Patient Presentation
A 3-year-old female came to clinic for her health supervision visit.
Her mother had recently been diagnosed with Vitamin D deficiency based on screening tests.
She wanted to know if her daughter was also Vitamin D deficient particularly as it was currently fall and winter was coming with decreased sunlight.
The patient ate a general diet including eggs and 1-2 cups/day of milk, plus yogurt and some cheese regularly.
She also took a general children’s multivitamin.
Her mother said that she did play outside and they used sunscreen when they remembered to put it on.
The family history was negative for bone, kidney, or gastrointestinal disease.
The pertinent physical exam showed a smily preschooler of Middle Eastern descent.
Her growth parameters were in the 50-90% and her vital signs were normal.
She had no bony abnormalities including normal wrists, ribs and legs.
The diagnosis of a healthy 3 year old was made.
The mother decided that she did not want her child tested for Vitamin D as it appeared that she probably was getting enough from her diet.
The pediatrician discussed that she needed at least 400 IU (international units) of Vitamin D/day. The mother was also going to check the multivitamin and how much Vitamin D was in it.
Discussion
Vitamin D is an important vitamin for bone formation and mineral homeostasis.
Vitamin D deficiency can cause hypocalcemia, hypophosphatemia, osteomalacia, rickets and tetany.
Deficiency is caused by inadequate dietary intakes of Vitamin D, inadequate exposure to sunlight or patients with fat malabsorption or renal disease.
Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure.
Adequate sunlight exposure for infants is considered 30 minutes/week clothed in a diaper only, or 2 hours/week fully clothed but without a hat.
25-hydroxy Vitamin D (calcidiol) is the best indicator of Vitamin D status.
For a review of the production of Vitamin D, click here.
Learning Point
Human breast milk is low in Vitamin D. Therefore all infants who are exclusively breastfed need supplementation.
Infants with darker pigmentation or living in northern climates with less sunlight are particularly susceptible to Vitamin D deficiency.
This supplementation can be stopped if the infant is taking at least 1 liter or quart/day of formula or Vitamin D fortified whole milk.
Children taking less than 1 liter/day of Vitamin D fortified milk should also receive supplementation of 400 IU/day. Note that soy milk may or may not be Vitamin D fortified.
The Vitamin D content of foods rich in Vitamin D is below. All are in IU.
- Milk
- Human milk – 22/L
- Infant formula – 62/100 kcal, usually 5 ounces
- Cow’s milk, fortified – 100/8 ounces
- Soy milk – may or may not be Vitamin D fortified, usually 100/8 ounces
- Rice milk – may or may not be Vitamin D fortified, usually 100/8 ounces
- Other foods made with milk or soy may or may not be fortified such as yogurt, pudding, tofu, etc.
- Cereals, fortified – 40-50/8 ounces
- Egg yolk – 21
- Fish and Shellfish (3 ounces)
- Catfish – 425
- Halibut – 510
- Herring – 1383
- Oyster – 272
- Mackerel – 213
- Pink salmon – 530
- Sardine – 231
- Shrimp – 129
- Tuna – 200
- Cod liver oil – 450 / teaspoon
- Shiitake mushrooms – 249 per 4
- Orange juice, fortified -100/8 ounces
- Multivitamins – may or may not be Vitamin D fortified, even within brands there can be differing content so individual bottles need to be checked.
Questions for Further Discussion
1. How do you balance the need for adequate sunlight for Vitamin D synthesis versus the risks of sunlight and skin cancer?
2. What other blood testing may be helpful to evaluate overall Vitamin D metabolism?
Related Cases
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Rickets and Vitamins.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
New York State Department of Health. Vitamin D and Healthy Bones.
Available from the Internet at http://www.health.state.ny.us/diseases/conditions/osteoporosis/vitd.htm (rev. 11/03, cited 11/13/08).
Linus Pauling Institute. Vitamin D.
Available from the Internet at http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/ (rev. 11/7/08, cited 11/13/08).
American Academy of Pediatrics. Pediatric Nutrition Handbook. Kleinman RE, edit. 6th Edit. 2008;458, 464-66.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
January 5, 2009
Pediatric Education 