Identify and Treat Patients With Vitamin D Insufficiency

Many children and teenagers are not getting enough vitamin D, and this is an common problem.

I started seeing medical consequences years ago. We did a study of breastfed infants – all were African American – who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7).

Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We’ve had vitamin D–deficient teenagers present with seizures, and we also see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But only about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: "How many glasses of milk do you drink a day?" For everyone who responds one glass or less, we check their serum vitamin D level.

When taking a patient history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids we evaluated with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key here is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It’s not ideal, but it’s better than no milk at all.

Also make sure your patients get adequate calcium in their diet, which is about 700 mg/day for a young child and about 1,200-1,300 mg for an adolescent. Recommend a multivitamin, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut. Without sufficient vitamin D, a patient will not absorb enough dietary calcium.

I recommend milk with 1% or less fat. A lot of people erroneously believe that whole milk provides more vitamin D, but that is not the case. Also, if you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we’re about age 20 years. After that, if we live long enough, we’re going to slide down the hill – we will all get osteoporosis. But if you’ve had your milk and followed recommendations, you’ll start your slide downward from the top of the mountain.

In addition to poor diets, those with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It’s becoming like obesity. We need the general pediatrician’s help to screen and treat most of these patients. We can help via telephone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

A few laboratory tests are useful in screening and diagnosis. To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to also get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I also do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposure triggers a reaction that provides vitamin D. The necessary amount of sunshine for infants is about 30 minutes per week if they are wearing only diapers or 2 hours per week if fully clothed. That evidently provides an adequate amount of vitamin D. Of course, the concern about skin cancer leads us to recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, which is when most get exposure, they’re putting on sunscreens that block about 95% of the rays. So we have become dependent on diet for our vitamin D, and we’re not getting it.

This column, "Subspecialist Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Robert Schwartz is professor of pediatrics and chief of pediatric endocrinology at Wake Forest University in Winston-Salem, N.C. He said that he had no relevant financial disclosures. E-mail him at pdnews@elsevier.com.

Many children and teenagers are not getting enough vitamin D, and this is an common problem.

I started seeing medical consequences years ago. We did a study of breastfed infants – all were African American – who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7).

Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We’ve had vitamin D–deficient teenagers present with seizures, and we also see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But only about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: "How many glasses of milk do you drink a day?" For everyone who responds one glass or less, we check their serum vitamin D level.

When taking a patient history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids we evaluated with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key here is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It’s not ideal, but it’s better than no milk at all.

Also make sure your patients get adequate calcium in their diet, which is about 700 mg/day for a young child and about 1,200-1,300 mg for an adolescent. Recommend a multivitamin, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut. Without sufficient vitamin D, a patient will not absorb enough dietary calcium.

I recommend milk with 1% or less fat. A lot of people erroneously believe that whole milk provides more vitamin D, but that is not the case. Also, if you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we’re about age 20 years. After that, if we live long enough, we’re going to slide down the hill – we will all get osteoporosis. But if you’ve had your milk and followed recommendations, you’ll start your slide downward from the top of the mountain.

In addition to poor diets, those with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It’s becoming like obesity. We need the general pediatrician’s help to screen and treat most of these patients. We can help via telephone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

A few laboratory tests are useful in screening and diagnosis. To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to also get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I also do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposure triggers a reaction that provides vitamin D. The necessary amount of sunshine for infants is about 30 minutes per week if they are wearing only diapers or 2 hours per week if fully clothed. That evidently provides an adequate amount of vitamin D. Of course, the concern about skin cancer leads us to recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, which is when most get exposure, they’re putting on sunscreens that block about 95% of the rays. So we have become dependent on diet for our vitamin D, and we’re not getting it.

This column, "Subspecialist Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Robert Schwartz is professor of pediatrics and chief of pediatric endocrinology at Wake Forest University in Winston-Salem, N.C. He said that he had no relevant financial disclosures. E-mail him at pdnews@elsevier.com.

Many children and teenagers are not getting enough vitamin D, and this is an common problem.

I started seeing medical consequences years ago. We did a study of breastfed infants – all were African American – who developed rickets because they were so deficient in vitamin D (J. Pediatrics 2000;137:153-7).

Based on these data, North Carolina Women, Infants, and Children Program clinics started distributing free multivitamin supplements to breastfeeding infants, and now we see fewer cases in our area.

