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Prevention and treatment of vitamin D and calcium deficiency in children and adolescents: Indian Academy of Pediatrics (IAP) guidelines

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Abstract

Justification

Vitamin D deficiency (VDD) is being increasingly reported from India from all age-groups. Reports suggest that VDD affects all age groups, from neonates to adolescents. Further, habitually low calcium intakes are also reported in Indian children. Given the multiple guidelines, peculiarities of Indian circumstances, changing lifestyles, and lack of fortification, the Indian Academy of Pediatrics (IAP) felt the need for a Practice Guideline for Pediatricians for the prevention and treatment of vitamin D and calcium deficiency in children and adolescents.

Process

The ‘Guideline for Vitamin D and Calcium in Children’ committee was formed by the IAP in September 2016. A consultative committee meeting was held in November 2016 in Mumbai. Evidence from Indian and international studies and other previous published recommendations, which were pertinent to the Indian circumstances, were collated for the preparation of these guidelines.

Objectives

To present a practice guideline for pediatricians for the prevention and treatment of deficiency of vitamin D and calcium in the Indian context.

Recommendations

For the prevention of rickets in premature infants, 400 IU of vitamin D and 150-220 mg/kg of calcium, and in neonates, 400 IU of vitamin D and 200 mg of calcium are recommended daily. For prevention of rickets and hypocalcemia in infants (after neonatal period) upto 1 year of age, and from 1-18 years, 400 IU and 600 IU vitamin D/day and 250-500 mg/day and 600-800 mg/day of calcium, respectively, are recommended. For treatment of rickets in premature neonates, infants upto 1 year and from 1-18 years, 1000 IU, 2000 IU and 3000-6000 IU of vitamin D daily, respectively, and elemental calcium of 70-80 mg/kg/day in premature neonates and 500-800 mg daily for all children over that age are recommended. Larger doses of vitamin D may be given from 3 months to 18 years of age as 60,000 IU/week for 6 weeks.

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References

  1. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009;20:1807–20.

    Article  CAS  PubMed  Google Scholar 

  2. Puri S, Marwaha RK, Agarwal N, Tandon N, Agarwal R, Grewal K, et al. Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: relation to nutrition and lifestyle. Br J Nutr. 2008;99:876–82.

    Article  CAS  PubMed  Google Scholar 

  3. Garg MK, Marwaha RK, Khadgawat R, Ramot R, Obroi AK, Mehan N, et al. Efficacy of vitamin D loading doses on serum 25-hydroxy vitamin D levels in school going adolescents: an open label non-randomized prospective trial. J Pediatr Endocrinol Metab. 2013;26:515–23.

    Article  CAS  PubMed  Google Scholar 

  4. Ekbote VH, Khadilkar AV, Mughal MZ, Hanumante N, Sanwalka N, Khadilkar VV, et al. Sunlight exposure and development of rickets in Indian toddlers. Indian J Pediatr. 2010;77:61–5.

    Article  CAS  PubMed  Google Scholar 

  5. Rathi N, Rathi A. Vitamin D and child health in the 21st century. Indian Pediatr. 2011;48:619–25.

    Article  PubMed  Google Scholar 

  6. Kajale NA, Khadilkar VV, Mughal Z, Chiplonkar SA, Khadilkar AV. Changes in body composition of Indian lactating women: a longitudinal study. Asia Pac J Clin Nutr. 2016;25:556–62.

    PubMed  Google Scholar 

  7. Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V. High prevalence of vitamin D deficiency among pregnant women and their newborns in northern India. Am J Clin Nutr. 2005;81:1060–4.

    CAS  PubMed  Google Scholar 

  8. Balasubramanian S. Vitamin D deficiency in breastfed infants and the need for routine vitamin D supplementation. Indian J Med Res. 2011;133:250–2.

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Sanwalka NJ, Khadilkar AV, Mughal MZ, Sayyad MG, Khadilkar VV, Shirole SC, et al. A study of calcium intake and sources of calcium in adolescent boys and girls from two socioeconomic strata, in Pune, India. Asia Pac J Clin Nutr. 2010;19:324–9.

    CAS  PubMed  Google Scholar 

  10. Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D, Srinivasarao PV, Sarma KV, et al. High prevalence of low dietary calcium, high phytate consumption and vitamin D deficiency in healthy south Indians. Am J Clin Nutr. 2007;85:1062–7.

    CAS  PubMed  Google Scholar 

  11. Lips P, van Schoor NM. The effect of vitamin D on bone and osteoporosis. Best Pract Res Clin Endocrinol Metab. 2011;25:585–91.

