Vitamin d Ppt Final 1
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Transcript of Vitamin d Ppt Final 1
Case 1 8 months old female child Acute gastroenteritis with low grade fever Had 2 episodes of convulsions during this
morbidity Ex BF –till 6 months,Complimentary feeds
added at 6 months,Poor intake,Intermittent some vitamins given
Investigations:CBC Normal,BSL Normal, Serum ca:Total 6.3,Ionised;0.83meq/l PH :4 (3.7-5.6),Alk po4ase:845
Case 1 (ct)
Serum electrolytes :Normal, Anion gap 18.3 VitaminD:14.6ng/ml(20-32 N) X-Ray Wrist :S/O Rickets Birth Wt 2500gms with slow growth in last 8 months EEG normal Clinical diagnosis: Hypopcalcemic seizures with Vitamin D Deficiency with Rickets
Case 2: 10 months old child ,regular follow up in well baby
clinic Growing well,10kg wt at 10months Exclusive BF till age 6 months then complimentary
feeds added Iron supplementation given Clinically wide AF and some wrist widening Xray wrist S/O Rickets: Biochemically:Ca :N,PH; N,Alkpo4ase :958 Electrolytes: N Anion gap N Vitamin D levels not done:
Case 2:(ct)
Clinical Diagnosis:
Nutritional Rickets
Case 3:
15 months old child referred by Orthopedic surgeon.
C/O Kyphosis/scoliosis not learnt to stand
8.5 kg child,Motor and mental mile stones normal except delay in independent standing and walking
On examination wrist widening ,maleolar widening noted
Case ;3 (ct)
CNS exam mild hypo tonia noted.Mild kyphoscoliosis notedXRay :Classical changes of rickets notedMRI had already been done by
orthopedic surgeonSerum Electrolytes :NCa :8.9,PH ;4.2,Alk po4ase :765Vitamin D level not done
Case 3(ct)
Clinical diagnosis :Nutritional rickets
Post treatment child has started walking independently
Kyphoscoliosis is also very mild 3 months after treatment
VITAMIN D: WHY MORE IMPORTANT THAN EVER?
Vitamin D supplementation in infancy was associated with greater bone mineral content and increased bone mineral density.
Breastfed infants whose mothers are not exposed to
adequate sunlight, d
ark skinned infants and in
fants born
during the winter
months also should receive a
supplementation of 4
00 IU of v
iatmin D daily
particularly
if breast fe
d.
WHY IS VITAMIN D DEFICIENCY A BIG DEAL?Hypovitaminosis D can result from a number of factors including: Inadequate intake coupled with inadequate sunlight (UVB) exposureDisorders that limit its absorption from the gastrointestinal tractConditions that impair conversion of vitamin D into active metabolites, such as liver or kidney disorders Body characteristics such as skin color and body fat. Rarely deficiency can result from a number of hereditary disorders
SUNLIGHT AS A SOURCE OF VITAMIN D
Adequate supplies of vitamin D3 can be
synthesized with sufficient exposure to
solar ultraviolet B radiation
Depends on latitude and season
Melanin, clothing or sunscreens that
absorb UVB will reduce cutaneous
production of vitamin D3
VITAMIN D
Fat soluble ‘vitamin’
Synthesised in skin, food sources include fish oils, cod
liver oil
Physiological forms - vitamin D3 (cholecalciferol)
- vitamin D2 (ergocalciferol)
Hormonal form synthesised in kidney
Functions - intestine: calcium absorption
- bone : promotes mineralization
Deficiency syndromes - children: rickets
- adults: osteomalacia
Mechanism of action - receptor mediated
VITAMIN D AND HUMAN HEALTH
Benefits
The major function of vitamin D is the maintenance
of blood serum concentrations of calcium and
phosphorus.
PLASMA CALCIUM HOMEOSTATIS
Low 25OHD
Muscle strength Mineralisation PTH
Falls Bone fragility
Fractures
• Osteomalacia, Osteoperosis, Osteopeni
a
in adults.
• Vitamin D malnutrition is also
linked to an increased
susceptibility to several chronic
diseases viz. high B.P., TB, cancer,
periodontal disease, multiple sclerosis,
chronic pain,
seasonal affective disorder,
peripheral artery disease,
cognitive impairment including
memory loss & foggy brain, and
several autoimmune diseases
including type 1 diabetes.
• Rickets in children, a childhood
disease characterized by
impeded growth & deformity of the
long bones, is an example of extreme
VDD with a peak incidence between 3
to 19 months of age.
• This causes bowed, soft bones,
muscle weakness, stunted growth
and high risk of low bone density
later in life.
• The role of diet in the development of
rickets was determined between
1918–1920.
