Children low on vitamin D were 2X more likely to have diarrhea and vomiting - June 2013

www.medscape.com

Vitamin D Deficiency Associated With Increased Incidence of Gastrointestinal and Ear Infections in School-age Children

Kathryn A. Thornton, DMD, MPH, Constanza Marín, RD, Mercedes Mora-Plazas, MSc, RD, Eduardo Villamor, MD, DrPHPediatr Infect Dis J. 2013;32(5):585-593.

Abstract

Background: Vitamin D deficiency (VDD) is highly prevalent among children worldwide. The effects of VDD include alterations of the immune response and increased risk of infection but little evidence exists in school-age children. We investigated the association of vitamin D status with morbidity in a prospective study of school-age children from Bogotá, Colombia.

Methods: We measured plasma 25-hydroxyvitamin D (25(OH)D) concentrations in a random sample of 475 children (mean ± standard deviation age: 8.9 ± 1.6 years) and followed them for an academic year. Caregivers were asked to record daily information on the incidence of morbidity episodes using pictorial diaries. Baseline vitamin D status was classified according to 25(OH)D concentrations as deficient (<50 nmol/L), insufficient (≥50 and <75 nmol/L) or sufficient (≥75 nmol/L). We used Poisson regression to estimate incidence rate ratios and 95% confidence intervals for days with diarrhea, vomiting, diarrhea with vomiting, cough with fever and earache or discharge with fever, comparing vitamin D-deficient with vitamin D-sufficient children. Estimates were adjusted for child's age, sex and household socioeconomic status.

Results: The prevalence of VDD was 10%; an additional 47% of children were vitamin D-insufficient. VDD was associated with increased rates of diarrhea with vomiting (adjusted incidence rate ratio: 2.05; 95% confidence interval: 1.19, 3.53) and earache/discharge with fever (adjusted incidence rate ratio: 2.36; 95% confidence interval: 1.26, 4.44). VDD was not significantly related to cough with fever.

Conclusions: These results suggest that VDD is related to increased incidence of gastrointestinal and ear infections in school-age children. The effect of correcting VDD on reducing risk of these infections needs to be tested in supplementation trials.

Introduction

Inadequate vitamin D status is highly prevalent in children worldwide, even in equatorial regions where it had not been previously suspected. In Latin America, reported prevalence of vitamin D insufficiency and deficiency among children and adolescents ranges from 28% in Costa Rica¹ to 56% in Bogotá, Colombia² and 62% in São Paulo, Brazil.³ Emerging evidence suggests that the consequences of vitamin D deficiency (VDD) extend beyond its well-known effects on bone metabolism and calcium homeostasis, and also include alterations of specific arms of immunity. The immunomodulatory properties of vitamin D may influence susceptibility to infection.⁴ These effects are primarily mediated through the vitamin D receptor (VDR),⁵ which is expressed in many cells of the immune system, including T and B lymphocytes, neutrophils, monocytes, macrophages and dendritic cells.^6–10

Recent epidemiologic studies indicate that low plasma vitamin D concentrations are related to increased incidence of respiratory infections, including acute lower respiratory tract infections^11–14 and respiratory syncytial virus (RSV) disease¹⁵ in infants and children less than 5 years of age. Furthermore, vitamin D supplementation in randomized controlled trials conducted among schoolchildren resulted in reduced incidence of influenza A infection¹⁶ and acute respiratory infection.¹⁷ In another trial among Afghan children less than 3 years of age, vitamin D supplementation decreased the risk of pneumonia;¹⁸ nevertheless, a larger randomized controlled trial showed no effect among infants from the same setting.¹⁹

Infection is a significant cause of morbidity throughout childhood.²⁰ Among school-age children, respiratory and gastrointestinal infections account for increased school absenteeism and parental absenteeism from work,²¹ as well as a sizeable proportion of physician visits.^22,23 However, relatively little is known about the effect of vitamin D on infection-related morbidity in children more than 5 years of age. We conducted a prospective study to investigate the association between VDD and morbidity among school-age children in Bogotá, Colombia. We hypothesized that vitamin D-deficient children are at increased risk of gastrointestinal and respiratory morbidity.

Materials and Methods

Study Population

This study was conducted in the context of the Bogotá School Children Cohort, an ongoing longitudinal investigation of health and nutrition in school-age children. Details on the cohort design²⁴ and vitamin D substudy² have been previously reported. Briefly, in February 2006, we recruited a randomly selected group of 3202 children aged 5–12 years who were enrolled in public primary schools in Bogotá. Because the public school system enrolls a majority of children from low-income and middle-income families in the city,²⁵ the sample is representative of children from these strata living in Bogotá. Information on sociodemographic characteristics and health habits of the children and their families was elicited from parents through a self-administered questionnaire at the time of enrollment (82% response). Anthropometric measurements and fasting blood samples were obtained from the children by trained research assistants who visited the schools in the following weeks. Using standardized techniques,²⁶ weight was measured to the nearest 0.1 kg with Tanita HS301 electronic scales (Tanita, Arlington Heights, IL), and height was measured to the nearest 1 mm with wall-mounted Seca 202 stadiometers (Seca, Hanover, MD).

During the academic year after enrollment into the cohort, parents or primary caregivers recorded daily information on the incidence of morbidity episodes using a pictorial diary that was distributed and returned weekly. The diaries have drawings that depict children with symptoms including vomiting, diarrhea, fever, stomach ache, cough and earache/discharge. Caregivers were asked to check each day the child demonstrated these symptoms. Recording in diaries does not require a high level of education, and previous studies suggest that they are adequate to capture incidence of morbidity in developing countries.^27–29

The parents or primary caregivers of all children gave ritten informed consent prior to enrollment into the study. The study protocol was approved by the Ethics Committee of the National University of Colombia Medical School. The Institutional Review Board at the University of Michigan approved the use of data and samples from the study.

