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- Vitamin D and calcium intakes in general pédiatrie populations: A French expert consensus paper
- VitaminDWiki - Consensus Vitamin D category
- VitaminDWiki - Infant-Child category has
Vitamin D and calcium intakes in general pédiatrie populations: A French expert consensus paper
Arch Pediatr. 2022 Mar 16;S0929-693X(22)00073-2. doi: 10.1016/j.arcped.2022.02.008.
J. Bacchettaa,b'c'*, T. Edouardd, G. Lavernye, J. Bernardorbf, A. Bertholet-Thomasa,b, M. Castanetg, C. Garniera, I. Gennerod, J. Harambath'', A. LapillonneJ',k, A. Molin1, C. Nauda, J.P. Sallesd,
S. Laboriem, P. Touniann, A. Linglarto
Objectives: Nutritional vitamin D supplements are often used in general pediatrics. Here, the aim is to address vitamin D supplementation and calcium nutritional intakes in newborns, infants, children, and adolescents to prevent vitamin D deficiency and rickets in general populations.
Study design: We formulated clinical questions relating to the following categories: the Patient (or Population) to whom the recommendation will apply; the Intervention being considered; the Comparison (which may be “no action,” placebo, or an alternative intervention); and the Outcomes affected by the intervention (PICO). These PICO elements were arranged into the questions to be addressed in the literature searches. Each PICO question then formed the basis for a statement. The population covered consisted of children aged between 0 and 18 years and premature babies hospitalized in neonatology. Two groups were assembled: a core working group and a voting panel from different scientific pediatric committees from the French Society of Pediatrics and national scientific societies.
Results: We present here 35 clinical practice points (CPPs) for the use of native vitamin D therapy (ergocalciferol, vitamin D2 and cholecalciferol, vitamin D3) and calcium nutritional intakes in general pediatric populations.
Conclusion: This consensus document was developed to provide guidance to health care professionals on the use of nutritional vitamin D and dietary modalities to achieve the recommended calcium intakes in general pediatric populations. These CPPs will be revised periodically. Research recommendations to study key vitamin D outcome measures in children are also suggested.
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Clinical practice points
- 1. We recommend measuring only serum total 25(OH)D concentration in assessing vitD status in children.
- 2. We recommend measuring serum total 25(OH)D concentration in the same lab for a given child.
- 3. We recommend that assays of 1,25(OH)2D or other metabolites should not be used routinely in pediatrics.
- 4. We do not recommend systematic measurement of serum total 25(OH)D concentration in general pediatric populations.
- 5. We recommend measurement of serum total 25(OH)D levels when there are symptoms of rickets.
- 6. We recommend a 25(OH)D level >20 ng/mL (50 nmol/L) in general pediatric populations to prevent rickets.
- 7. We suggest a 25(OH)D level >30 ng/mL (75 nmol/L) in general pediatric populations to avoid any mineralization defects and seasonal variability.
- 8. We suggest a 25(OH)D level <60 ng/mL (150 nmol/L) in general pediatric populations.
- 9. Toxicity has been described when 25(OH)D levels are above 80 ng/mL (200 nmol/L) in general pediatric populations.
- 10. We recommend supplementing healthy children 0-18 years of age with a minimum of 400 1U of vitD per day. Level A evidence
- 11. We recommend supplementing healthy children 0-18 years of age with a maximum of 800 1U of vitD per day. Level C evidence
- 12. We recommend daily supplementation in children 0-2 years using D2 or D3.
- 13. We suggest preferring daily supplementation in children 2 -18 years using D2 or D3.
- 14. We suggest intermittent supplementation in the case of nonadherence in children 2-18 years using vitD3 with either 50,000 1U quarterly or 80,000-100,000 1U twice in fall and winter.
- 15. We recommend avoiding of 200,000 1U of vitD in one shot.
- 16. We recommend using only licensed pharmaceutical native vitD supplements.
- 17. We recommend a minimum of 800 1U and a maximum of 1600 1U of vitD per day in children 2-18 years of age in the case of decreased availability of vitD (obesity, black ethnicity, absence of skin exposure to sun) or decreased intake (vegan diet).
- 18. In such children, we recommend daily supplementation with vitD2 or D3.
- 19. In such children, we suggest intermittent supplementation in the case of nonadherence using vitD3 with either 50,000 1U every 6 weeks or 80,000-100,000 1U quarterly.
