I have worked in middle east and in my experience Vitamin D deficiency is a big problem there despite having abundant sub shine. The main reason is actually lack of exposure to sun light as women are completely covered and due to intense heat the children are not allowed to play out in sun. I recommend that vit D supplementation should be prescribed. How much and for how long is a policy decision which can be worked out

Vitamin D deficiency is quite commonly encountered in Asian children. The causation can not be merely attributed to lack of sun exposure alone. Dietary factors also play an important role.

In case of infants the mothers health status during the pregnancy is also vital.

Main clinical features encountered during my clinical practice are - frontal bossing, wide sutures and widened wrists.

I emphasize the need for calcium and vit.D supplementation to mothers during their pregnancy, and advise on supplementation for the child with commercially available oral calcium/Vit D syrups. Some cases also warrant an intramuscular injection of Vit.D.

I usually advise on calcium/Vit D supplementation for a period of 2 months for children with nutritional rickets, mainly because of the costs incurred by the patient( Here in India costs are a tad bit high for the patients who mostly belong to the lower SES). Regular assessment and proper dietary advice are of great benefit.

Many patients do show improvement.

As far as newborns are concerned, We have started adopting vitamin D supplementation policy for all our NICU graduates, and in case features of rickets are noted on baby clinics, oral supplementation is advised for 2 month periods. If compliance of the parents is in doubt we do provide Injectable Vit.D on an Out patient basis.

Dear Mohammad

According to guidelines in IRAN, vitamin D supplement is recommended for all neonates aged > 14 days.

In Lebanon where I used to work, vitamin D supplementaion is recommended to all neonates after 2 weeks of age (as in Iran) and we continue prescribing it till age of 4 years when the children are able to consume the adequate amount of vitamin D from natural sources.

In Lebanon, there are plenty of vitamin D preparations in dropper form to be given to neonates for daily supplement and all of them are affordable for the public use, but here in Bahrain and even in Saudi arabia it is not available !!!!!!!!

Thank you for all the responses. We are not doing Vit D supplementation as a policy but in my opinion it should be started. However I am supplementing all the premature NICU graduates with Vit D drops. Here the dropper preparations are expensive. However many injectable preparations are available which can also be given orally. What is the efficacy of dropper Vit D preparation as compared to injectables which can be taken orally

I am from IRAN. In tehran, vit D deficiency is common and we check 25-OH vit D routinely in endocrinolorgy clinic and treat vit D deficiency and we get vitD to newborn from 15 days old untill 2 years old.

Thank you all for sharing your experience it is really outstanding..... Dear Fatemeh & Hazir since you both are from Iran...... do u have any idea how much does it cost per dropper or bottle ? and what are the brands available there ?

we have pearl vit D 50000 u weekly for 6 weeks for child older than 5 years old and syrup calcium 50 mg/kg

Do we need to give calcium along with Vit D routinely in cases of Vit D def?

Hi , yes, we need to give calcium along with Vit D routinely in cases of Vit D deficiency , because when 25 OH vitD is low , vit D supplement cause percipitate calcium on the bone and may cause laryngial spasm .

Dear my collague,

In Turkey, all newborns were given Vitamin D till they became 1 year old by our ministry of health. In my practice I recommended vitamin D almost the infant became 2 years old. Not only Vitamin D, omega 3 and DHA contained supplements were my choice.

Great discussion. I Canada we also give vit D especially to infants of breast feeding mothers. We have started to recommend vit D to all children and to give higher dosages (800 IU). There is a rise in rickets and with the use of body cover up and sun screen in the summer and Winter the children are receiving less natural sun to skin . The other population I have been interested in are my research children with CHARGE syndrome (they are delayed in walking , have poor diets and have hypogonadic hypotrophism. As a consequence they are osteopaenic and have low BMD) .We work hard on supplementing them with 800 - 1,000 units of vit D all their paediatric life . More literature is arising that we should supplement at higher levels all children at risk , those on steroids , the children who do not do much weight bearing exercises, and the ones at risk of delayed puberty.

In my country vitamin D were given 400U/d from 15 days or even early until 2 years of age.