What is new is that we are seeing the adverse effects of vitamin D deficiency in older kids. We’ve had vitamin D–deficient teenagers present with seizures, and we also see osteoporosis in teenagers. We had one adolescent who broke his hip from just twisting around who was found to have a severe deficiency of vitamin D.

This is a preventable problem. But only about 20% of children and teenagers get the recommended amounts of calcium and vitamin D.

Who do you screen for deficiency? We screen in our clinic with one useful question to ask parents and our kids: "How many glasses of milk do you drink a day?" For everyone who responds one glass or less, we check their serum vitamin D level.

When taking a patient history, determine if patients take medications that might interfere with vitamin D metabolism. For example, some antiseizure medicines cause vitamin D to break down more quickly. Obviously, if a child has a severe seizure disorder, that individual needs seizure medicine. But you may need to check the vitamin D level and increase supplementation accordingly.

We found 75% of 48 kids we evaluated with a history of inadequate milk intake had a vitamin D level below 30 ng/mL; 30% of the children had deficient levels (below 20 ng/mL).

The key here is prevention. I recommend that infants start drinking vitamin D–fortified milk after they wean off breast milk or formula. We are finding that a tremendous number of kids do not drink milk, and they go directly from the breast or formula to juice and soda. I tell them to drink a glass of milk with their breakfast, lunch, and supper, hoping they will get at least two glasses per day. I accept chocolate milk. It’s not ideal, but it’s better than no milk at all.

Also make sure your patients get adequate calcium in their diet, which is about 700 mg/day for a young child and about 1,200-1,300 mg for an adolescent. Recommend a multivitamin, which typically has a minimum of 400 U of vitamin D – as well as a calcium supplement. This combination is important because vitamin D facilitates absorption of calcium from the gut. Without sufficient vitamin D, a patient will not absorb enough dietary calcium.

I recommend milk with 1% or less fat. A lot of people erroneously believe that whole milk provides more vitamin D, but that is not the case. Also, if you have lactose-intolerant patients, suggest that they drink a soy milk product fortified with vitamin D.

A good way to explain the importance of vitamin D to kids and parents is that we build up our bones until we’re about age 20 years. After that, if we live long enough, we’re going to slide down the hill – we will all get osteoporosis. But if you’ve had your milk and followed recommendations, you’ll start your slide downward from the top of the mountain.

In addition to poor diets, those with chronic disease, with malabsorption, or who are confined to the indoors are at higher risk for vitamin D deficiency. If they are severely deficient, you will need to use higher doses of vitamin D or refer them to a specialist.

Specialists cannot see all these patients because vitamin D insufficiency is so common. It’s becoming like obesity. We need the general pediatrician’s help to screen and treat most of these patients. We can help via telephone consultation or referral for severely deficient patients, particularly those who experience a seizure or multiple fractures because of their deficiency.

A few laboratory tests are useful in screening and diagnosis. To diagnose a suspected deficiency of vitamin D, order a serum 25-hydroxyvitamin D level. With that you might want to also get a calcium and phosphorus level and an alkaline phosphatase assay (a measure of bone formation).

Do not order a 1,25-dihydroxyvitamin D test. It is easily ordered by mistake with electronic test ordering. But the 1,25 form does not reflect true vitamin D sufficiency or insufficiency, and can confuse clinical diagnosis.

I also do not recommend bone density measurements (such as dual-energy x-ray absorptiometry, or DXA) because many of these scans can be misread. You want to take a history, get a vitamin D level, and treat. Otherwise, you are just going to run up medical expenses.

No column on vitamin D would be complete without addressing sunlight. Ultraviolet light from sun exposure triggers a reaction that provides vitamin D. The necessary amount of sunshine for infants is about 30 minutes per week if they are wearing only diapers or 2 hours per week if fully clothed. That evidently provides an adequate amount of vitamin D. Of course, the concern about skin cancer leads us to recommend sunscreen for people who are outdoors for more than just a short period. If children and teenagers are really out in the summer, which is when most get exposure, they’re putting on sunscreens that block about 95% of the rays. So we have become dependent on diet for our vitamin D, and we’re not getting it.

This column, "Subspecialist Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Robert Schwartz is professor of pediatrics and chief of pediatric endocrinology at Wake Forest University in Winston-Salem, N.C. He said that he had no relevant financial disclosures. E-mail him at pdnews@elsevier.com.