    Article  CAS  PubMed  Google Scholar 

  12. Golden NH, Abrams SA; Committee on Nutrition. Optimizing bone health in children and adolescents. Pediatrics. 2014;134:e1229–43.

    Article  PubMed  Google Scholar 

  13. Maiya S, Sullivan I, Allgrove J, Yates R, Malone M, Brain C, et al. Hypocalcaemia and vitamin D deficiency: an important, but preventable, cause of life-threatening infant heart failure. Heart. 2008;94:581–4.

    Article  CAS  PubMed  Google Scholar 

  14. Theodoratou E, Tzoulaki I, Zgaga L, Ioannidis JP. Vitamin D and multiple health outcomes: Umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials. BMJ. 2014;348:g2035.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Thacher TD, Fischer PR, Strand MA, Pettifor JM. Nutritional rickets around the world: causes and future directions. Ann Trop Paediatr. 2006;26:1–16.

    Article  PubMed  Google Scholar 

  16. Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, et al. Global consensus recommendations on prevention and management of nutritional rickets. J Clin Endocrinol Metab. 2016;101:394–415.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Indian Council of Medical Research (ICMR), Nutrient Requirements and Recommended Dietary Allowances for Indians, a Report of the Expert Group of the Indian Council of Medical Research 2010. Hyderabad, India: National Institute of Nutrition; 2010.

  18. Khadilkar AV. Vitamin D deficiency in Indian adolescents. Indian Pediatr. 2010; 47:755–6.

    Article  CAS  PubMed  Google Scholar 

  19. Harinarayan CV, Ramalakshmi T, Venkataprasad U. High prevalence of low dietary calcium and low vitamin D status in healthy south Indians. Asia Pac J Clin Nutr. 2004;13:359–64.

    CAS  PubMed  Google Scholar 

  20. Awumey EM, Mitra DA, Hollis BW, Kumar R, Bell NH. Vitamin D metabolism is altered in Asian Indians in the southern United States: a clinical research center study. J Clin Endocrinol Metab. 1998;83:169–173.

    CAS  PubMed  Google Scholar 

  21. Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM. The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child. 2002;87:111–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Meena P, Dabas A, Shet D, Malhotra RK, Madhu SV, Gupta P. Sunlight exposure and vitamin D status in breastfed infants. Indian Pediatr. 2017;54:105–11.

    Article  PubMed  Google Scholar 

  23. Ritu G, Gupta A. Fortification of Foods with Vitamin D in India. Nutrients. 2014; 6:3601–23.

    Article  CAS  Google Scholar 

  24. Nehra D, Carlson SJ, Fallon EM, Kalish B, Potemkin AK, Gura KM, et al. A.S.P.E.N.clinical guidelines: Nutrition support of neonatal patients at risk for metabolic bone disease. J Parenter Enteral Nutr. 2013;37:570–98.

    Article  Google Scholar 

  25. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911–30.

    Article  CAS  PubMed  Google Scholar 

  26. A Catharine Ross; Institute of Medicine (U.S.). Committee to Review Dietary Reference Intakes for vitamin D and Calcium. (2011). DRI, dietary reference intakes: calcium, vitamin D. Washington, D.C.: National Academies Press.

  27. Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122:1142–52.

    Article  PubMed  Google Scholar 

  28. Roth HJ, Schmidt-Gayk H, Weber H, Niederau C. Accuracy and clinical implications of seven 25-hydroxyvitamin D methods compared with liquid chromatography-tandem mass spectrometry as a reference. Ann Clin Biochem. 2008;45:153–9.

    Article  CAS  PubMed  Google Scholar 

  29. Laboratory Procedure Manual. 2015. Available from http://www.cdc.gov/nchs/data/nhanes/nhanes_05_06/VID_D_ met_Vitamin_D.pdf. Accessed November 15, 2016.

  30. Wang M, Yang X, Wang F, Li R, Ning H, Na L, et al. Calcium-deficiency assessment and biomarker identification by an integrated urinary metabonomics analysis. BMC Med. 2013;11:86.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Munns CF, Simm PJ, Rodda CP, Garnett SP, Zacharin MR, Ward LM, et al. Incidence of vitamin D deficiency rickets among Australian children: an Australian Paediatric Surveillance Unit study. Med J Aust. 2012;196:466–8.

    Article  PubMed  Google Scholar 

  32. Vogiatzi MG, Jacobson-Dickman E, DeBoer MD; Drugs, and Therapeutics Committee of the Pediatric Endocrine Society. Vitamin D supplementation and risk of toxicity in pediatrics: A review of current literature. J Clin Endocrinol Metab. 2014;99:1132–41.

    Article  CAS  PubMed  Google Scholar 

  33. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. 6, Tolerable Upper Intake Levels: Calcium and Vitamin D. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56058/. Accessed November 26, 2017.