- 20. We recommend considering at increased risk of developing rickets and vitD deficiency children and teenagers with the following conditions: malabsorption, maldigestion, chronic kidney disease, nephrotic syndrome, cholestasis, hepatic insufficiency, cystic fibrosis, secondary bone fragility, chronic inflammatory diseases, anorexia nervosa, skin diseases, anticonvulsant medications, or long-term corticosteroids.
- 21. We suggest that general pediatricians/physicians verify adherence to vitD supplementation in these children.
- 22. We recommend that physicians rule out the use of over-the-counter vitD preparations before prescribing native vitD supplementation.
- 23. We suggest monitoring 25(OH)D levels in patients receiving treatment doses above the upper ranges currently recommended.
- 24. We recommend measuring 25(OH)D levels in the following conditions to adjust vitD supplementation: family history of vitD intoxication, hypercalcemia, hypercalciuria, kidney stones, and/or nephrocalcinosis.
- 25. We suggest preferring daily vitD supplementation in these patients.
- 26. We recommend that, from the age of 1 to 18 years, children and adolescents should consume at least three to four portions of dairy products per day to cover calcium needs.
- 27. We recommend prescribing 500-1000 mg per day of calcium supplementation in children and adolescents receiving less than 300 mg adjusted for calcium bioavailability of nutritional calcium per day, especially in those following a vegan diet.
- - - - Nutritional calcium
- 28. We recommend evaluating dietary calcium intakes in children with fractures and bone pain.
- 29. Diagnosis of calcium deficiency requires a dietary calcium intake evaluation, radiographs of wrists and knees, and measurement of plasma ALP, PTH, 25(OH)D, calcium and phosphate, and urinary excretion of calcium.
- - - -PREMATURE
- 30 We recommend optimizing nutritional calcium and phosphate intakes in premature neonates
- 31 We suggest that, during the initial stay in the NICU, preterm infants receive between 600 IU and 1000 IU per day of vitD, taking into account the content of vitD in milk and parenteral nutrition, vitD supplementation during pregnancy, and birth weight
- 32 We recommend measurement of 25(OH)D in children born before 32 weeks of gestation or weighing less than 1500 grams at 1 month of age
- 33 We recommend 50 nmol/L as the lower target level and 120 nmol/L as the upper target level of 25 (OH)D in premature neonates
- 34. After discharge from the NICU, we suggest following recommendations in general pediatric populations.
- - - - French overseas territories:
- 35. We suggest the same pattern of supplementation as in Metropolitan France.
VitaminDWiki observations on consensus
- Consensus 9 says levels >80 = toxicity. Do not recall seeing that in any pediatric or adult studies
- Consensus 10 and 11 incorrectly recommend the same amount independent of age
- See green chart below
- Consensus 12, 13, 18 says D2 is OK - but vets declared 10 years ago that no mammal should ever be given D2
- Consensus 14, 19 says quarterly and twice a year supplementation is OK - It is not
- Consensus 147 says up to 1600 IU in special conditions. AMA years ago recommended 1600 IU normally
- Consensus 33 says max 48 ng for preemies but says max 60 ng in #8
- Consensus fails to comment on injections being useful for infrequent supplementation
- Consensus fails to comment on getting vitamin D via breastfeeding
- Consensus fails to comment on gut-friendly forms of vitamin D needed sometimes
- Consensus fails to comment on the use of loading dose to quickly raise vitamin D levels
- What are the molecular and cellular mechanisms underlying 1,25D3-dependent calcium homeostasis?
- Are extraskeletal effects observed in adults also applicable in children?
- Is CYP27B1 regulated in the same way in children as in adults in all the target cells?
- What other metabolites of vitD are interesting to evaluate?
- Are adult data adaptable to children?
- How should data be adapted from RCTs conducted in vitD-deficient subjects in general pediatric populations?
- Could the weekly supplementation be used in general pediatric populations?
- What are the real-life data (insurance database)?
- What would be the ideal vitD supplementation protocol in obese children, depending on their ethnicity?
- How should data be adapted from RCTs conducted in vitD-deficient subjects in general pediatric populations?
- What is the optimal schedule of vitD supplementation and monitoring in children and teenagers with hypercalciuria and nephrolithiasis?
- How should the variability of calcium absorption be evaluated in children?
- Is there a reliable laboratory parameter to assess calcium status and to recommend calcium supplementation in the case of deficiency?
- What is the role of C3 epimerization in neonates and pregnant women?
- What is the optimal schedule of vitD supplementation and monitoring in premature babies?