Presentation in child
Tender /swollen joints, classically wrists Deformed bones Bone pain or tenderness Fits or irritability Breathing difficulties Occurs during rapid growth Bow legs or knock knees Delayed walking or waddling gait Rickety rosary Tetany or convulsions Apnoea or stridor Impaired growth or delayed fontanelle closure Delayed eruption of teeth or enamel hypoplasia
VDD – STAGES & CLINICAL SIGNS
Who is at risk for Vitamin D deficiency?
The answer to this question is everyone. Every human
being irrespective of his age, sex, race, culture,
religions, etc. is suspected to suffer from VDD in his
life.
Is Vitamin D deficiency common?
Not known to many but the answer is yes.
Testing for Vitamin D
There is a simple blood test — 25 hydroxy vitamin D level.
DIAGNOSIS OF VITAMIN D DEFICIENCY
The level of 25(OH)-D (25-hydroxyvitamin-D) measured in
blood (serum) should be at least 50 nmol/L. Insufficient /
deficient is under 50, and to be conservative, toxic upper
levels might start at about 150 to 200 nmol/L.
A blood calcidiol (25-hydroxy-vitamin D) level is the
accepted way to determine vitamin D nutritional status.
Supplementation of 100 IU (2.5 microgram) vitamin D3
raises blood calcidiol levels by 2.5 nmol/litre (1 ng/ml).
Vitamin D Status in Relation to 25(OH)-D Levels
Vitamin D Status Level25(OH)-D
Severe deficiency < 10 ng/ml
Deficiency 10-20 ng/ml
Insufficiency 21-30 ng/ml
Sufficiency >30 ng/ml
Excess >100 ng/ml
Intoxication >150 ng/ml
GRADING
Based on serum 25-OHD concentrations89, vitamin D deficiency is
classified as:
Mild vitamin D deficiency: Serum 25-OHD concentration of 25-50 nmol/l.
Serum levels over 50 nmol/l prevents secondary hyperparathyroidism and
elevated alkaline phosphatase levels.
Moderate vitamin D deficiency: Serum 25-OHD concentration of 12.5-25
nmol/l. The incidence of hypocalcaemia and rickets increases with moderate
deficiency.
Severe vitamin D deficiency: Serum 25-OHD concentration <12.5 nmol/l.
Vitamin D concentrations <12.5 nmol/l are seen in over 70% of children with
rickets and over 90 % of children with hypocalcaemia.
TREATMENT OF VITAMIN D DEFICIENCY
High dose vitamin D therapy (stoss therapy) is an effective
method for treating established or recalcitrant vitamin D
deficiency.
Oral or intramuscular administration of the total
treatment dose of vitamin-D 6,00,000 IU either as a single
dose (as this produces rapid healing allowing earlier
differential diagnosis from genetic vitamin D resistant
rickets) or as oral vitamin D3 at a dose of 2000-6000 IU
producing radiologic clearing in 2-4 wk.
Akcam et al92 had observed that the increase in bone
mineral densities with two different therapy regimens of
vitamin D [either a single dose of vitamin D (600,000 IU)
or 20,000 IU/day given orally for 30 days] in infants with
vitamin D deficiency rickets was similar and not superior
to each other.
Food Sources of Vitamin D
Milk and cereal grains are often fortified
with vitamin D.
Fish liver oils, such as cod liver oil, 1 Tbs
provides 1,360 IU (one IU equals 25 ng)
Fatty fish species, such as: Herring, 85 g
(3 ounces (oz)) provides 1383 IU, Catfish
85 g (3 oz) provides 425 IU, Salmon
cooked 100 g (3.5 oz]) provides 360 IU,
Mackerel cooked 100 g (3.5 oz]), 345 IU,
Sardines canned in oil & drained 50 g
(1.75 oz), 250 IU, Tuna canned in oil 85 g
(3 oz) 200 IU
One whole egg, provides 20 IU
PREVALENCE In the western view, VDD was considered to be rare in India.
Till 2000, there was no systematic study that directly assessed
body vitamin D status of Indians.
In 2000 Goswami et al. first measured serum 25(OH)D using
sensitive and specific assay in apparently healthy subjects in Delhi
and showed significant hypovitaminosis D in up to 90% of them.
Subsequently, series of studies from different parts of our country
have pointed towards widespread VDD in Asian Indians of all age
groups including toddlers, school children, pregnant women and
their neonates and adult males and females residing in rural or
urban areas.
PREVALENCE OF HYPOVITAMINOSIS D IN INDIA
PREVALENCE OF VITAMIN D DEFICIENCY IN INFANTS
Vitamin D plays a critical function in
maintaining the immune system through
out life.
Vitamin D deficiency causes hypocalcemic
seizures particularly in the infancy period.
Infants are a vulnerable population for
development of vitamin D deficiency
because of their rate of skeletal growth.
