40
Dr.S.Balasubramanian, MD,DCH,MNAMS, Senior Consultant in Pediatrics Kanchi Kamakoti CHILDS Trust Hospital, Chennai -600 034. Tamil Nadu.
DrSBalasubramanian MDDCHMNAMS
Senior Consultant in Pediatrics
Kanchi Kamakoti CHILDS Trust Hospital
Chennai -600 034 Tamil Nadu
Introduction
bull Exclusive breast feeding -recommended up to 6 months of age with all its beneficial effects on child survival
bull Increase in breast-feeding rates leads to decreased vitamin D intake from other sources and there by Rickets
(Cara FJ Vitamin D deficiency rickets in breast fed infants Available from httpwwwmedscapecomview article420205)
Vitamin D in Breast Milk
Breast Milk is deficient in Vitamin K
Vitamin D and Iron
Concentrations of vitamin D average only 35 IUL in African American women and 68 IUL in white women far below the daily amount of 200 IUday recommended for infants by the Food and Nutrition Board of the National Academy of Sciences
Breast feeding amp Vit D Deficiency
bull Breast milk contains between 20 and 60 IUL of vitamin D and hence adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D in a breast-feeding infant
(Hollis BW Roos BA Draper HH Vitamin D and its metabolites in
human and bovine milk J Nutr1981 111 1240-1248)
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Introduction
bull Exclusive breast feeding -recommended up to 6 months of age with all its beneficial effects on child survival
bull Increase in breast-feeding rates leads to decreased vitamin D intake from other sources and there by Rickets
(Cara FJ Vitamin D deficiency rickets in breast fed infants Available from httpwwwmedscapecomview article420205)
Vitamin D in Breast Milk
Breast Milk is deficient in Vitamin K
Vitamin D and Iron
Concentrations of vitamin D average only 35 IUL in African American women and 68 IUL in white women far below the daily amount of 200 IUday recommended for infants by the Food and Nutrition Board of the National Academy of Sciences
Breast feeding amp Vit D Deficiency
bull Breast milk contains between 20 and 60 IUL of vitamin D and hence adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D in a breast-feeding infant
(Hollis BW Roos BA Draper HH Vitamin D and its metabolites in
human and bovine milk J Nutr1981 111 1240-1248)
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
bull Increase in breast-feeding rates leads to decreased vitamin D intake from other sources and there by Rickets
(Cara FJ Vitamin D deficiency rickets in breast fed infants Available from httpwwwmedscapecomview article420205)
Vitamin D in Breast Milk
Breast Milk is deficient in Vitamin K
Vitamin D and Iron
Concentrations of vitamin D average only 35 IUL in African American women and 68 IUL in white women far below the daily amount of 200 IUday recommended for infants by the Food and Nutrition Board of the National Academy of Sciences
Breast feeding amp Vit D Deficiency
bull Breast milk contains between 20 and 60 IUL of vitamin D and hence adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D in a breast-feeding infant
(Hollis BW Roos BA Draper HH Vitamin D and its metabolites in
human and bovine milk J Nutr1981 111 1240-1248)
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Vitamin D in Breast Milk
Breast Milk is deficient in Vitamin K
Vitamin D and Iron
Concentrations of vitamin D average only 35 IUL in African American women and 68 IUL in white women far below the daily amount of 200 IUday recommended for infants by the Food and Nutrition Board of the National Academy of Sciences
Breast feeding amp Vit D Deficiency
bull Breast milk contains between 20 and 60 IUL of vitamin D and hence adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D in a breast-feeding infant
(Hollis BW Roos BA Draper HH Vitamin D and its metabolites in
human and bovine milk J Nutr1981 111 1240-1248)
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Breast feeding amp Vit D Deficiency
bull Breast milk contains between 20 and 60 IUL of vitamin D and hence adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D in a breast-feeding infant
(Hollis BW Roos BA Draper HH Vitamin D and its metabolites in
human and bovine milk J Nutr1981 111 1240-1248)
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Requirements of Vitamin D
bull 200 IUday of vitamin D has been recommended for normal infants children and adolescents beginning in the first 2 months of life
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New
Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
bull 200ndash400 IUday recommended in pregnancy and lactation
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Vit D amp Breast Feeding
bull Half-life of serum 25(OH)D is 3 wk thereforeeven if neonates do not receive an exogenous supply of vitamin D during the first weeks of life 25(OH)D concentrations should decrease to values associated with vitamin D deficiency only toward the end of the second month provided that the maternal vitamin D status is adequate during pregnancy