Laboratory Methods

Blood samples were collected by venipuncture in 2816 (88%) children at baseline, during the month of February 2006. This month is considered part of a slightly warmer time of year in Bogotá, but there is no substantial seasonal variation within the samples' collection period. Packed in ice and protected from sunlight, the samples were transported to the National Institute of Health (Bogotá, Colombia) where plasma was separated from an ethylenediaminetetraacetic acid-coated aliquot and cryopreserved at -70°C until transportation to the United States. Quantification of plasma 25-hydroxyvitamin D (25(OH)D), a biomarker of vitamin D status,³⁰ was completed in 479 randomly selected samples at the Clinical and Epidemiologic Research Laboratory of Children's Hospital Boston (Boston, MA). An enzyme immunoassay (Immunodiagnostics Systems Inc, Scottsdale, AZ) with a competitive binding technique was used to quantify concentrations of plasma 25(OH)D. The assay has a sensitivity of 5 nmol 25(OH)D/L, intraclass coefficient of variation (CV) of 5.3–6.7% and interclass CV of 4.6–8.7%. Samples were analyzed in duplicate.

Data Analysis

Vitamin D status, the main exposure of interest, was categorized according to plasma 25(OH)D concentrations as deficient (<50 nmol/L), insufficient (≥50 and <75 nmol/L) or sufficient (≥75 nmol/L).³¹ The primary outcomes were rates of gastrointestinal and respiratory morbidity, including diarrhea, vomiting, diarrhea with vomiting, cough with fever and earache or ear discharge with fever. Report of these symptoms has been related to clinically diagnosed episodes of gastrointestinal and respiratory infections.^32–34 Rates were calculated as the number of days with each symptom or combination of symptoms divided by the number of days the child was under observation.

Four children without morbidity diaries were excluded from the analyses; thus, the final sample size was 475. To identify potential confounders of the association between vitamin D and morbidity, we first compared the distribution of baseline child and maternal characteristics according to vitamin D serostatus with the use of Cochran-Armitage and Wald tests for trend. Children's height-for-age Z scores and body mass index-for-age Z scores were estimated according to the World Health Organization reference.³⁵ Maternal body mass index was calculated with measured height and weight in 26% of mothers and from self-reported data in the remaining. Household socioeconomic status corresponded to the government's assigned stratum to each household for tax and planning purposes.

Next, we estimated incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for morbidity among children with VDD and insufficiency compared with those who were vitamin D-sufficient using Poisson regression models with the log-link function. Adjusted estimates were obtained from multivariable models that included child's age, sex and household socioeconomic status as covariates. We assessed whether the associations of vitamin D with morbidity differed between girls and boys by testing an interaction term between vitamin D status and sex with use of the likelihood ratio test. All analyses were conducted with Statistical Analysis System software (version 9.2; SAS Institute Inc, Cary, NC).

Results

The mean (± standard deviation) age of children at recruitment was 8.9 ± 1.6 years, and 52% of children were girls. The mean (± standard deviation) plasma concentration of 25(OH)D was 73.2 ± 19.8 nmol/L; 10.1% of children were vitamin D-deficient, whereas 46.7% of children were vitamin D-insufficient. Children contributed 62,642 days of observation with a median (interquartile range) 140 (91, 182) days per child; the distribution of total child-days did not vary significantly by vitamin D status. At baseline, vitamin D serostatus was inversely associated with female sex, age, body mass index-Z and single mother status ().

Table 1. Distribution of Sociodemographic Characteristics According to Vitamin D Status in School-age Children From Bogotá, Colombia

Vitamin D-deficientVitamin D-insufficientVitamin D-sufficientP*
25(OH)D <50 nmol/L25(OH)D ≥50 and <75 nmol/L25(OH)D ≥75 nmol/L
Total (n)	48	222	205
Child characteristics
Girls (%)	62.5	57.2	44.9	0.004
Age (yr)	9.2 ± 1.8	9.1 ± 1.5	8.6 ± 1.6	0.001
Stunted^† (%)	12.5	9.6	7.0	0.4
BMI-for-age Z score^‡	0.3 ± 1.2	0.2 ± 1.0	0.0 ± 1.0	0.02
Time spent playing outdoors (h/wk)	6.6 ± 8.7	7.3 ± 7.9	7.4 ± 8.4	0.6
Maternal characteristics
Single mother (%)	35.4	27.7	17.0	0.002
Education (yr)	8.5 ± 3.5	8.5 ± 3.3	8.7 ± 3.4	0.5
BMI (kg/m²)	24.6 ± 4.6	24.8 ± 4.0	24.0 ± 3.9	0.09
Lowest socioeconomic strata (%)^§	52.1	37.1	41.0	0.5

For all binary variables except stunting, P value is from the Cochran-Armitage test for trend. For stunting, P value is estimated with Fisher exact test. For continuous characteristics, P value was from a test for linear trend for a variable representing 25(OH)D categories as continuous.

^†Height-for-age Z score less than −2.0 according to the World Health Organization (WHO) reference.³⁵

^‡According to the WHO reference.³⁵

^§Strata 1 or 2 of a maximum of 4 in the sample, according to the government's classification of households for tax and planning purposes.

BMI indicates body mass index.

Children with VDD had higher rates of vomiting, diarrhea with vomiting and earache or ear discharge with fever than vitamin D-sufficient children (). Compared with children who were vitamin D-sufficient, those who were deficient had twice as many days with diarrhea and vomiting after adjustment for child's age, sex and household socioeconomic status (P = 0.009). In addition, vitamin D-deficient children had 2.4 times as many days with earache or ear discharge with fever compared with vitamin D-sufficient children (P = 0.008). This association was particularly strong among boys (adjusted IRR: 5.74; 95% CI: 2.32, 14.18) compared with girls (adjusted IRR: 1.09; 95% CI: 0.46, 2.60; P test for interaction with sex = 0.001).