In Ferrara, Italy, we give vit D to infants of breastfeeding mothers (400 U/die) during the first year of life.

You probably need to consider Vit D status of the mother. I have seen a few neonates with hypocalcemia and turned out to be a vit D deficient mother. If Vit D. deficient is common in your area the I will suggest you to put your newborn on 400 U/d supply.

Dear Sara, why do you routinely give Vit D drops to mother fed babies. I am under the impression that Italy being a developed country, mothers are not mal nourished there so why the babies being breast fed need Vit D supplementation. Are the mothers also supplemented?

Vitamin D in breast milk is quite low.

Should we be giving calcium supplementation along with vit D in cases of rickets. Vit D will cause deposition of calcium in bones but it will also increase absorption of calcium from gut and will also decrease calcium excretion from kidneys.

It's important to give vitamin D to pregnant women, and not only to newborns. Pregnant women need to take vitamin D during their pregnancy to provide their baby with enough vitamin D for the first few months of its life. There is also found a link between vitamin D deficiency during pregnancy and babies' brain development. Research indicates that it even may be linked to schizophrenia: http://tinyurl.com/c8ajqee

Breast milk is deficient in vit D. Vitamin D is deficient in mothers as well

Rapidly growing baby need higher doses of vit. D.

So we need to give vit D for newborn.

Dear Dr. Ghazal .... Is vitamin D dropper form available in Saudi market ???? because I tried to prescribe it for neonates and the parents tried to get it from KSA as it is not available here in Bahrain, but they could not find it there. So I stopped stopped this practice for now !!!!

Yes it is widely available but sometimes we got shortage because of high consumption

In Bosnien, we give vIn Bosnien, we give vit D 400U/d from 15 days, to all infants during the first year of life and in the winter next year ..Only 10 minutes of sun exposure a day is enough to convert vitamin D in photo form that is embedded in the bone.

Inspite of adequate sun light in pakistan, number of rickets cases are on the rise due to high rise buildings and poor sunlight exposure vit d drops are added to the newborn specially living in high rise apartments

Dear Dr Javed, It is really an interesting insight regarding the Vit D status in children but I think the impact of high rise building will come later in life and not in the neonatal stage, unless the mother is Vit D deficient.

Sarmiento JL Protocol

At 24 hr. after birth in normal neonate you will give Vit C 50mg for madurate the liver phisiology, at 8th. day you prescrib at breast feeding infant Vit D 400 UI every day for 1 year and sun light expusure on white skin 15 minutes and dark skin 30 minutes for actívate the Vit D in the skin for prevent rickets.

You can recognized this for that increase the diameter of costal cartilagues ( osario rickets) Please in Nelson´s´Texbook of Pediatric there is a Picture and Information.

Yes Vitamin D3 has to be supplemented in all babies starting at age of one month. Dose recommended is 400 IU daily.

It is very exciting to read opinions from different practice. I believe it is contexty related issue. Say Dr. Mohammad Hourani mentioned that Vit D is not available in his area then you can not do anything about it. But, what about cod or shark liver oil extract which may have certain amount of Vit D. Children near equator may not need as much of Vit D as in Europe or America if they have appropriate exposure to the sun. yes, Vit D. may prevent mental or cancer in certain reports but we need to have a better evidence to prove it. I live in mid-west area where winter can last for 6 months so Vit D is a must for our practice.

Interestingly......in this part of the world, in spite of sunny climate there are a lot of case with Vitamin D efficiency

Yes I recommend it for all newborns! Especially, in newborns to undernourished mothers.

Hi Mohammed,

Ideally the baby won't need vitamin D supplementation if the mother's vitamin D status is fine. It should have enough stores to see it through the first few months of life. However, as you know vitamin D deficiency is extremely prevalent in the Gulf, especially among young mothers due to a combination of cultural factors. As such, it is likely that many deficient mothers will not transfer sufficient vitamin D to the fetus during the third trimester to meet its ex utero needs. Under such circumstances supplementation of the newborn infant is the most appropriate course of action as supplementing the mother - even at relatively high doses of 2,000-5,000 IU/day - may not always improve breastmilk sufficiently to prevent deficiency in the typical Gulf infant.* That said, it's likely that the mother may benefit from supplementation during lactation for her own health as well as that of her baby.

