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Vitamin D Deficiency in Children

Bridget Coffie
Senior Seminar in Nutrition
NFS 4950
December 7, 2016
Prof. Laura Freeman Kull

In recent times, there have been numerous records indicating a high prevalence of
inadequate vitamin D status in children across the world.1 Connected with growing concerns

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about the health risks related to vitamin D status in children, this has stemmed into a global
increased interest in the topic of vitamin D deficiency in children. Scientists now recognize that
vitamin D deficiency has long-term consequences.2 A prolonged vitamin D deficiency is a
detriment to the a growing skeleton, resulting in rickets, an irrevocable bowing of the leg bone
and abnormality of the joint and teeth with long term implications on skeletal growth.3 Numerous
researchers have discovered the risk factors for vitamin D deficiency in children and these
include limited sun exposure,1 skin pigmentation, and low intake of vitamin D rich foods.4 Also,
low maternal-circulating vitamin D levels during pregnancy and lactation may impact bone
development.5 However, global vitamin D deficiency in children is preventable.3 This can be
achieved through lifestyle changes; a potentially powerful means of improving children's health
Vitamin D performs essential roles in the body which comprises of skeletal and
extraskeletal that are responsible for immune function and also accountable for calcium
homeostasis in ideal skeletal health. Vitamin D intensifies the intestinal potency in calcium
absorption. Again, vitamin D impedes autoimmune diseases, diabetes and also improves
immunity. Nevertheless, vitamin D has receptors, which are found in tissues such as type 1
helper T cells, macrophages, the prostate, the brain, and other tissues for proper functioning.
Research has documented that Vitamin D is deficient in children who are seriously sick.6
Vitamin D is pivotal for intestinal absorption of calcium and phosphorus into the bloodstream
because these two nutrients work collaboratively for proper development of bone to maximize
growth. Therefore, there is the need to keep this vitamin within normal range in the body.3
Studies revealed that the function of vitamin D is to elevate intestinal calcium absorption for
proper mineralization of bone.6

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Vitamin D is both a nutrient obtained from the food we eat and a hormone manufactured
by the body. Vitamin D is produced in the body in two forms, vitamin D2 called ergocalciferol
and vitamin D3 also known as cholecalciferol. The body manufactures vitamin D from
cholesterol via a process stimulated by the action of sunlight on the skin, yet some children do
not have enough vitamin D.6 Vitamin D is naturally formed when the skin becomes in contact
with ultraviolet B (UVB) radiation from sunlight. When this happens, the UVB perforate the
skin and have a connection with a substance called 7-dehydrocholesterol in the skin and
transforms it into vitamin D3. Vitamin D3 is then conveyed to the liver, where vitamin D2 is
obtained from food joins at this point and modify to 25-hydroxyvitamin D (25(OH)D which is
recognized as vitamin D status. This, in turn, changes in the kidneys to the active form of vitamin
D 1,25-dihydroxyvitamin D (1-25(OH)2D). 1-25(OH)2D function in collaboration with
parathyroid hormone (PTH) and calcitonin to sustain plasma calcium levels and is highly
controlled.4 These substances attach to vitamin D receptors to monitor expression of genes that
manage cell growth, immune function, muscle function, and calcium homeostasis.3
Vitamin D status is evaluated through the measurement of the blood concentration of its
metabolite, 25 (OH) D, which is the utmost circulating form of the vitamin, as an evidence of
both the dietary intake and cutaneous skin synthesis. Vitamin D deficiency occurs when
25(OH)D level is lower than 25 nmol/L; insufficiency is defined as between 25 and 50 nmol/L.3
World Health Organization (WHO) revealed that there is a global pandemic of acute and chronic
diseases such as disorders of calcium metabolism, autoimmune disease and infectious disease as
a result of vitamin D deficiency. Infants and young children who have vitamin D deficiency are
capable to remain in this condition for the rest of their lives and they are at a higher risk of
developing type 1 diabetes, multiple sclerosis, rheumatoid arthritis, and various forms of

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cancers. Again, vitamin D deficient children are at higher risk of insulin resistance and
metabolic syndrome.6