Table 2. Morbidity According to Vitamin D Status in Colombian Schoolchildren

Vitamin D-deficientVitamin D-insufficientVitamin D-sufficient
<50 nmol/L≥50 and <75 nmol/L≥75 nmol/L
Total (n)	48	222	205
Child-days of observation	6707	29,723	26,212
Diarrhea
Days with symptom	78	342	275
Rate per child-year	4.24	4.20	3.83
Unadjusted rate ratio (95% CI)	1.11 (0.86, 1.43)	1.10 (0.94, 1.29)	1.0
Adjusted rate ratio (95% CI)*	1.17 (0.90, 1.52)	1.00 (0.85, 1.18)	1.0
Vomiting
Days with symptom	99	302	276
Rate per child-year	5.39	3.71	3.84
Unadjusted rate ratio (95% CI)	1.40 (1.11, 1.76)	0.97 (0.82, 1.14)	1.0
Adjusted rate ratio (95% CI)	1.30 (1.02, 1.66)	0.86 (0.72, 1.01)	1.0
Diarrhea with vomiting
Days with symptom	21	47	46
Rate per child-year	1.14	0.58	0.64
Unadjusted rate ratio (95% CI)	1.78 (1.06, 2.99)	0.90 (0.60, 1.35)	1.0
Adjusted rate ratio (95% CI)	2.05 (1.19, 3.53)	0.92 (0.61, 1.39)	1.0
Earache/discharge with fever
Days with symptom	16	16	35
Rate per child-year	0.87	0.20	0.49
Unadjusted rate ratio (95% CI)	1.79 (0.99, 3.23)	0.40 (0.22, 0.73)	1.0
Adjusted rate ratio (95% CI)	2.36 (1.26, 4.44)	0.35 (0.19, 0.65)	1.0
Cough with fever
Days with symptom	55	177	253
Rate per child-year	2.99	2.17	3.52
Unadjusted rate ratio (95% CI)	0.85 (0.63, 1.14)	0.62 (0.51, 0.75)	1.0
Adjusted rate ratio (95% CI)	0.77 (0.57, 1.04)	0.53 (0.44, 0.65)	1.0

From Poisson regression models adjusted for child's age, sex and household socioeconomic stratum

We noted that vitamin D-insufficient (25(OH)D ≥50 and <75 nmol/L) children had lower rates of earache or ear discharge with fever and cough with fever, compared with children with 25(OH)D ≥75 nmol/L. The relation with cough and fever was mainly apparent in girls; vitamin D-insufficient girls reported 66% fewer days of cough with fever than girls who were vitamin D-sufficient (adjusted IRR: 0.34; 95% CI: 0.26, 0.43), whereas no significant association was observed in boys (adjusted IRR: 1.10; 95% CI: 0.81, 1.50; P test for interaction with sex < 0.0001).

Discussion

In this prospective study of school-age children, VDD was associated with increased rates of vomiting, diarrhea with vomiting and earache or ear discharge with fever. These associations persisted after adjustment for potential confounders, including age, sex and socioeconomic status.

The association of VDD with diarrhea and vomiting could represent an effect on incidence or severity of gastrointestinal infections. Diarrhea and vomiting are symptoms often present in children with acute viral and bacterial gastrointestinal infections.^36–40 Norovirus infection is a common cause of diarrhea with vomiting or vomiting alone in school-age children.^41–43 These symptoms are likely the result of the virus's pathogenic effects on the intestinal epithelial barrier.⁴⁴ A protective effect of vitamin D in the course of norovirus infection could be related to VDR-mediated upregulation of tight junction proteins expressed in the intestinal epithelium.^45,46 Bacterial agents, such as Salmonella and Shigella, also cause diarrhea and vomiting in school-age children.^47,48 Animal and in vitro studies have demonstrated that VDR expression is associated with reduced Salmonella colonization and mucosal invasion.⁴⁹Shigella can downregulate expression of antimicrobial peptides, a component of the innate immune system that serves as part of the first line of mucosal defense against invading pathogens.⁵⁰ On the contrary, vitamin D influences innate immunity through expression of the cathelicidin antimicrobial peptide gene as well as promotion of macrophage activity.^51,52 Thus, vitamin D-deficient children may be more susceptible to develop more severe symptoms or may be more likely to become infected with these microorganisms through different mechanisms that are likely pathogen-specific.

Few previous studies have reported on the potential effect of vitamin D on gastrointestinal infections in children (). Tanzanian children born to mothers with serum 25(OH)D <80 nmol/L during pregnancy had no increased risk of diarrhea over a median follow-up time of 58 months.⁵⁶ Vitamin D supplementation in a randomized controlled trial in school-age children did not reduce the incidence of gastroenteritis, a secondary outcome of the trial.¹⁶ Consistent with our findings, a cross-sectional study of 458 Qatari children reported a significantly higher prevalence of gastroenteritis among those who were vitamin D-deficient.⁶⁵ However, in this cross-sectional study, vitamin D status was measured concurrently with disease diagnosis; thus, the potential for reverse causation in which infection may have affected 25(OH)D concentrations cannot be excluded. Immune cells are able to alter vitamin D metabolism in several diseases.⁶⁸

Table 3. Epidemiologic Studies Evaluating the Relation of Vitamin D Serostatus With Infection Outcomes in Infants, Children and Adolescents

Author, Publication Year, ReferenceType of StudyLocationSample SizeAge of ChildrenHealth Status of ChildrenVitamin D Dosage/ExposureOutcomeResultsVariables Adjusted for
Morcos et al, 1998⁵³	RCT	Egypt	24	1.5–13 yr	Tuberculosis (TB)	Vitamin D3 (VD3) 1000 IU/d + TB treatment vs. TB treatment only for 2 mo	Improvement in TB signs and symptoms after 2 mo	VD3 group: more evident improvement clinically and on abdominal sonography compared with controls
Urashima et al, 2010¹⁶	RCT	Japan	430	6–15 yr	With or without underlying diseases	VD3 1200 IU/d vs. placebo daily for 4 mo	Influenza A, influenza B, influenza-like illness, pneumonia, gastroenteritis over 4 mo	VD3 group: ↓ influenza A (RR: 0.58; 95% CI: 0.34, 0.99; P = 0.04);