- What is the ideal upper target of 25(OH)D levels in premature babies for bone outcomes but also global outcomes?
- What is the exact frequency of vitD deficiency and overdose in very preterm infants?
- Establish data on vitD status and needs for supplementation in overseas territories
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VitaminDWiki - Consensus Vitamin D category
66 Vitamin D consensus publications
- French pediatric consensus: 30 – 60 ng of Vitamin D – Feb 2022
- 15 Clinical guidelines now recommend vitamin D – Nov 2021
- 34 clinical practice Vitamin D guidelines, huge diversity – Nov 2021
- Minimum National Vitamin D recommendations range from 200 to 4,000 IU – July 2021
- Controversies and consensus in Vitamin D – 3rd Conference Sept 2019
- Vitamin D Consensus 4,000 to 10,000 IU, upper limit 100 ng – Italy 2018
- 4,000 IU of Vitamin D is OK - 19 organizations agree - 2018 six say 10,000 IU is OK
- Why are doctors reluctant to accept vitamin D 10 reasons as of May 2021
- Doctors and medical communities appear to be poor audiences to convience that vitamin D is good
VitaminDWiki - Infant-Child category has
- No consensus on MINIMUM International Units (IU) for healthy infant of normal weight
- 400 IU Vitamin D is no longer enough
Was OK in the past century, but D levels have been dropping for a great many reasons.
FDA doubles the amount of vitamin D permitted in milk – July 2016
- No consensus: range is 600 to 1600 IU – based on many randomized controlled trials
- Review of 400 IU to 2000 IU daily and higher if non-daily
- Fewer pre-infants were vitamin D deficient when they got 800 IU – RCT Feb 2014
- 1600 IU was the conclusion of three JAMA studies
1000 IU recommended in France and Finland – 2013 - appears to be a good level
- 5X less mite allergy after add vitamin D
- Child bone fractures with low vitamin D were 55X more likely to need surgery
- 75 % of SIDS had low vitamin D
- Children stayed in ICU 3.5 days longer if low vitamin D – Dec 2015
- 5 out of 6 children who died in pediatric critical care unit had low vitamin D – May 2014
- Infants have gotten free 400 IU of vitamin D in Turkey since 2005, More for longer would be even better – Feb 2022
- Preemies should have vitamin D supplements – reaching an agreement – April 2021
- Vitamin D loading dose was as effective as daily dosing (rickets in this case) – RCT July 2021
Having a good level of vitamin D cuts in half the amount of:
- Asthma, Chronic illness, Doctor visits, Allergies, infection
Respiratory Tract Infection, Growing pains, Bed wetting
Need even more IUs of vitamin D to get a good level if;
- Have little vitamin D: premie, twin, mother did not get much sun access
- Get little vitamin D: dark skin, little access to sun
- Vitamin D is consumed faster than normal due to sickness
- Older (need at least 100 IU/kilogram, far more if obese)
- Not get any vitamin D from formula (breast fed) or (fortified) milk
Note – formula does not even provide 400 IU of vitamin D daily
Infants-Children need Vitamin D
- Sun is great – well known for 1,000’s of years.
US govt (1934) even said infants should be out in the sun
- One country recommended 2,000 IU daily for decades – with no known problems
- As with adults, infants and children can have loading doses and rarely need tests
- Daily dose appears to be best, but monthly seems OK
- Vitamin D is typically given to infants in the form of drops
big difference in taste between brands
can also use water-soluable form of vitamin D in milk, food, juice,
- Infants have evolved to get a big boost of vitamin D immediately after birth
Colostrum has 3X more vitamin D than breast milk - provided the mother has any vitamin D to spare
- 100 IU per kg of infant July 2011, Poland etc.
More than 100 IU/kg is probably better
747 items in the category Infant/Child See also
- 34 pages in VitaminDWiki had BREASTFE*in title as of Jan 2022
- "BIRTH DEFECTS" 172 items as of July 2016
- Stunting OR “low birth weight” OR LBW OR preemie OR preemies OR preterm 1940 items as of Oct 2018
- 96 VitaminDWiki pages contained PRETERM or PREEMIE in title as of Aug 2021
- "SUDDEN INFANT DEATH" OR SIDS 214 items as of Dec 2020
- Overview of Rickets and Vitamin D
- Youth category listing has
166 items along with related searchesFrench pediatric consensus: 30 – 60 ng of Vitamin D – Feb 2022 959 visitors, last modified 21 Mar, 2022,This page is in the following categories (# of items in each category)