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A deficiency of vitamin D compromises the absorption of dietary calcium and
phosphorus, which causes poor mineralization of the skeleton.3 Statisticss obtained by the
Nutritional Diet and Nutrition Surveys (NDNS) divulged that the wide spread of vitamin D
deficiency in children is 7.5% of 1 -3-years old who are suffering from vitamin D deficiency.7
Rickets is mainly caused by vitamin D deficiency, in which defective mineralization of osteoid in
growing bones stems in soft bones and deformities of the skeleton. Moreover, numerous studies
have discovered that vitamin D deficiency in children can trigger muscle weakness and seizures
(owing to hypocalcaemia and severe deficiency in the perinatal period and early infancy). This
has a tendency of developing lifelong cardiomyopathy and may also promote myopathy of
skeletal muscle, which in toddlers may reflect as delayed motor development.3 A report from
pediatricians in the United Kingdom (UK) showed there is a growing number of rickets among
infant and children. Rickets is a manifestation of bowed legs that occurs when the child develops
weight on soft bones and as time goes by the child finds it difficult to walk. This condition has a
tendency to cause pain and muscle weakness and where there is hypocalcaemia (low calcium
level), the child may experience twitching, tingling, cramps and fits. Children normally become
vitamin D deficient for quite some time before rickets is detected and therefore the child is likely
to be in pain prior to detection of his or her problem of rickets.7 Again, vitamin D deficiency
causes dental problems with delay in tooth eruption and eventually develops cavities.7

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Nonetheless, statistics have shown that vitamin D deficiency has life-threatening
consequences in children. Research has increasingly associated chronic vitamin D deficiency
with serious health consequences consisting of osteoporosis, tuberculosis, type-1 diabetes,
cardiovascular disease, multiple sclerosis and several forms of cancer.8 Moreover, studies
investigated to find out if low vitamin D levels correlate increased risk for a wide variety of
diseases and conditions, including cancer, cardiovascular disease, hypertension, diabetes,
metabolic syndrome, falls, asthma, inflammatory bowel disease, Crohns disease, multiple
sclerosis, rheumatoid arthritis, systemic lupus erythematosus, tuberculosis, influenza, upper
respiratory infections, autism, cognitive function, depression, and pre-eclampsia. Some studies
confirmed that low vitamin D levels corresponded to an increased risk for the above mentioned
problems. Furthermore, the Harvard cohort studies also discovered the association between
decreasing vitamin D levels and increasing cancer risk. In addition, the Health Professional
Follow-Up Study disclosed that male children with deficient vitamin D levels are at a higher risk
for a myocardial infarction.9 Vitamin D deficiency has been reviewed as an important pediatric
health issue with complications, including
hypocalcemic seizures, rickets, limb pain, and
fracture. It has been discovered that clinical rickets
are the final stage of vitamin D deficiency, and the
child may live with the deficiency for several
months before rickets is diagnosed. 2
Comparatively, consequences of vitamin D
deficiency and insufficiency in children are bone
mineralization defects causing rickets. Vitamin D

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deficiency is a detriment to bone fractures and retard bone growth during bone development in
childhood. These consequences can virtually be averted with sufficient vitamin D intake or
supplementation.2 Calcium and vitamin D are considered as essential materials in human
systems because they do not only function in growth and bone health, but also contribute to
many other functions in the body, including muscle formation, the growth of blood vessels
(angiogenesis), the curb of glucose and insulin sensitivity, vascular health and the immune
system. Perturbation of calcium and vitamin D metabolism have been involved in the
development of adiposity, and cancer. Currently, there has been much discussion about whether
poor calcium and vitamin D status have a link with pre-eclampsia, premature birth and other
poor birth outcomes; poor organ formation and life-threatening conditions such as type 1
diabetes and multiple sclerosis; susceptibility to infection, autoimmune diseases, hypertension
and obesity.10
Vitamin D is vital for intestinal calcium absorption. The body has difficulty absorbing
calcium from the intestines when there is a deficiency of vitamin D, resulting in calcium
excretion from the kidney. In order to maintain plasma calcium levels, the body draws calcium
from the bones through the action of high levels of PTH, and this eventually leads to rickets in
children.4 Vitamin D is absorbed via the small intestine as a fat-soluble vitamin alongside with
dietary fat and is incorporated into chylomicrons and delivered through hepatic transport of
chylomicrons, which are the basic form of lipoproteins formed for the transport of dietary lipids.
Children with a gastrointestinal disease are prone to deficiencies of vitamin D. Symptoms that
are responsible for poor vitamin D status in children who have gastrointestinal diseases include
low vitamin D intake, fat malabsorption, loss of absorptive surface, increased intestinal
permeability, bile salt deficiency, and decreased liver function. Vitamin D has important effects