PREGNANT WOMEN & VITAMIN D DEFICIENCY
Vitamin D nutrition has a profound effect on the
development of an infant.
Vitamin D status of mothers and their infants are
closely correlated.
If the mother is vitamin D-deficient, the infant will be
deficient because of decreased maternal foetal
transfer of vitamin D.
Infants born to vitamin D deficient mothers are at a
significant high risk to develop hypocalcaemia
seizures due to vitamin D deficiency.
Contd.
Bone mass of the newborn is related to the
vitamin D status of the mother.
Maternal vitamin D deficiency ≈ Impaired foetal
bone ossification .
Risk factors associated with low maternal 25-
OHD - low educational level, insufficient intake
of vitamin D in diet, dressing habits & pollution.
Contd.
Several studies have shown that breastfed
infants born to and nursed by vitamin D.
Reports have indicated that there is a high
prevalence of hypovitaminosis D in India,
particularly amongst pregnant and
lactating women.
Using logistic regression, infants born to mothers with 25 (OH) D
<10 ng/ml had 40 times increased risk of hypovitaminosis D
when compared to those born to mothers with 25 (OH) D >10
ng/ml.
BENEFITS OF VITAMIN D – A MULTITALENTED VITAMINPrevent Vitamin D
deficiency and its
associated risks
AAP has recommended that all infants receive a daily
supplement of vitamin D starting from first month of life to
prevent rickets and vitamin D deficiency. Prevention of
vitamin D deficiency helps in preventing hypocalcemia and
its associated seizures.
Bone health Vitamin D maintains strong healthy bones. Vitamin D helps
in absorbing calcium which is important for bone health.
Muscle strength Vitamin D maintains muscle strength and can also relieve
non-specific muscle pain.
Immune function Vitamin D plays a vital role in maintaining innate immunity.
Vitamin D supplementation in infancy and early childhood
may decrease the incidence of type 1 diabetes mellitus.
RECOMMENDATIONS FOR DOSAGE OF VITAMIN D
VITAMIN D IS
RECOMMENDED BYRECOMMENDED FOR
RECOMMENDED
DAILY INTAKE
Canadian Pediatric
Society Health CanadaBreastfed infants 400 IU
American Academy of
PediatricsBreastfed and partially breastfed infants
400 IU
American Academy of
Pediatrics
All non-breast fed infants, as well as older children,
who are consuming less than one quarter/day of
vitamin D fortified formula or milk.
400 IU
American Academy of
Pediatrics
Adolescents who do not obtain 400 IU of vitamin D per
day through foods
400 IU
American Academy of
Pediatrics
Children with increased risk of vitamin D deficiency,
such as those taking certain medications, may need
higher doses of vitamin D.
400 IU
International guidelines on dosage in Infants
Year Associations Dosage
2008 AAP 400 IU/Day
2008 Canada AP 800 IU/Day
2009 Vitamin D council 1000 IU/Day
2010 Endo meet (US) 1000 IU/Day
AGE DOSAGE
At 2 months 400 IU/day
>6 mon to 1 year 600-700 IU/day
In premature infants 400 IU/day
In malnourished & infantsWith recurrent RTI
Upto 1000 IU/day
In children 1000-1500 IU/day
Adolescents 2000 IU/day
Indian Endocrinologist recommendation
Vitamin D Supplements To be sure you get enough
vitamin D, many experts say you need to take a supplement.
Most multivitamin tablets contain 400 IU of vitamin D, which means taking one or two tablets a day will provide the current recommended amount of vitamin D for most people.
You can also find vitamin D by itself in higher-dose tablets and in combination with calcium.
Vitamin D and Other Drugs Steroid medications can
interfere with metabolism of vitamin D.
The same is true for the weight loss drug orlistat,
seizure drugs such as phenobarbitol.
Cholesterol-lowering statins, on the other hand, will raise vitamin D levels.
D2 or D3? That's the Question. Vitamin D is available in
supplements in two forms: D2 and D3.
Both forms are effective, and either can be taken to ensure adequate levels of vitamin D.
But 2 is not equal to 3. D3 is the kind of vitamin D the
body makes.
Recent studies suggest that D3 can be up to three times more effective in raising the vitamin D level quickly and staying longer.
Vitamin D for Older Children Vitamin D-fortified
whole milk and foods can provide the vitamin D that growing kids need — as long as they get enough of it.
The AAP recommends that children who do not get at least 400 IU of vitamin D per day from their diet should be given a daily supplement of 400 IU.
How Much Is Too Much? There is an upper limit
to how much vitamin D you can safely take
. Current Institute of
Medicine recommendations for adults say that a daily intake of up to 2,000 IU of vitamin D safe. Some experts say that limit is far too low.
. The upper limit for
infants is lower.
