Less than half of health providers recommend 600 to 1000 IU of vitamin D (age 1-18) – May 2018

Vitamin D Prescribing Practices in Primary Care Pediatrics: Underpinnings From the Health Belief Model and Use of Web-Based Delphi Technique for Instrument Validity

Journal of Pediatric Health Care, online 24 May 2018, https://doi.org/10.1016/j.pedhc.2018.03.003
Nancy J. DelGiudice, DNP, RN, CPNP-PC, , Nancy Street, ScD, PPCNP-BC, Ronald J. Torchia, BS CE, MS EE, Susan S. Sawyer, PhD, RN, CPNP, Sylvia Allison Bernard, DNP, RN,

Vitamin D deficiency and insufficiency is a pandemic problem in children and adolescents in the United States. The problem may be aggravated by the inconsistent implementation of current clinical practice guidelines for vitamin D management by pediatric primary care providers. This study examines the relationship between primary care providers' prescribing vitamin D to children ages 1 through 18 years and their practice actions and knowledge. A descriptive correlation design was used. Participants were recruited from a purposive sample of pediatricians and pediatric nurse practitioners through an online invitation to participate in a survey. Reliability and validity was established for the survey developed by the principal investigator using a web-based Delphi technique.

Results from this study indicate that although most providers are aware that vitamin D insufficiency and deficiency are problems, fewer than half currently recommend 600- to 1,000-IU supplementation to their patients ages 1 through 18 years.

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• Children need vitamin D - good global overview, poor recommendations for Italian children - May 2018
• Children getting 60,000 IU monthly got to vitamin D level of 33 ng – Sept 2015
  • which is about 2,000 IU daily, double of what the maximun that the survey found half to provide
• Russian children need 2,000-4,000 IU of Vitamin D to get most above 40 ng - Dec 2017
• Breastfed infant bones not helped by 800 IU of Vitamin D (not enough) – RCT Dec 2017
• Children helped by 2,000 IU of vitamin D, but not RDA amount (600 IU) – RCT Sept 2017

Infant-Child category starts with

• 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

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Heavier than Children (adults)

• 2000 IU of vitamin D- doctors trained that it was too much, but it is often too little
• 6,000 IU needed for many to achieve 40 ng of Vitamin D - Feb 2017
• 1000 IU should be the new vitamin D RDA (if you think 20 ng is enough) - May 2017
• Vitamin D supplementation guidelines (adults – 50,000 IU per week) – Feb 2017
• Review of vitamin D recommendations around the world – April 2017

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17 reasons why are doctors reluctant to accept vitamin D has the following

#Myth: Excess vitamin D will turn the human body into marble

+Until recently medical students were told that > 2,000 IU of vitamin D could cause toxicity and Calcifications +It is difficult to unlearn something. +See Myth for 50 years: 2000 IU of vitamin D is toxic - still taught as fact in 2010

• Williams Syndrome mistaken diagnosis
• Or. perhaps due to a ancient translation error 1000 IU of vitamin D (per kg) can indeed be toxic – 1947

1. Would require ignoring the position of the medical profession on supplements.
   Medical societies first supported then reversed themselves on the need for supplements
   Doctors got burned by first telling patients to take supplement X and then later having the patients stop taking supplement X
   Doctors are reluctant to endure yet another supplement reversal
    
2. Risk being sued if exceed guidelines
   Increase risk of being sued for Malpractice if exceeds current medical guidelines
   Example: prescribe 6,000 IU of vitamin D during pregnancy instead of the 400 IU in most guidelines
    
3. Experts do not agree on how much is needed
   There is a worldwide agreement that 400 IU of vitamin D is needed to prevent Rickets, but little else is agreed upon
   (Raised to 600 IU in the US in 2010, most countries are still at 400 IU, and some are still at 200 IU)
   Some improvement: 4,000 IU of Vitamin D is OK - 19 organizations agree - 2018
    