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on the immune system and preventive measures for certain cancers.2 Periods of increased needs
of vitamin D are early childhood, adolescence, pregnancy and when lactating.8
Notwithstanding, the metabolic pathway for vitamin D depends on a functioning liver
and gastrointestinal tract. Disturbances of the liver and gastrointestinal tract and surgical
procedures can negatively affect the absorption of vitamin D. Children with gastrointestinal
diseases are particularly vulnerable to vitamin D deficiency for multiple reasons. Many children
with inflammatory bowel disease (IBD) or celiac disease are periodically lactose intolerant,
which is capable of lowering vitamin D intake. Vitamin D absorption is chylomicron dependent,
such that children with fat malabsorption or bile salt deficiency are not able to absorb reasonable
amounts of vitamin D. Liver dysfunction can decrease the bioactivation of vitamin D and the
secretion and reabsorption of vitamin D metabolites and can also decrease the transport of
vitamin D. Certain diseases can alter intestinal function causing loss of absorptive surface or
increased permeability may fail to respond normally to the active vitamin D metabolites with
respect to calcium and phosphate absorption. Infants and children with chronic cholestatic liver
disease experience the consequences of malabsorption of fat and fat-soluble vitamin compounds
from the gastrointestinal tract.2
Apparently, many studies have concluded that vitamin D deficiency and insufficiency is
primarily caused by lack of exposure to sunlight and UVB rays.1 The prevalence of vitamin D
deficiency may be partially explained by the social and cultural practices that prevent children,
specifically girls, from receiving adequate exposure to sunshine. Particularly, females are often
expected to wear a veil for cultural reasons and to cover their bodies except for the face and
hands. The highest rate of vitamin D deficiency has been reported in other cultures and religions
that support the use of head coverings. Moreover, milk, the fundamental source of calcium for

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people in certain parts of the world, is quite expensive. It has been exhibited that low calcium
intake is the cause of childhood rickets. Dietary calcium deficiency can result in secondary
vitamin D deficiency.5 It is obvious that those individuals who are covered when outside for
religious or cultural reasons are unlikely to be sufficiently exposed to UVB to maintain optimal
vitamin D status.4
Surprisingly, there is a discovery of certain factors that reduce the ability of the skin to
synthesize vitamin D and this includes ultraviolet light from the sun being blocked by air
pollution, clothes, tall buildings, indoor dwelling, and sunscreens.2 In addition, children with a
body mass index of 30 or greater require a higher amount of vitamin D than normal intakes of
vitamin D to achieve 25 (OH) D levels as compared to those of average weight. It has also been
discovered that obesity does not influence the skins capacity to synthesize vitamin D, but greater
amounts of subcutaneous fat stores more of the vitamin and changes its release into circulation.
Also, people with dark skin or sedentary lifestyles, will need higher than recommended doses to
retain adequate levels of vitamin D for proper utilization. Vitamin D deficiency can transpire
when intake is lower than recommended levels over time, exposure to sunlight is limited, or
absorption of vitamin D from the digestive tract is inadequate; vitamin D deficient diets are also
connected with milk allergy, lactose intolerance, and Veganism.1
Extensive studies have documented that skin pigmentation affects the synthesis of
vitamin D in the body. The darker the skin, the more burdensome it becomes for UVB to reach
the part of the epidermis containing 7-dehydrocholesterol. It takes a longer period of time for
dark skin to synthesize vitamin D than light skin.4 Findings suggested that the geographic
incidence of sunshine exposure has a primary correspondence with the high rate of the disease.1
It has been expressed that there is also a genetic predisposition in populations across the world to