↔ influenza B, influenza-like illness, pneumonia, gastroenteritis
Manaseki- Holland et al, 2010¹⁸	RCT	Afghanistan	453	1–36 mo	Pneumonia	VD3 100,000 IU vs. placebo single dose	Pneumonia over 3 mo	↔ Duration of initial pneumonia episode (P = 0.2);

VD3 group: ↓ risk of (RR: 0.78; 95% CI: 0.64, 0.94; P = 0.01) and ↑ time to (HR: 0.71; 95% CI: 0.53, 0.95; P = 0.02) repeat episode of pneumonia
Camargo et al, 2012¹⁷	RCT	Mongolia	247	9–11 yr	Presumably healthy	VD3 300 IU/d in Mongolian milk vs. regular Mongolian milk daily for 7 wk	Parent-reported ARI over 3 mo	VD3 group: ↓ ARI (RR: 0.52; 95% CI: 0.31, 0.89)
Manaseki-Holland et al, 2012¹⁹	RCT	Afghanistan	3046	1–11 mo	Presumably healthy	VD3 100,000 IU vs. placebo every 3 mo for 18 mo	Pneumonia, hospital admissions, all-cause mortality over 18 mo	↔ Incidence (IRR: 1.07; 95% CI: 0.90, 1.27; P = 0.48) or severity (IRR: 1.13; 95% CI: 0.74, 1.73; P = 0.58) of pneumonia, hospital admissions, or all-cause mortality;

VD3 group: ↑ repeat pneumonia episodes (IRR: 1.69; 95% CI: 1.28, 2.21; P < 0.0001)
Mehta et al, 2009⁵⁴	Prospective cohort	Tanzania	884	Neonates	Born to HIV-infected women	Maternal serum 25(OH)D <80 nmol/L	HIV infection, mortality up to 2 yr of age	↑ HIV infection (RR: 1.46; 95% CI: 1.11, 1.91; P < 0.01) and mortality (RR: 1.58; 95% CI: 1.26, 1.97; P < 0.01)	Maternal age, HIV disease stage, CD4 cell counts at baseline, multivitamin regimen
Belderbos et al, 2011¹⁵	Prospective cohort	The Netherlands	156	Neonates	Healthy	Mean cord blood 25(OH)D; VDD*	RSV lower respiratory tract infection (LRTI) by 1 yr of age	Mean cord blood 25(OH)D: ↓ RSV LRTI (P = 0.02); VDD:↑ RSV LRTI (RR: 6.2; 95% CI: 1.6, 24.9; P = 0.01)	Birth month, birth weight, maternal ethnicity
Camargo et al, 2011⁵⁵	Prospective cohort	New Zealand	922	Neonates	Apparently healthy	Cord blood 25(OH) D <25 nmol/L	Respiratory infection, any infection by 3 mo of age	↑ respiratory (OR: 2.16; 95% CI: 1.35, 3.46) and any (OR: 2.21; 95% CI: 1.26, 3.90) infection	Season of birth
Finkelstein et al, 2012⁵⁶	Prospective cohort	Tanzania	609	Neonates	Born to HIV-infected women	Maternal serum 25(OH)D <80 nmol/L	Respiratory and gastrointestinal morbidity over median of 58 mo	↑ cough (RR: 1.11; 95% CI: 1.02, 1.21; P = 0.01); ↔ cough and fever (RR: 1.08; 95% CI: 0.93, 1.26; P = 0.29), other respiratory symptoms, or diarrhea (RR: 1.02; 95% CI: 0.87, 1.21; P = 0.79)	Maternal and child factors†
Morales et al, 2012⁵⁷	Prospective cohort	Spain	1693	Infants	Presumably healthy	Maternal plasma 25(OH)D in pregnancy	LRTI by 1 yr of age	↓ trend for LRTI across cohort and season-specific quartiles of maternal 25(OH)D (Q4 vs. Q1: OR: 0.67; 95% CI: 0.50, 0.90; test for trend, P = 0.02)	Sex, number of siblings, breastfeeding duration, day-care attendance; maternal education, smoking, prepregnancy BMI and asthma
Wayse et al, 2004¹²	Case-control	India	150	<5 yr	Severe acute lower respiratory tract infection (ALRI) vs. healthy controls	Serum 25(OH)D >22.5 nmol/L	Severe ALRI	↓ severe ALRI (OR: 0.09; 95% CI: 0.03, 0.24; P < 0.001)	Age, height-for-age Z score, breastfeeding history, hemoglobin level, sun exposure, cooking fuel
Stephensen et al, 2006⁵⁸	Case-control	United States	359	14–23 yr	HIV-infected vs. HIV-uninfected controls	Mean plasma 25(OH)D; plasma 25(OH)D <37.5 nmol/L	HIV infection	↔ mean plasma 25(OH)D (P = 0.62) or prevalence of plasma 25(OH)D <37.5 nmol/L (P = 0.91)	Sex, sex × HIV status
Karatekin et al, 2009¹⁴	Case-control	Turkey	40	Neonates	ALRI vs. healthy controls	Mean serum 25(OH) D; serum 25(OH) D <25 nmol/L or <50 nmol/L	ALRI	Mean serum 25(OH)D: lower in cases (P = 0.01); serum 25(OH) D <25 nmol/L: ↑ ALRI (OR: 4.25; 95% CI: 1.06, 17.07; P = 0.04); serum 25(OH)D <50 nmol/L: ↔ ALRI (P = 0.50)
McNally et al, 2009⁵⁹	Case-control	Canada	197	<5 yr	ALRI vs. hospital controls without respiratory symptoms	Mean serum 25(OH) D; VDD	ALRI	Mean serum 25(OH)D: ↔ (P = 0.71); VDD:↑ admission to pediatric intensive care unit for ALRI (OR: 8.23; 95% CI: 1.4, 48.0; P = 0.02)	Age, sex, prematurity status
Roth et al, 2009⁶⁰	Case-control	Canada	129	1–25 mo	ALRI vs. controls undergoing elective surgery with no history of ALRI	Mean serum 25(OH) D; 10 nmol/L increase in serum 25(OH)D	ALRI	Mean serum 25(OH)D: ↔ (P = 0.96); ↑ in serum 25(OH)D of 10 nmol/L: ↔ ALRI (OR: 1.00; 95% CI: 0.998, 1.002)
Oduwole et al, 2010⁶¹	Case-control	Nigeria	34	2–60 mo	Pneumonia vs. hospital controls without pneumonia	Mean plasma 25(OH)D	Pneumonia	↔ (P = 0.50)
Roth et al, 2010¹¹	Case-control	Bangladesh	50	1–18 mo	ALRI vs. controls matched on age, sex and village	Mean serum 25(OH) D; 10 nmol/L increase in serum 25(OH)D	ALRI	Mean serum 25(OH)D: 10.0 nmol/L lower in cases (95% CI: 6.32, 13.68; P = 0.01); ↑ in serum 25(OH)D of 10 nmol/L: ↓ ALRI (OR: 0.23; 95% CI: 0.06, 0.81)	Underweight status, socioeconomic status
Elemraid et al, 2011⁶²	Case-control	Yemen	149	0.6–15 yr	Chronic suppurative otitis media (CSOM) vs. healthy controls	Mean serum 25(OH) D; VDD	CSOM	Mean serum 25(OH)D: 2.0 nmol/L higher in cases than controls (95% CI: 1.78, 2.28; P = 0.001); VDD: ↓ CSOM (OR: 0.22; 95% CI: 0.06, 0.82; P = 0.02)	Age
Rutstein et al, 2011⁶³	Case-control	United States	453	5–23 yr	Perinatally acquired HIV vs. healthy controls	Mean serum 25(OH) D; serum 25(OH) D <27.5 nmol/L	HIV infection	Mean serum 25(OH)D: lower in cases (P < 0.0001); serum 25(OH) D <27.5 nmol/L: ↔ HIV infection (OR: 0.6; 95% CI: 0.2, 1.8; P = 0.33)	Age, sex, BMI Z score, season, season × group, race
Williams et al, 2008⁶⁴	Cross-sectional	United Kingdom	64	0.1–17 yr	Active or latent TB		Prevalence of serum 25(OH)D <20 nmol/L and <75 nmol/L	25(OH)D <20 nmol/L: 37.5% of children