* Saadi HF, Dawodu A, Afandi B, et al. Effect of combined maternal and infant vitamin D supplementation on vitamin D status of exclusively breastfed infants. Matern Child Nutr. 2009;5(1):25-32)

There should be adequate amounts of vitamin D in most reputable brands of infant formula milk, but obviously one would not recommend switching to formula feeding purely on this basis since there are many important health advantages to exclusive breastfeeding and supplementation of the mother and infant is simple, easy and safe, providing the dose does not exceed 400 IU (10ug) per day.

Drops need to be carefully administered as infants are much more susceptible to hypervitaminosis D and the consequences could be extremely serious. The Tolerable Upper Limit in Europe and North America has been set at 1,000 IU (25ug) per day and there is some risk that intakes could exceed this amount if the infant is both supplemented AND formula fed. 'More' is definitely not always 'better'!

I gather vitamin D drops are freely available in KSA, although a colleague recently discovered the other day that one of more common brands contains very small amounts of ethanol! Presumably this is to keep the hydrophobic vitamin D in solution and you'd probably ingest a lot more ethanol in naturally fermented foods. But if you're extremely strict about alcohol intake then this may be an issue that you need to check out with the manufacturer, just to be sure!

Hope this helps,

Simon

I agree in some subtropical/tropical area Vit D. deficiency is not rare because the culture is to wrap the newborn baby up. However, if the culture allows the baby to dress a little bit less than it should not be a common problem.

Is there a role of calcium supplementation along with Vit D? In our conditions the malnourished babies are calcium deficient and vit D will will help to deposit calcium in bones only if adequate amount of calcium is available in serum.

Hi Jawad, The effectiveness of vitamin D in promoting calcium absorption in the gut* is dependent upon there being enough calcium in the diet. So if the baby is breastfed, the mother's milk will in most cases contain enough highly bioavailable calcium to meet the infant's requirements.

Of course, if the infant is displaying symptoms of hypocalcaemia or has very low serum Ca levels, then parenteral (symptomatic) or oral (asymptomatic) Ca supplementation may be indicated. But I am not aware of supplemental calcium being used as a purely preventive measure in newborns with poor vitamin D status. Remedial vitamin D alone should suffice.

______________________

* 1,25(OH)2D facilitates transcellular absorption of Ca by upregulating production of calbindin in gut cells. Once that Ca is absorbed into the systemic circulation, it can be used to maintain serum Ca levels - the greatest priority - or used for other purposes such as bone mineralisation. Vitamin D in its hormonal form also causes Ca to be released from the bone matrix ('resorption') and to be retained in the kidney, all of which serve to maintain serum Ca levels at all stages of life, including infancy. Severe vitamin D deficiency prevents all three actions from occurring, eventually causing hypocalcaemia.

P.S. - I am not a clinician, I'm a nutrition scientist. So please use advice accordingly!

Thank you Simon. That is according to the book but in our country where more than half the nursing mothers are malnourished I have doubts that their milk would contain enough calcium. As is my humble experience that in mothers of higher socio economic group vit D supplementation suffices but in lower socio economic group simple vit D supplementation is not adequate.

Also in babies fed on buffaloe milk show signs of rickets. Should they be given only vit D or should be supplemented with calcium

Well Dr. Jawad,

Why not to study this question since you have many underourshed mothers?

Vitamin D3 has to be given from 15th day of life until 1 year old to all babies from ministery of health in Turkey. I prefer to give until 2 years old. Recommended dose is 400 IU daily. Vitamin D3 in mother milk is not sufficient .

we prescribe vitamin D as a supplement to all newborn above 15 days in iran

yes

we recommend vit D suplement for all neonates ,because vit d intak is lower than 400 Iu per day.

Regards

Dear Dr Jasim

How do you suggest we can study this problem. We do have a lot of mal nourished mothers but we dont have the resources to check the vit D levels of mothers or babies.

