyckoff • Associate Editor
More than 350 medical, professional and advocacy organizations signed on to a letter drafted by the
Academy to President Donald Trump expressing “unequivocal support” for the safety of vaccines.
The 28-page letter ( http://bit.ly/2lqOkGx) cites and abstracts more than 40 studies on vaccine safety
and effectiveness. Co-signers of the Feb. 7 letter represent every AAP chapter along with state and national
medical, research and advocacy groups, including the American Medical Association, the March of Dimes
and Autism Speaks.
“Vaccines protect the health of children and adults and save lives,” the letter states. “They prevent
The letter points out that despite successes, outbreaks of vaccine-preventable diseases still occur. “As
life-threatening diseases, including forms of cancer. Vaccines have been part of the fabric of our society
for decades and are one of the most significant medical innovations of our time.”
As the new administration takes shape, the Academy and others wanted to be on the record early to
demonstrate strong support for vaccines and the recommended immunization schedule.
a nation, we should redouble our efforts to make needed investments in patient and family education
about the importance of vaccines … to increase the rate of vaccination among all populations,” the letter
concludes. “Put simply: Vaccines are safe. Vaccines are effective. Vaccines save lives.”