Prophylaxis of vitamin D deficiency — Polish Recommendations 2009

Profilaktyka dotyczaca niedoborow witaminy D — polskie zalecenia 2009

SZKOLENIE PODYPLOMOWE/POSTGRADUATE EDUCATION
Endokrynologia Polska/Polish Journal of Endocrinology Tom/Volume 61; Numer/Number 2/2010 ISSN 0423-104X

(PDF is attached at the bottom of this page. Text is extracted for ease of translation to other languages)

Adequate vitamin D intake and its status are important not only for bone health and Ca-P metabolism, but for optimal function of many organs and tissues throughout the body. Due to documented changes in dietary habits and physical activity levels, both observed in growing children and adults, the prevalence of vitamin D insufficiency is continuously increasing. National consultants and experts in the field have established some Polish recommendations for prophylactic vitamin D supplementation in infants, toddlers, children, and adolescents as well as in adults, including pregnant and lactating women basing on a review of current literature. (Pol J Endocrinol 2010; 61 (2): 228-232)

Odpowiedni stan zaopatrzenia ustroju w witamine- D jest istotny nie tylko dla prawidlowego funkcjonowania uktadu szkieletowego i utrzymania homeostazy wapniowo-fosforanowej, ale rowniez funkcji wielu innych narzadow i tkanek w naszym organizmie. W zwiazku ze zmiana stylu zycia obejmujaca zmiane nawykow zywieniowych, powszechne stosowanie filtrow UV oraz mniejsza aktywnosc na swiezym powietrzu obserwuje si§ wzrost odsetka niedoborow witaminy D w populacji zarowno wieku rozwojowego, jak i u osob doro-slych. Opierajac sie na wynikach najnowszych badan naukowych, zespol ekspertow przedstawia polskie zalecenia dotyczace profilak-tycznej podazy witaminy D u niemowlat, dzieci, mlodziezy i doroslych, w tym kobiet ciezarnych i karmiacych piersia. (Endokrynol Pol 2010; 61 (2): 222-232)
Stowa kluczowe: witamina D, profilaktyka

Members of Recommending Committee

• Prof. Jadwiga Charzewska — Head of the Department of Epidaemiology and Norms of Nutrition, National Food and Nutrition Institute
• Prof. Danuta Chlebna-Sokol — Chairman of Section of Bone Metabolic Diseases in Children and Adolescents, Polish Foundation of Osteoporosis
• Prof. Alicja Chybicka — President of Polish Paediatric Society
• Dr n. med. Justyna Czech-Kowalska — Head of the Neonatal Unit, Children's Memorial Health Institute
• Prof. Anna Dobrzanska — National Consultant in Paediatrics
• Prof. Ewa Helwich — National Consultant in Neo-natology
• Dr hab. n. med. Jacek R. Imiela — National Consultant in Internal Diseases
• Dr n. przyr. Elzbieta Karczmarewicz — Head of Pathophysiology Unit, The Children's Memorial Heath Institute
• Prof. Janusz B. Ksiazyk — Head of the Paediatrics and Nutrition Clinic, Children's Memorial Health Institute
• Prof. Andrzej Lewinski — National Consultant in Endocrinology
• Prof. Roman S. Lorenc — President of Interdisciplinary Osteoporotic Forum, Member of the Bard of IOF and ISCD
• Prof. Witold Lukas — National Consultant in Family Medicine
• Prof. Jacek Lukaszkiewicz — Member of Scientific Board of the Pharmaceutical Faculty, Warsaw Medical University
• Prof. Ewa Marcinowska-Suchowierska — Head of the Family Medicine and Internal Diseases Clinic, The Medical Centre of Postgraduate Medicine
• Prof. Andrzej Milanowski — Head of the Department of Paediatrics, Mother and Child Institute
• Prof. Andrzej Milewicz — President of the Polish Society of Endocrinology
• Dr n. med. Pawel Pludowski — Head of Department of Biochemistry and Experimental Medicine, The Children's Memorial Heath Institute
• Prof. Ewa Pronicka — Member of the Human Development Committee at the Polish Science Academy, Member of SSIEM
• Prof. Stanislaw Radowicki — National Consultant in Gynaecology and Obstetrics
• Prof. Jozef Ryzko — Head of the Gastroenterology, Hepatology and Immunology Clinic at the Children's Memorial Health Institute
• Prof. Jerzy Socha — Head of the Children's and Adolescents' Nutrition Committee, Polish Academy of Science
• Prof. Jerzy Szczapa — President of the Polish Neonatal Society
• Doc. Halina Weker — Head of the Nutrition Department, Mother and Child Institute

Introduction

There is a great deal of concern about the continuously increasing prevalence of vitamin D insufficiency in different age groups in the Polish population [1-3]. Vitamin D deficiency may cause not only rickets, osteomalacia, and osteoporosis but also may increase risk of many others diseases, e.g. diabetes, cancers (breast, colon, prostate), autoimmunological disease (multiple sclerosis, rheumatoid arthritis, lupus), cardiovascular diseases, and metabolic syndrome [3]. Taking into consideration pleiotropic vitamin D action and safety aspects, maintaining appropriate vitamin D status is a crucial issue.