25(OH)D <75 nmol/L: 86% of children
Bener et al, 2009⁶⁵	Cross-sectional	Qatar	458	<16 yr	Healthy	VDD	Gastroenteritis	↑ Gastroenteritis (P = 0.02)
Katikaneni et al, 2009⁶⁶	Cross-sectional	United States	315	<3 mo	Hospital and pediatric clinic sample	Vitamin D supplementation	Urinary tract infection (UTI)	↑ UTI in infants exclusively formula-fed (RR: 2.24; 95% CI: 1.29, 3.90)
Gray et al, 2012⁶⁷	Cross-sectional	Australia (refugees)	328	0.5–17.5 yr	Active, latent, or no TB	Mean serum 25(OH) D; VDD	TB	Mean serum 25(OH)D: lower in children with active (P = 0.05) or latent TB (P = 0.03);VDD: ↔ (P = 0.1)
Inamo et al, 2011¹³	Case series	Japan	28	1–48 mo	ALRI	Serum 25(OH)D <25 nmol/L	Severity of ALRI	↑ Need for supplementary oxygen or ventilator management (P < 0.01)

Direction of the arrow refers to direction of association between exposure and outcome:↑ indicates statistically significant positive association with outcome;↓, statistically significant inverse association with outcome; ↔, no association with outcome.

VDD defined as serum or plasma 25(OH)D <50 nmol/L.

†Maternal factors adjusted for included age, education, occupation, WHO HIV disease stage, CD4 T-cell counts, short stature, anemia, mid-upper arm circumference and multivitamin regimen. Child factors adjusted for included sex, gestational age, low birth weight, mid-upper arm circumference, breast-feeding status and HIV status.

RCT indicates randomized controlled trial; RR, relative risk; OR, odds ratio; BMI, body mass index; HR, hazard ratio; ARI, acute respiratory infection.
We also found that VDD was associated with increased report of days with earache or ear discharge and fever, especially among boys. These symptoms are typical of otitis media, usually caused by bacteria including Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae.^69,70 Increased production of antimicrobial peptides that form part of the initial mucosal defense in the respiratory tract is one possible mechanism through which vitamin D might enhance resistance to infection by these pathogens.⁷¹ Although an association of VDD with ear infection has not been documented before, previous investigations suggest a protective role of vitamin D against other respiratory tract infections. In infants and children, maternal or child 25(OH)D serum or plasma levels have been inversely associated with risk or severity of acute lower respiratory infection,^{11–14,57,59} RSV¹⁵ or tuberculosis.⁶⁷ In addition, a polymorphism of the VDR gene was associated with higher risk of severe RSV disease in case-control studies of hospitalized children with RSV infection in The Netherlands and South Africa.^72,73 By contrast, 1 case-control study of Yemeni children found an inverse relation between VDD and chronic suppurative otitis media.⁶² This study may have been limited by reverse causation bias given that 25(OH)D levels were measured in children who had had ear discharge for at least 2 weeks before enrollment. Although VDD increased the risk of earache/discharge with fever in our cohort, vitamin D insufficiency was associated with a reduced incidence of these symptoms. Whether this might be due to heterogeneity in the etiology of ear disease deserves further investigation. Chronic suppurative otitis media involves a broader spectrum of bacterial pathogens than acute otitis media,⁷⁴ and the nonlinearity of the association of vitamin D status with ear symptoms in our study may represent a weaker or detrimental effect of vitamin D on chronic infection than on the acute forms of disease.