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Prevalence of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Reported to be 82 52 amp 20 from UAE Pakistan and China respectively
1 Dawodu A Agarwal M Hossain M Kochiyil J Zayed R Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer a justification for vitamin D supplementation of breast-feeding infants J -Pediatr 2003 142169-73
2 Atiq M Suria A Nizami SQ Vitamin D status of breastfed Pakistani infants Acta Paediatr 1998 87737-740 3 Ho ML Yen HC Tsang RC Specker BL Chen XC Nichols BL Randomized study of sunshine exposure and
serum 25-OHD in breast fed infants in Beijing China J Pediatr1985 107928-31
bull There is paucity of data from India
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Risk factors For Vitamin D Deficiency in Exclusively Breastfed Infants
bull Low maternal levels of vitamin D
bull Indoor confinement during the day
bull Living at higher altitudes
bull Living in urban areas with tall buildings
bull Air pollution
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Risk factors
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Risk factors
bull Use of sunscreen and covering much or all of the body when outside
bull Dark Skin
bull Low educational level
bull No reports of correlation between the number of pregnancies and vit D deficiency
bull Preterm VLBW amp ELBW babies
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Sunlight amp Vit D
Two hours is the required minimum weekly period of exposure to sunlight for infants if only the face is exposed or 30 minutes if the upper and lower extremities are exposed
(Specker BL Valanis B Hertzberg V Edwards N Tsang RC Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants J Pediatr 1985 107372-6)
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
bull Effects of sunlight exposure decreases with individuals who have darker skin pigmentation
(Fuller KE Casparian JM Vitamin D balancing cutaneous and systemic considerations South Med J2001 9458 ndash64)
Intense exposure to solar ultra violet rays during childhood and adolescence increases a personrsquos risk of developing melanoma and basal cell carcinoma
(American Academy of Pediatrics Committee on Environmental Health Ultraviolet light a hazard to children Pediatrics 1999104 328 ndash333)
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Protective measures to reduce skin cancer
bull Avoiding the sun between 10 AM and 4 PM
bull Wearing sun-protective clothing when exposed to the sun
bull Using sunscreen with a sun protection factor (SPF) of 15 and
bull Avoiding artificial sources of UV light
(Etzel RA Balk SJ eds Pediatric Environmental Health 2nd ed Elk Grove Village IL American Academy of Pediatrics 2003)
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Risk of Vitamin D Deficiency still heightened by AAP recommendations
-To keep infants lt 6 months out of sunlight
-Childrens activities should minimize sunlight exposure by use of protective clothing ampsunscreens
(Gartner ML Greer RF Prevention of Rickets and Vitamin D Deficiency New Guidelines for Vitamin D Intake Section on Breastfeeding and Committee on Nutrition Pediatr 2003111 908-910)
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Clinical features of Vitamin D Deficiency in Exclusively Breastfed Infants
bull Symptomatic or Asymptomatic
Stage 1 Hypocalcemic symptoms
Stage 2 Skeletal deformities
Stage 3 Worsening of symptoms of 1amp2
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Manifestations of Vit D Def
bull Symptomatic vitamin D deficiency manifests as craniotabes rickety rosary swelling of the ends of long bones frontal bossing of the skull hypocalcemic seizures or tetany and slow motor development
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
bull The development of clinical vitamin D deficiency rickets is dependent not only on the severity of the vitamin D deficiency[circulating concentrations of 25(OH)D] but also on the duration of the deficiency on the rate of the childs growth (which influences calcium demands) and on the dietary calcium content
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Hypocalcemia due to vitamin D deficiency in Exclusively Breastfed Infants
bull Indian Pediatr 2006 Mar43(3)247-51 Balasubramanian S
Shivbalan S Kumar PS
bull 13 infants most in Upper Middle Class bull All presented with Seizuresbull All Born Term amp Unsupplementedbull All mothers had poor Sunlight Exposure amp were
Biochemically Vit D Deficient
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Hypocalcemia due to Vitamin D deficiency in Exclusively Breastfed Infants
(Balasubramanian et al Indian Pediatr2006)
bull The youngest was 2 months age and the oldest being 6 months with signs of rickets (rachitic rosary and craniotabes) observed in only one of these 13 infants and radiological features in only 2 of them