Serum 25- hydroxyvitamin D level (25-OHD — the main circulating vitamin D metabolite — is used to classify vitamin D status.
Serum 25-OHD levels of
20-60 ng/mL (50-150mmol/L) in children and
30-80 ng/mL (75-200 nmol/L) in adults)) are considered optimal [3-8].

Adequate vitamin D and calcium supply (Table I) as well outdoor physical activity are essential for appropriate bone growth and mineralization, and civilization diseases risk reduction. A diversified diet rich in food containing large amounts of calcium and vitamin D including milk, dairy products, and fish is extremely important (Tables II, III). If dietary vitamin D and calcium consumption are insufficient, the use of pharmacological preparations are essential.

Exposure to sunlight—inducing vitamin D production in the skin—is the main endogen source of vitamin D in the body. Importantly, the sunscreens which are widely used nowadays may reduce skin synthesis by 90% [3, 9]. In Poland, skin synthesis is effective from April to September if there is exposure of 18% of the body surface to the sun (uncovered forearms and partly uncovered legs) without using sunscreen for 15 minutes a day between 10 a.m. and 3 p.m. [6, 10]. There is no skin synthesis from October to March [3, 6, 10]. We should balance the advantages and disadvantages of sun exposure providing appropriate vitamin D status,

Table I. Calcium supply (sufficient intake) in age groups [7]
   Tabela I. Podaz wapnia (zvystarczajqce spozycie) w grupach wiekowych [7]
Table II. Foods with calcium content (240 mg) equal to one medium glass of milk [8]
   Tabela II. Produkty zywnosciowe odpowiadajqce pod wzgledem zawartosci wapnia (240 mg) jednej sredniej szklance mleka [8]
Table III. Vitamin D content of foods [8]
   Tabela III. Zawartosc witaminy D w polskich produktach zywnosciowych [8]

Recommendations

1. Term newborns

• all newborns should be supplemented with 400 IU/d of vitamin D beginning from the first few days of life

2. Preterm newborns

• vitamin D supplementation should be introduced from the first few days of life (if enteral feeding is possible) and followed up to the corrected age of 40 weeks post conception;
• total vitamin D intake from all sources should be 400-800 IU/day [5, 11, 12] (in the case of formula feeding or breast milk with fortifier feeding, the regimen take into account vitamin D intake from the diet);
• subsequent (beyond 40 weeks post conception) vitamin D dose should be 400 IU/d, as in term infants.

3. Term infants

• breastfed infants should be supplemented with 400 IU/d of vitamin D*
  Breastfeeding mother supplementation with vitamin D up to 2000 IU/d does not require any change in the infant's vitamin D dosage [13, 14]
• formula fed infants should be supplemented with 400 IU/d of vitamin D (total intake from diet and supplements).
• if formula consumption ensures 400 IU/d (about 1000 mL of beginning formula and about 700-800 mL of follow-up formula), additional vitamin D supplementation is not necessary.
• in the case of mixed feeding (mother's milk and formula milk), the dosage of vitamin D should be defined by a physician,
  taking into account vitamin D intake from the formula.
  Vitamin D intake from human milk may be omitted because of its very low vitamin D concentration (about 50 IU/L).

4. Children and adolescents (2-18 years)

• total vitamin D intake from all sources (diet and/or supplements) should be 400 IU/d between October and March,
  and throughout the whole year in the case of inadequate vitamin D skin synthesis during the summer time;
• in overweight/obese children, supplementation with a higher dosage of vitamin D 800-1000 IU/d should be considered.

5. Adults

• total vitamin D intake from all sources (diet and/or supplements) should be 800-1000 IU/day between October and March,
  and throughout the whole year in the case of inadequate vitamin D skin synthesis during the summer time.
• in patients over 65 years of age, due to reduced skin synthesis and the evidenced anti-fracture and anti-fall effect,
  supplementation with 800-1000 IU/d of vitamin D throughout the year is recommended.

6. Pregnant and lactating women

• it is important to ensure proper vitamin D resources before planning pregnancy;
• vitamin D intake in a dose of 400 IU/d (equal to that derived from multivitamin supplements for pregnant/lactating women)
  is not sufficient to build appropriate vitamin D status in pregnant/lactating women and their offspring [3-5, 14];
• supplementation with 800-1000 IU/d of vitamin D beginning in the second trimester of pregnancy is recommended in cases of inadequate intake from diet and/or skin synthesis;
• determination of vitamin D status should be considered by measurements of serum 25(OH)D level to define the optimal dosage and assess the efficacy of supplementation.
  The goal of the supplementation is to obtain and maintain 25-OHD level > 30 ng/mL. Monitoring of serum calcium and its urinary excretion should be also considered;
• some authors emphasize the need for vitamin D supplementation with more than 1000 IU/d [3-5, 13, 14].