4. Doctors are rarely been trained in nutrition
   When I went to medical school, nutrition was not really on the radar,
       and taking vitamins was even trivialized by some as a great way to “make expensive urine.”
   Vitamin D is arguably the most complex supplement - the amount needed varies with:
      Weight, Skin color, Latitude, Season, Co-factors, Current meal, Recent surgery/trauma, Neighborhood, etc.
       see also Why isn’t nutrition a bigger part of conventional medical school education? The question at Research Gate 2013 with > 400 responses
    
5. Medical training has an emphasis on treatment, not prevention
   Medical training and practice emphasizes treatment, not prevention.
   The primary benefit of vitamin D is prevention. (but Vitamin D does treat 70+ diseases) but typically need >5,000 IU
   They have learned that most patients are either reluctant to change so as to prevent a future problem (lose weight, stop smoking, . . )
   or will often not continue with the change. So why should the doctor try?
    
6. Doctors have tried prescribing small vitamin D doses recommended by govts., but with minimal success
   A frequent sequence of events:
   1) A doctor hears that people might have low Vitamin D
   2) The doctor recommends a vitamin D test for some of his patients
   3) The test result often shows low
   4) The doctor prescribes the RDA (far too little)
   5) Retesting finds that the levels did not rise and patient-reported no health improvement (too little dose or test too soon)
   6) The country/health profession decides that tests are costly and do not improve health
7. Doctors often can only prescribe D2 anyway (true in US before March, 2012)
   Kaiser Health research continues to only use Vitamin D2 (2019)
   Some doctors are aware that D2 does not help nearly as much as D3
   And, in some cases, Vitamin D2 actually lowers levels of D3
    
8. Doctors have too little time to read outside of their specialty
    
9. Seems like too much of a “wonder drug”
   ‘Nothing can be that great’
    
10. Fear possible loss of income
    If Vitamin D is truly a ‘wonder drug’, it would reduce the number of patient visits, and therefore reduce income.
    Note: in 2012 one doctor reduced patient visits from 4 per year to 1 per year by getting all 2,000+ patients to have >80 ng     Net result of vitamin D: Lost too much business and retired early.
    • "It is difficult to get a man to understand something when his salary is dependent upon his not understanding it”  Upton Sinclair
    • See also Do not expect a doctor to recommend a pill which will eliminate his job (vitamin D)
    • Note: getting everyone >40 ng should not endanger medical jobs the way that >80 ng does
11. Might fear the loss of control and respect if people can deal with some of their own health problems
     
12. No profit for Big Pharma, so doctors not rewarded
     
13. The Vitamin D dose needed often varies by 4X between individuals for many health problems
    Doctors prefer using a single dose of a drug for all patients
     
14. Doctors are uncomfortable prescribing 4,000+ IU of vitamin D
     
15. in many countries doctors can only prescribe D2 (which does not work as well), not D3
     
16. Doctors often just want to use a monotherapy
    Reluctant to also prescribe Zinc or Resveratrol or Magnesium or Omega-3. etc. when needed

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See also VitaminDWiki

• Would you be opposed to my getting more vitamin D a question to your doctor that minimizes his risk
• 20 reasons for not taking Vitamin D debunked
• Do not expect your doctor to know about vitamin D
• Do not expect a doctor to recommend a pill which will eliminate his job (vitamin D)
• Overview Evidence for vitamin D
• Curing patients is not a sustainable business model – Goldman Sachs – April 2018
• VITAMIN D: Public Shouldn’t Wait For Doctors To Usher In New “Golden Era” Of Preventive Medicine
• Let 1000 die from vitamin D deficiency rather than incur 1 lawsuit
• Should people at high risk for vitamin D deficiency wait 5 years -Feb 2013
• Survey Shows Dogma Not Data Can Dictate Doctors' Decisions - June 2010
• Consensus Vitamin D category listing has 70 items along with related searches
• Hospitals do not want to lose income
  • Insurance companies would also lose income if medical costs were reduced since their income is a % of the billing

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