Although several previous studies have found increased risk of respiratory illness with VDD, we did not find an elevated rate of cough with fever among vitamin D-deficient school-age children. Most of the literature describing the effects of vitamin D on infection in children has been limited to age groups less than 5 years. It is possible that the effect of vitamin D on respiratory illness varies among children of different ages because the pathogens involved in the etiology of respiratory infection differ. For example, in a study of children hospitalized with lower respiratory tract infections, the proportion of infections due to viral agents was highest in infants, whereas the proportion of identifiable infections attributable to bacterial pathogens was greatest in children more than 5 years of age.⁷⁵ Cough and fever are nonspecific symptoms of respiratory infections, such that they cannot be used to differentiate among the potential etiologic agents of disease, including viruses, bacteria and atypical organisms.⁷⁶ We relied on self-reported symptoms of common childhood infections but it was not possible to establish clinical diagnoses or confirm an infectious etiology of the reported morbidities.

It is unclear why the association between vitamin D serostatus and rates of earache/discharge with fever and cough with fever varied by sex. Randomized trials show sex-differential effects of vitamin A supplementation administered with bacille Calmette-Guérin vaccine with respect to vaccine response, mortality and measles incidence.^77–80 While boys demonstrated a more prominent Th1 profile than girls, girls had a more robust Th2 profile. Data from in vitro and animal studies generally show that vitamin A enhances the Th2-type response to infection.⁸¹ Vitamin D similarly dampens the Th1-type response in favor of a Th2-type response,⁸² and this might help explain the differential effects of inadequate vitamin D status on morbidity in boys and girls.

One strength of our study is its longitudinal design, which largely precludes the possibility of reverse causation bias. In addition, prospective collection of information on the morbidity events prevents the occurrence of outcome misclassification bias due to differential recall. A possible limitation is the use of 1 measurement of 25(OH)D levels to ascertain exposure status at baseline. However, repeated measures of 25(OH)D concentrations over time indicate that within-subject correlation is high, suggesting that a single measurement could represent long-term exposure.⁸³

In summary, VDD was associated with increased rates of ear and gastrointestinal morbidity in a cohort of school-age children. These results add to the growing body of evidence supporting a role for vitamin D in the susceptibility to infection-related illness in children. Randomized intervention trials are needed to ascertain whether vitamin D supplementation reduces the risk of otitis media and gastrointestinal morbidities experienced in children more than 5 years of age.

References

Brehm JM, Celedón JC, Soto-Quiros ME, et al. Serum vitamin D levels and markers of severity of childhood asthma in Costa Rica. Am J Respir CritCare Med. 2009;179:765–771.

Gilbert-Diamond D, Baylin A, Mora-Plazas M, et al. Vitamin D deficiency and anthropometric indicators of adiposity in school-age children: a prospective study. Am J Clin Nutr. 2010;92:1446–1451.

Peters BS, dos Santos LC, Fisberg M, et al. Prevalence of vitamin D insufficiency in Brazilian adolescents. Ann Nutr Metab. 2009;54:15–21.

Van Belle TL, Gysemans C, Mathieu C. Vitamin D in autoimmune, infectious and allergic diseases: a vital player? Best Pract Res Clin EndocrinolMetab. 2011;25:617–632.

Laaksi I. Vitamin D and respiratory infection in adults. Proc Nutr Soc. 2012;71:90–97.

Morgan JW, Morgan DM, Lasky SR, et al. Requirements for induction of vitamin D-mediated gene regulation in normal human B lymphocytes. JImmunol. 1996;157:2900–2908.

Baeke F, Korf H, Overbergh L, et al. Human T lymphocytes are direct targets of 1,25-dihydroxyvitamin D3 in the immune system. J Steroid Biochem MolBiol. 2010;121:221–227.

Takahashi K, Nakayama Y, Horiuchi H, et al. Human neutrophils express messenger RNA of vitamin D receptor and respond to 1alpha,25-dihydroxyvitamin D3. Immunopharmacol Immunotoxicol. 2002;24:335–347.

Bhalla AK, Amento EP, Clemens TL, et al. Specific high-affinity receptors for 1,25-dihydroxyvitamin D3 in human peripheral blood mononuclear cells: presence in monocytes and induction in T lymphocytes following activation. J Clin Endocrinol Metab. 1983;57:1308–1310.

Brennan A, Katz DR, Nunn JD, et al. Dendritic cells from human tissues express receptors for the immunoregulatory vitamin D3 metabolite, dihydroxycholecalciferol. Immunology. 1987;61:457–461.

Roth DE, Shah R, Black RE, et al. Vitamin D status and acute lower respiratory infection in early childhood in Sylhet, Bangladesh. Acta Paediatr. 2010;99:389–393.

Wayse V, Yousafzai A, Mogale K, et al. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 y. Eur J Clin Nutr. 2004;58:563–567.

Inamo Y, Hasegawa M, Saito K, et al. Serum vitamin D concentrations and associated severity of acute lower respiratory tract infections in Japanese hospitalized children. Pediatr Int. 2011;53:199–201.

Karatekin G, Kaya A, Salihoğlu O, et al. Association of subclinical vitamin D deficiency in newborns with acute lower respiratory infection and their mothers. Eur J Clin Nutr. 2009;63:473–477.

Belderbos ME, Houben ML, Wilbrink B, et al. Cord blood vitamin D deficiency is associated with respiratory syncytial virus bronchiolitis. Pediatrics. 2011;127:e1513–e1520.

Urashima M, Segawa T, Okazaki M, et al. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Am JClin Nutr. 2010;91:1255–1260.

Camargo CA Jr, Ganmaa D, Frazier AL, et al. Randomized trial of vitamin D supplementation and risk of acute respiratory infection in Mongolia. Pediatrics. 2012;130:e561–e567.

Manaseki-Holland S, Qader G, Isaq Masher M, et al. Effects of vitamin D supplementation to children diagnosed with pneumonia in Kabul: a randomized controlled trial. Trop Med Int Health. 2010;15:1148–1155.