7. Treatment of severe vitamin D deficiency [6, 8, 9]

• Severe vitamin D deficiency (25-OHD < 10 ng/ml) requires treatment dosage for 3 months.
• < 1month of age — 1000 IU/d;
• 2-12 months of age — 1000-3000 IU/d;
• Children >1 year of age — 5000 IU/d;
• Adults — up to 7000 IU/d;
• Serum 25-OHD, alkaline phosphatase activity, calcium, and calciuria should be assessed every 1-3 months.

A summary of current recommendations is summarized in the algorithm.

Attention!

The Recommendation Committee underlines the lack of substantive background to change vitamin D dosage, taking into account exclusively the crown of the head, delayed dentition, delayed appearance of nucleuses of ossification in the head of the femur, craniotabes, and excessive sweating. Craniotabes in healthy infants receiving recommended vitamin D dose does not allow the diagnosis of rickets. Craniotabes could be secondary to excessive phosphate supply in the diet and are also seen in completely healthy infants with high body weight gains. If there is any doubt about vitamin D status, assessment of calcium-phosphorus homeostasis and 25-OHD levels should be assayed. If rickets is suspected, radiogram of the wrist should be done additionally.

References

1. Andersen R, Molgaard C, Skovgaard LT et al. Teenage girls and elderly women living in northern Europe have low Winter vitamin D status. Eur J Clin Nutr 2005; 59: 533-541.
2. Czech-Kowalska J, Dobrzanska A, Janowska J et al. Zasoby ustrojowe witaminy D a homeostaza wapniowo- fosforanowa u noworodkow donoszo-nych w 3 tygodniu zycia. Med Wiek Rozw 2004; 8: 115-124.
3. Pludowski P, Karczmarewicz E, Czech-Kowalska J et al. Nowe spojrzenie na suplementacj - witaminy D. Stand Med 2009; 1: 23 -1.
4. Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 2008; 122: 1142-1152.
5. Godel JC and First Nations, Inuit and Health Committee, Canadian Paediatric Society. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatrics & Child Health 2007; 12:583-589.
6. Holick MF. Vitamin D deficiency. NEJM 2007; 357: 266-281.
7. Lips P. Which circulating level of 25-hydroxyvitamin D is appropriate? J of Steroid Bioch & Molecular Biol 2004; 89-90: 611-614.
8. Heaney RP. Vitamin D: criteria for safety and efficacy. Nutr Rev 2008; 66 (Suppl. 2): 178S-1S.
9. Misra M, Pacaud D, Petryk A et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendation. Pediatrics 2008; 122: 398-417.
10. Webb AR, Kline Z, Holick MF. Influence of season and latitude on the coetaneous synthesis of vitamin D3 in human skin. J Clin Endocrinol Metab 1988; 67: 373-378.
11. Wesol-Kucharska D, Laskowska J, Sibilska M et al. Zapobieganie osteope-nii wczesniakow. Med Wiek Rozw 2008; 12: 926-934.
12. Rigo J, Pieltain C, Salle B et al. Enteral calcium, phosphate and vitamin D requirements and bone mineralization in preterm infants. Acta Paediatr 2007; 96: 969-974.
13. Hollis BW, Wagner CL. Vitamin D requirements during lactation: high -dose maternal supplementation as a therapy to present hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr 2004; 80 (Suppl.): 1752S-1758S.
14. Taylor SN, Carol L, Wagner MD Et al. Vitamin D supplementation during lactation to support infant and mother. J Am Col Nutr 2008; 27: 690-701.

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See also VitaminDWiki

• Conference on Vitamin D in Poland - Oct 2012
• Finland hopes to double Vitamin D dose for elderly from 400 to 800 IU in 2012
• [https://www.vitamindwiki.com/tiki-browse_categories.php?parentId=103&sort_mode=created_desc

  All items in category Europe and Vitamin D]

  *Vitamin D before, during, and after pregnancy Overview which has the following table May 2012

  IU| Cumulative Benefit | Blood level| Co-factors|Calcium| $*/year

400 | Less Rickets
3X less adolescent Schizophrenia
Fewer child seizures| 20-30 ng/ml| Not needed| No effect| $3
2000 | 2X More likely to get pregnant naturally/IVF
2X Fewer dental problems with pregnancy
8X less diabetes
4X fewer C-sections (>37 ng)
4X less preeclampsia (40 ng vs 10 ng)
5X less child asthma
2X fewer language problems age 5 | 42 ng/ml | Desirable| < 750 mg| $15
4000| 2X fewer pregnancy complications
2X fewer pre-term births| 49 ng/ml | Must have
co-factors| < 750 mg| $75
6000 |Probable: larger benefits for above items
Perhaps prevent 2nd autistic child
   clinical trials underway
Just enough D for breastfed infant| |Must have
co-factors| < 750 mg| $85||

• Vitamin D Recommendations from around the world which includes many graphics, such as