  34. Calcium imbalances. In: Metheny NM. Fluid and Electrolyte Imbalances: Nursing considerations. 5th edition. USA: Jones & Bartlett Learning, LLC; 2015. 91-110.

  35. Panel on Dietetic Products, Nutrition and Allergies. Scientific Opinion on the Tolerable Upper Intake Level of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA). EFSA J. 2012;10:2815.

    Article  Google Scholar 

  36. Hosking DJ. Calcium homeostasis in pregnancy. Clin Endocrinol (Oxf). 1996;45:1–6.

    Article  CAS  PubMed  Google Scholar 

  37. Abrams SA. Committee on Nutrition. Calcium and vitamin d requirements of enterally fed preterm infants. Pediatrics. 2013;131:e1676–83.

    PubMed  Google Scholar 

  38. Backstrom MC, Maki R, Kuusela AL, Sievänen H, Koivisto AM, Ikonen RS, et al. Randomised controlled trial of vitamin D supplementation on bone density and biochemical indices in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1999;80:F161–F6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Hollis BW, Wagner CL. Vitamin D requirements during lactation: High-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr. 2004;80:1752S–8S.

    Google Scholar 

  40. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month followup pilot study. Breastfeed Med. 2006;1:59–70.

    Article  PubMed  Google Scholar 

  41. Mimouni F, Campaigne B, Neylan M, Tsang RC. Bone mineralization in the first year of life in infants fed human milk, cow-milk formula, or soy-based formula. J Pediatr. 1993;122:348–54.

    Article  CAS  PubMed  Google Scholar 

  42. Fomon SJ, Nelson SE. Calcium, phosphorus, magnesium, and sulfur. In: Fomon SJ, editor. Nutrition of Normal Infants. Mosby-Year Book, Inc.; St. Louis, MO, USA: 1993. p. 192–218.

    Google Scholar 

  43. Widdowson EM. Absorption and excretion of fat, nitrogen, and minerals from “filled” milks by babies one week old. Lancet. 1965;2:1099–105.

    Article  CAS  PubMed  Google Scholar 

  44. Hollis BW, Pittard WB. Evaluation of the total feto-maternal vitamin D relationships at term: evidence for racial differences. J Clin Endocrinol Metab. 1984;59:652–7.

    Article  CAS  PubMed  Google Scholar 

  45. Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000;72:690–3.

    CAS  PubMed  Google Scholar 

  46. Greenbaum LA. Rickets and Hypervitaminosis D. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, eds. Nelson Textbook of Paediatrics. 20th edition. Philadelphia (PA): Elsevier Health Sciences; 2015. p.331–40.

    Google Scholar 

  47. Aggarwal V, Seth A, Aneja S, Sharma B, Sonkar P, Singh S, et al. Role of calcium deficiency in development of nutritional rickets in Indian children: A case control study. J Clin Endocrinol Metab. 2012;97:3461–6.

    Article  CAS  PubMed  Google Scholar 

  48. Mughal MZ. Metabolic Bone Disorders. In: Desai MP, Menon P, Bhatia V, editors. Pediatric Endocrine Disorders. 3rd ed. Chennai: Orient Longman Private Ltd.; 2014. p.401–05.

    Google Scholar 

  49. Khadgawat R, Ramot R, Chacko KM, Marwaha RK. Disparity in cholecalciferol content of commercial preparations available in India. Indian J Endocr Metab. 2013;17:1100–3.

    Article  Google Scholar 

  50. Heaney RP, Dowell MS, Bierman J, Hale CA, Bendich A. Absorbability and cost effectiveness in calcium supplementation. J Am Coll Nutr. 2001;20:239–46.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Indian Academy of Pediatrics ‘Guideline for Vitamin D and Calcium in Children’ Committee, New Delhi, India

    Anuradha Khadilkar, Vaman Khadilkar, Jagdish Chinnappa, Narendra Rathi, Rajesh Khadgawat, S. Balasubramanian, Bakul Parekh & Pramod Jog

  2. Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India

    Anuradha Khadilkar

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  1. Anuradha Khadilkar
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  2. Vaman Khadilkar
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  3. Jagdish Chinnappa
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Correspondence to Anuradha Khadilkar.

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Khadilkar, A., Khadilkar, V., Chinnappa, J. et al. Prevention and treatment of vitamin D and calcium deficiency in children and adolescents: Indian Academy of Pediatrics (IAP) guidelines. Indian Pediatr 54, 567–573 (2017). https://doi.org/10.1007/s13312-017-1070-x

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  • DOI: https://doi.org/10.1007/s13312-017-1070-x

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