Human breast milk is adequate for the growth of healthy full-term newborns, but several studies have shown that it is poor in vitamin D. Exclusively breastfed infants require at least 400 IU/day of supplemental vitamin D.

Beside of rickets prevention because of many benefits of vit D for infant I recommend it to all babies in the world at least for one year .

Vitamin D is necessary for good bone health and deficiency causes rickets in children. The main source of vitamin D comes from sunlight and unfortunately natural dietary sources of vitamin D are limited. Human breast milk contains very low vitamin D, about 2 IU (0.05 microgram) per 100 mls. In addition, most infants' food are not adequately fortified with vitamin D which predisposes them to high risk of deficiency. There has been controversies on the ideal daily intake of vitamin D and the duration in infants. Most countries have started routine vitamin D supplementation in infants. In Ireland where I work, all infants from birth to 12 months receive 200 IU (5micrograms) of vitamin D3 daily.

Your question is to know if you should or not supplement children in Vitamin D. Consider what ctoddlers receive as milk mother's milk or industrial milk and how much vit D the later contains. Seeking advise from many of us may be misleading as we do not practice in same climatic conditions. In France as said earlier, winter period is poor in sun exposure, recommandations are that we supplement during first two years systematically. Concerning your question on how many children with Vit D deficiency we see, this is variable here in our place black african and north african arab children are those at risk and follow-up here is closer. Why not make your own experience now that you are in place ? Best wishes. Are there recommandations by the local health authorities ? I see an opportunity for some clinical research here, so best of luck. Simon

We do not routinely give vitamin D supplements to infants in my center and vitamin D deficiency rickets is not commonly seen in our area. Of course we have enough sunshine in Nigeria and vitamin D deficiency rickets is not a common problem in our environment, with a few exceptions where some people are made to stay indoors with doors/windows closed for sociocultural reasons.

Vit D supplementation could be reasonable for premature neonates, but for full term neonates; the body storage of Vit D is sufficient till the age of 3 months. However, osteomalacic or rachitic mothers or mother with other forms of malnutrition, their babies could suffer from early Vit D deficiency. However, fortunately most of malnourished mothers are usually from countries with good sun exposure which can compensate for the oral intake. Black skinned neonates could also be a target to early Vit D deficiency. I think, generalized VIt D prescription to all neonates is not reasonable and neonates how will be prescribed oral vit D supplement should be assessed first for the need for Vit D supplementation.

I personally feel that we should not get away with natural habits. therapeutic additions should only be after considering all factors

I think the vitamin D supplementation strategy should be region specific. In the areas where the sun exposure or parda is being practiced , it is possible that a lots of mother be Vitamin D deficient. You can check the mother's Vitamin d levels and accordingly prescribe. That is what we do here. The rate of neonatal rickets in the Southern India is quiet high.The dosage for the treatment and maintenance differ.

Germany - YES

Sweden- YES, from one month of age every day until 2 years and up to 5 years of age in risk-groups such as children born to vitamin-D-deficient mothers.

Finland -YES. From two weeks until 2 years( 10 µg/d). A supplement is recommended also for older children.

I am from Poland, all newborns from the first days of live are received orally 400U vitamin D per day. It is standard, current recomendation.

I am from Turkey. All newborns from two weeks are received 400 IU vitamin D. Although in our country sun shines most of the year, most of the mothers are vitamin d deficient.

Our ministry of health gives vitamin d drops till end of first year without any cost.

Pakistan- No national guidelines but I recommend vit d drops 400 i.u daily for the whole first year of life. The sun exposure required to get the daily requirement of vit D is not possible with changing life styles. It requires sun exposure for more than 20 min daily between 10 am to 4 pm. The sunlight beyond this time period does not help in making vit D as it has to traverse through a lot of atmosphere due to oblique angle of the sun. In the summers nobody exposes to bright sun light during afternoon hours.

Yes of course

Yes I agree, apart from the direct effect of vitamin D because it has the additional benefit of reducing the risk of diabetes for children's health is one of them.

Vitamin D3 is definitely better.