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Myelofibrosis and vitamin D deficient rickets--a rare association
Balasubramanian S Varadharajan R Ganesh R Shivbalan SIndian Pediatr 2005 May42(5)482-4
bull An excusively Breast Fed Infant Succumbed to myelofibrosis due to Vit D Deficiency
bull Vit D inhibits proliferation of Megakaryocytes
bull Promotes maturation of Macrophages amp Monocytes which inhibit degradation of Collagen
bull Sec Hyperparathyroidism leads to myelofibrosis
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Vitamin D deficiency rickets in breast-fed infantspresenting with Hypocalcaemic Seizures
bull Acta Paediatr 1995 Aug84(8)941-2 Ahmed I Atiq M Iqbal J KhurshidM Whittaker P
bull Prophylactic vitamin D 400 IU administered to infants up to 2 years and 800 IU to women in pregnancy and during lactation is recommended to prevent vitamin D deficiency
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Diagnosisbull The classical radiological features of rickets include
generalised osteopenia widening of the growth plates and cupping of metaphyseal regions of long bones
(Mughal et al BMJ1999)
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Biochemicalbull Mild vitamin D deficiency Serum 25-OHD
concentration of 25ndash50 nmolL Serum levels over 50 nmolL prevent secondary hyperparathyroidism and elevated alkaline phosphatase levels
bull Moderate vitamin D deficiency Serum 25-OHD concentration of 125ndash25 nmolL The incidence of hypocalcaemia and rickets increases with moderate deficiency
bull Severe vitamin D deficiency Serum 25-OHD concentration less than 125 nmolL Vitamin D concentrations less than 125 nmolL are seen in over 70 of children with rickets and over 90 of children with hypocalcaemia
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Treatment
bull It involves oral or intramuscular administration of the total treatment dose of vitamin D 600 000 IU either as a single dose or as oral vitamin D3 at a dose of 2000-6000 IU producing radiologic clearing in 2-4 weeks
(Heird CW Vitamin deficiencies and excessesIn Behrman
ERKliegman MRJenson BH editors Nelson text book of PediatricsPhiladelphiasaunders2004p177-190)
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Treatment of Vitamin D DeficiencyMegadose or Daily Dose
Treatment with either of the two different regimens increases the bone mineral intensities with similar efficacy
(Akcam M Yildiz M Yilmaz A Artan R Bone Mineral Density in
Response to Two Different Regimes in Rickets Indian Pediatr
200643423-427)
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Prevention of Vit D Def in EclusivelyBreast fed Infants
bull No Indian guidelines for vitamin D suplementation
bull No evidence of vitamin D deficiency in vitamin D unsupplemented exclusively breast fed infants
(Greer FR Marshall S Bone mineral content serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements J Pediatr 1989114 204- 212)
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Options for Prevention
bull Supplementation to Pregnant amp Lactating Women
bull Supplementation to Infants
bull Increased Exposure to Sunlight
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Maternal-infant vitamin D relationships during breast-feedingRothberg AD Pettifor JM Cohen DF Sonnendecker EW Ross FP
bull J Pediatr 1982 Oct101(4)500-3
bull Well-nourished white nursing mothers were given a placebo 500 IU vitamin Dday or 1000 IU vitamin Dday their infants were not given supplemental vitamin D A control group of infants who had received 400 IU vitamin Dday had even higher concentrations of 25-hydroxyvitamin D suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants Do They Contribute to
Rickets
bull PEDIATRICS Vol 113 No 1 January 2004 pp 179-180 Marsha L
Davenport Aysin Uckun Ali S Calikoglu
A decline in the number of
pediatricians who recommend Vit D
supplementation for breastfed infants
might be another contributing factor for
resurgence of Rickets
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Aggravating the situation is the possible resistance to vitamin D supplementation from the mothers themselves and from breastfeeding support groups as it is perceived that vitamin D supplementation detracts from the message that breast milk is a complete food that requires no further supplementation
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Summary
Vitamin D Deficiency in Exclusively Breastfed Infants not confined to Developed Countries
Symptomatic Vit D Deficiency in them - is it unrecognised or underreported
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Summary
bull Supplementation of Vit D to all exclusively breast fed infants-need of the hour
bull Promoting Exposure to sunlight by Change of Lifestyles needed
Thank You
Thank You