Manaseki-Holland S, Maroof Z, Bruce J, et al. Effect on the incidence of pneumonia of vitamin D supplementation by quarterly bolus dose to infants in Kabul: a randomised controlled superiority trial. Lancet. 2012;379:1419–1427.

Monto AS. Epidemiology of viral respiratory infections. Am J Med. 2002;112 Suppl 6A:4S–12S.

Neuzil KM, Hohlbein C, Zhu Y. Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families. Arch Pediatr Adolesc Med. 2002;156:986–991.

Horwood LJ, Fergusson DM, Shannon FT. Morbidity from 5 to 10 years. Aust Paediatr J. 1989;25:72–79.

Liao P, Ku M, Lue K, et al. Respiratory tract infection is the major cause of the ambulatory visits in children. Ital J Pediatr. 2011;37:43.

Arsenault JE, Mora-Plazas M, Forero Y, et al. Provision of a school snack is associated with vitamin B-12 status, linear growth, and morbidity in children from Bogota, Colombia. J Nutr. 2009;139:1744–1750.

Office of the Mayor of Bogota. Secretary of Education. Estad ısticas del sector educativo de Bogota 2005 y avances 2006. (Statistics of the educative sector of Bogota 2005 and advances 2006.) (in Spanish). Available at: http://www.sedbogota.edu.co/AplicativosSED/Centro_Documentacion/anexos/publicaciones_2004_2008/

+ +estadisticas_05_avances_2006.pdf. Accessed October 12, 2009.

Lohman T, Roche AF, Martorell R. Anthropometric Standardization ReferenceManual. Champaign, IL: Human Kinetics Books; 1988.

Wiseman V, Conteh L, Matovu F. Using diaries to collect data in resourcepoor settings: questions on design and implementation. Health Policy Plan.2005;20:394–404.

Goldman N, Vaughan B, Pebley AR. The use of calendars to measure child illness in health interview surveys. Int J Epidemiol. 1998;27:505–512.

Wright JA, Gundry SW, Conroy R, et al. Defining episodes of diarrhoea: results from a three-country study in Sub-Saharan Africa. J Health PopulNutr. 2006;24:8–16.

Martini LA, Wood RJ. Vitamin D status and the metabolic syndrome. NutrRev. 2006;64:479–486.

Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266–281.

de Wit MA, Koopmans MP, Kortbeek LM, et al. Etiology of gastroenteritis in sentinel general practices in the netherlands. Clin Infect Dis. 2001;33:280–288.

Ohmit SE, Monto AS. Symptomatic predictors of influenza virus positivity in children during the influenza season. Clin Infect Dis. 2006;43:564–568.

Carlin SA, Marchant CD, Shurin PA, et al. Host factors and early therapeutic response in acute otitis media. J Pediatr. 1991;118:178–183.

de Onis M, Onyango AW, Borghi E, et al. Development of a WHO growth reference for school-aged children and adolescents. Bull World HealthOrgan. 2007;85:660–667.

Payne DC, Staat MA, Edwards KM, et al. Active, population-based surveillance for severe rotavirus gastroenteritis in children in the United States. Pediatrics. 2008;122:1235–1243.

Sinclair MI, Hellard ME, Wolfe R, et al. Pathogens causing community gastroenteritis in Australia. J Gastroenterol Hepatol. 2005;20:1685–1690.

Olesen B, Neimann J, Böttiger B, et al. Etiology of diarrhea in young children in Denmark: a case-control study. J Clin Microbiol. 2005;43:3636–3641.

Rimoldi SG, Stefani F, Pagani C, et al. Epidemiological and clinical characteristics of pediatric gastroenteritis associated with new viral agents. ArchVirol. 2011;156:1583–1589.

Youssef M, Shurman A, Bougnoux M, et al. Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. FEMS Immunol Med Microbiol. 2000;28:257–263.

Arias C, Sala MR, Domínguez A, et al. Epidemiological and clinical features of norovirus gastroenteritis in outbreaks: a population-based study. Clin Microbiol Infect. 2010;16:39–44.

Rockx B, De Wit M, Vennema H, et al. Natural history of human calicivirus infection: a prospective cohort study. Clin Infect Dis. 2002;35:246–253.

Kaplan JE, Gary GW, Baron RC, et al. Epidemiology of Norwalk gastroenteritis and the role of Norwalk virus in outbreaks of acute nonbacterial gastroenteritis. Ann Intern Med. 1982;96(6, pt 1):756–761.

Troeger H, Loddenkemper C, Schneider T, et al. Structural and functional changes of the duodenum in human norovirus infection. Gut. 2009;58:1070–1077.

Kong J, Zhang Z, Musch MW, et al. Novel role of the vitamin D receptor in maintaining the integrity of the intestinal mucosal barrier. Am J PhysiolGastrointest Liver Physiol. 2008;294:G208–G216.

Fujita H, Sugimoto K, Inatomi S, et al. Tight junction proteins claudin-2 and -12 are critical for vitamin D-dependent Ca2+ absorption between enterocytes. Mol Biol Cell. 2008;19:1912–1921.

Wiegering V, Kaiser J, Tappe D, et al. Gastroenteritis in childhood: a retrospective study of 650 hospitalized pediatric patients. Int J Infect Dis. 2011;15:e401–e407.

Karacan C, Tavil B, Topal Y, et al. Evaluation of shigellosis in a Turkish children's hospital. Pediatr Int. 2007;49:589–592.

Wu S, Liao AP, Xia Y, et al. Vitamin D receptor negatively regulates bacterial-stimulated NF-kappaB activity in intestine. Am J Pathol. 2010;177:686–697.

Gudmundsson GH, Bergman P, Andersson J, et al. Battle and balance at mucosal surfaces–the story of Shigella and antimicrobial peptides. BiochemBiophys Res Commun. 2010;396:116–119.

Hewison M. Vitamin D and the immune system: new perspectives on an old theme. Endocrinol Metab Clin North Am. 2010;39:365–379, table of contents.