HYPERVITAMINOSIS
Too much Vitamin D can cause:
Thirst, vomiting, fatigue, confusion, & can lead to
Ca deposits in the Heart & kidneys = fatal
condition
Vit. D is the most toxic vitamin, if consumed in
excess amounts
1,250 mg or higher dose can cause hypercalcemia,
atherosclerosis, etc
Daily Dose for Breastfed Babies Breast milk provides multiple
benefits for babies, but it is not a good source for vitamin D. (15-50 IU/L)
The American Academy of Pediatrics (AAP) recommends that all breastfed babies receive a 400 IU daily supplement of vitamin D
starting shortly after birth and continuing until the baby is weaned and drinking at least 1,000 mL of vitamin D-fortified formula or whole milk
VITAMIN D CONTENT OF NORMALLY PRESCRIBED MULTIVITAMINS, CALCIUM AND VITAMIN D
SUPPLEMENTS
Multivitamins and Vitamin D/Calcium
Supplements
Present in form Amount /ml
Maltdex Zinc Syrup Vitamin D3 30 IU / ml
Osto-polybion D Vitamin D3 40 IU / ml
Ptifit drops Vitamin D3 200 IU / ml
ViSyenral drops Vitamin D2 400 IU / ml
Dvital Solution Vitamin D3 3000 IU / ml
Osteo-calcium
Calcium Sandoz
Calcium and Vit D3
ContentsSyp shelcal(per 5 ml)
Tab shelcal -250
(per tablet)
Syp calcimax(per 5 ml)
Tab ostocalcium(per tablet)
Calcium Calcium carbonate
(625mg/5ml ) Ele.
Ca=250mg
Calcium carbonate
(625mg/tab) Ele.
Ca=250mg
Calcium carbonate
(625mg/5ml ) Ele.
Ca=250mg
Tribasic Calcium
phosphate (0.323gm/tab)
Ele. Ca= 125mg
Ca:PO4 = 2:1
Vitamin D3 125 I.U. 125 I.U. 200 I.U. 400 I.U.
Magnesium - - Mg. hydroxide (180mg/5ml & E. Mg= 75mg)
-
Zinc - - Zinc gluconate (14mg/5ml & ele. Zn= 2mg)
-
Cost Rs. 55/- Rs. 68/- Rs. 77.50/- for 60 tab.
Contains Hovite RB(per ml)
ViSyneral(per ml)
Multidex-zn(per 5 ml)
Becozinc(per 5 ml)
Govt. supply(per tablet)
Ascorbic acid 40 mg 40 mg 50 mg 50 mg 50
Nicotinamide 10 mg 10 mg 20 25 mg 25
Tocopheryl acetate
3 mg 1.5 mg - - -
Elemental Zn 3 mg - 10 5 mg -
D-panthenol 2.5 mg 3 mg 5 mg 12.5 mg 1 mg
Thiamine hydrochloride
1 mg 2 mg 1.5 mg (mononitrate)
2.5 mg
(mononitrate)
2 mg
Riboflavine 1 mg 1 mg 1.5 mg 2.5 mg 2 mg
Pyridoxine hydrochloride
1 mg 1 mg 1.5 mg 1 mg 0.5 mg
Vit. A 1000 I.U. 1000 I.U. 1250 I.U. - 2500 I.U.
Cholecalciferol (Vit D3)
250 I.U. 400 I.U. 150 I.U. - 200 I.U.
Biotin - 20 mcg - - -
Cyanocobalamine
- - 1 mcg 3 mcg -
Energy 1.40 cal 3.245 cal Sorbitol solution 0.5 gms
- -
Carbohydrate 320 mg 957 mg - -
Fat 6.5 mg 10 mg - -
Tab. Supradyn(per tablet)
vitamins Mineral Trace elementsAscorbic acid 150mg Tribasic
calcium phosphate
129 mg Copper sulphate
3.39 mg
Nicotinamide 100mg Magnesium oxide
60 mg Zinc Sulphate 2.20 mg
Tocopheryl acetate
25mg Dried ferrous sulphate
32.4 mg Sodium Molybdate
0.25 mg
Ca++ pantothenate
16.3 mg Manganese sulphate
2.03 mg Sodium borate 0.88 mg
Thiamine mononitrate
10 mg Total phosphorus
25.80 mg
Riboflavine 10 mg
Pyridoxine hydrochloride
3 mg
Vit. A 10,000 I.U.
Cholecalciferol (Vit D3)
1,000 I.U.
Biotin 0.25 mg
Cyanocobalamine
15 mcg
Summary
Current data suggests VDD is widely prevalent.
It is unlikely that sun shine exposure alone would result in sufficiency of vitamin D.
Exclusively BF babies need supplementation. Hypocalcemia in infants look for vitamin d
status Active intervention in the form of vitamin D
fortification in the national programme is required.