Liu PT, Stenger S, Li H, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science. 2006;311:1770–1773.

Morcos MM, Gabr AA, Samuel S, et al. Vitamin D administration to tuberculous children and its value. Boll Chim Farm. 1998;137:157–164.

Mehta S, Hunter DJ, Mugusi FM, et al. Perinatal outcomes, including motherto-child transmission of HIV, and child mortality and their association with maternal vitamin D status in Tanzania. J Infect Dis. 2009;200:1022–1030.

Camargo CA Jr, Ingham T, Wickens K, et al.; New Zealand Asthma and Allergy Cohort Study Group. Cord-blood 25-hydroxyvitamin D levels and risk of respiratory infection, wheezing, and asthma. Pediatrics. 2011;127:e180–e187.

Finkelstein JL, Mehta S, Duggan C, et al. Maternal vitamin D status and child morbidity, anemia, and growth in human immunodeficiency virus-exposed children in Tanzania. Pediatr Infect Dis J. 2012;31:171–175.

Morales E, Romieu I, Guerra S, et al.; INMA Project. Maternal vitamin D status in pregnancy and risk of lower respiratory tract infections, wheezing, and asthma in offspring. Epidemiology. 2012;23:64–71.

Stephensen CB, Marquis GS, Kruzich LA, et al. Vitamin D status in adolescents and young adults with HIV infection. Am J Clin Nutr. 2006;83:1135–1141.

McNally JD, Leis K, Matheson LA, et al. Vitamin D deficiency in young children with severe acute lower respiratory infection. Pediatr Pulmonol. 2009;44:981–988.

Roth DE, Jones AB, Prosser C, et al. Vitamin D status is not associated with the risk of hospitalization for acute bronchiolitis in early childhood. Eur JClin Nutr. 2009;63:297–299.

Oduwole AO, Renner JK, Disu E, et al. Relationship between vitamin D levels and outcome of pneumonia in children. West Afr J Med. 2010;29:373–378.

Elemraid MA, Mackenzie IJ, Fraser WD, et al. A case-control study of nutritional factors associated with chronic suppurative otitis media in Yemeni children. Eur J Clin Nutr. 2011;65:895–902.

Rutstein R, Downes A, Zemel B, et al. Vitamin D status in children and young adults with perinatally acquired HIV infection. Clin Nutr. 2011;30:624–628.

Williams B, Williams AJ, Anderson ST. Vitamin D deficiency and insufficiency in children with tuberculosis. Pediatr Infect Dis J. 2008;27:941–942.

Bener A, Al-Ali M, Hoffmann GF. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009;60(suppl 5):60–70.

Katikaneni R, Ponnapakkam T, Ponnapakkam A, et al. Breastfeeding does not protect against urinary tract infection in the first 3 months of life, but vitamin D supplementation increases the risk by 76%. Clin Pediatr (Phila). 2009;48:750–755.

Gray K, Wood N, Gunasekera H, et al. Vitamin d and tuberculosis status in refugee children. Pediatr Infect Dis J. 2012;31:521–523.

Hewison M. Vitamin D and innate and adaptive immunity. Vitam Horm. 2011;86:23–62.

Lee HY, Andalibi A, Webster P, et al. Antimicrobial activity of innate immune molecules against Streptococcus pneumoniae, Moraxella catarrhalis and nontypeable Haemophilus influenzae. BMC Infect Dis. 2004;4:12.

Rovers MM, Schilder AG, Zielhuis GA, et al. Otitis media. Lancet. 2004;363:465–473.

Schaller-Bals S, Schulze A, Bals R. Increased levels of antimicrobial peptides in tracheal aspirates of newborn infants during infection. Am J RespirCrit Care Med. 2002;165:992–995.

Kresfelder TL, Janssen R, Bont L, et al. Confirmation of an association between single nucleotide polymorphisms in the VDR gene with respiratory syncytial virus related disease in South African children. J Med Virol. 2011;83:1834–1840.

Janssen R, Bont L, Siezen CL, et al. Genetic susceptibility to respiratory syncytial virus bronchiolitis is predominantly associated with innate immune genes. J Infect Dis. 2007;196:826–834.

Verhoeff M, van der Veen EL, Rovers MM, et al. Chronic suppurative otitis media: a review. Int J Pediatr Otorhinolaryngol. 2006;70:1–12.

Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004;113:701–707.

Klig JE. Office pediatrics: current perspectives on the outpatient evaluation and management of lower respiratory infections in children. Curr OpinPediatr. 2006;18:71–76.

Benn CS, Diness BR, Roth A, et al. Effect of 50,000 IU vitamin A given with BCG vaccine on mortality in infants in Guinea-Bissau: randomized placebo controlled trial. BMJ. 2008;336:1416–1420.

Benn CS, Fisker AB, Napirna BM, et al. Vitamin A supplementation and BCG vaccination at birth in low birthweight neonates: two by two factorial randomised controlled trial. BMJ. 2010;340:c1101.

Diness BR, Fisker AB, Roth A, et al. Effect of high-dose vitamin A supplementation on the immune response to Bacille Calmette-Guerin vaccine. AmJ Clin Nutr. 2007;86:1152–1159.

Diness BR, Martins CL, Bale C, et al. The effect of high-dose vitamin A supplementation at birth on measles incidence during the first 12 months of life in boys and girls: an unplanned study within a randomised trial. Br JNutr. 2011;105:1819–22.

Villamor E, Fawzi WW. Effects of vitamin a supplementation on immune responses and correlation with clinical outcomes. Clin Microbiol Rev. 2005;18:446–464.

Baeke F, Takiishi T, Korf H, et al. Vitamin D: modulator of the immune system. Curr Opin Pharmacol. 2010;10:482–496.

Jorde R, Sneve M, Hutchinson M, et al. Tracking of serum 25-hydroxyvitamin D levels during 14 years in a population-based study and during 12 months in an intervention study. Am J Epidemiol. 2010;171:903–908.