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vitamin D deficiency as a result of difference in vitamin D metabolism. Comparatively, some
studies have demonstrated that reductions in serum vitamin D and 25(OH)D occur as a result of
high increases of serum PTH and 1,25(OH)2D and this decreases serum calcium output in urine.4
Interestingly, maternal vitamin D status affects infants since the fetus obtains vitamin D
in the womb through the placenta, which supplies them with vitamin D for the first months of
life until they are capable of making their own. Therefore, babies born of mothers with a low
vitamin D status during pregnancy, are at risk of vitamin D deficiency.10 During pregnancy,
changes in the metabolism of calcium occur such that extra calcium can be apportioned for fetal
skeletal growth. Serum concentrations of 1,25-dihydroxyvitamin D [1,25 (OH) 2D] increase
levels by 50%100% during the second trimester and by 100% during the third trimester. It has
been propounded that the 1,25(OH)2D present in the maternal circulation may be of placental
genesis.
Nevertheless, maternal vitamin D levels during pregnancy demonstrate maternal and
neonatal calcium homeostasis. A woman who already has a high prevalence of vitamin
deficiency and poor dietary calcium intake, the problem is likely to worsen during pregnancy. It
has come to the realization that hypovitaminosis D during pregnancy may cause serious health
consequences such as rickets and tettany in the newborn.5 Although scientists have documented
that breast milk is the best source of food for babies, it does not contain adequate vitamin D.
Human milk contains just 15-50 IU/L vitamin D and this is too low to meet the recommended
requirements for babies. For this reason there is a tendency that when a woman is vitamin D
deficient during pregnancy, her offspring will also be vitamin D deficient. Newborn children of
women who have insufficiency of vitamin D status are more likely to have lower whole body
bone mineral content at age nine years.4 Again, investigations discovered that low maternal

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vitamin D can negatively impact the developing fetal brain, conceivably leaving affected
offspring at increased risk of adult-onset schizophrenia.5
However, vitamin D deficiency causing inconveniences in childrens lives has simple
preventive measures and this includes adequate sunlight exposure, dietary sources, and
supplementation. Prevention of vitamin D deficiency is very crucial to promote childrens
health. Public health professionals recommend sun exposure for at least 15 minutes daily to
prevent vitamin D deficiency in children.8 Sunlight has been considered to be the best source of
vitamin D as it it provides 80-90% to meet the bodys requirements. Sufficient vitamin D is
available during the day from 11:00am to 3:00 pm. Children should be allowed to play in the sun
unprotected for 5-30 minutes at least three times a week to maintain their vitamin D status.7 It is
advisable that at least the face, hands, and forearms should be exposed to the sun at the time of
playing for optimal vitamin D synthesis.3
Obviously, antenatal supplementation is critical in preventing vitamin D deficiency and
obtaining reasonable intake of vitamin D throughout childhood to eradicate the severity of health
related problems. Antenatal supplementation has been exhibited to increase maternal 25(OH)D,
which is directly linked to the infants serum 25(OH)D; however, levels of maternal
supplementation need to be appropriate and women need to be advised to take an antenatal
supplement containing vitamin D. Health professionals advise pregnant women and
breastfeeding mothers to take appropriate supplementation during the pregnancy/breastfeeding
period.4 As breast milk generally contains relatively little vitamin D, the National Institute for
Health and Care Excellence advocates the importance of educating women to appreciate vitamin
D supplementation during pregnancy and while breastfeeding.3 Recommendations of 8001,000

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IU daily are proposed for maintaining optimal vitamin D levels and maximizing the potential
preventive rickets-mechanism in children.
Undoubtedly, global studies have demonstrated a decrease in cancer occurrence, high rate
of rickets, and mortality with supplementation of 2,000 IU daily.1 The vitamin D status of an
infant is linked to the status of the mother during pregnancy, so infants born to mothers deficient
in vitamin D should be given supplementation from 1 month of age. Exclusively, breastfed
babies are at a greater risk of vitamin D deficiency. It has been suggested that all children aged 6
months to 5 years are given vitamin D supplements.7 Breastfed infant, of the age of 1 month, of
mothers who did not take vitamin D supplements during pregnancy should be given a daily
vitamin D supplement to combat deficiency. Children who have previously demonstrated to be
deficient or insufficient should keep on taking supplements in the long term until there is a
significant lifestyle change that improves vitamin D levels. Those who are identified as high risk
should also be advised to take supplements.3
Dietary intake rich in vitamin D is another essential tool for alleviating vitamin D
deficiency in children. Fresh salmon and cod liver oil contain a reasonable amount of vitamin D
which provides 6001,000 IU per serving, while fortified products such as milk, yogurt, orange
juice, and cereal provide only 100200 IU.1 It has been considered that oily fish e.g. mackerel,
salmon, red meat, egg yolks, mushrooms exposed to ultraviolet light, fortified margarine,
fortified breakfast cereals, yoghurt, and fortified infant formula contain significant amounts of
vitamin D.3
Vitamin D deficiency is a serious health problem among children across the world.
Children who are vitamin D deficient are at a high risk of skeletal deformities and they are also
prone to health related problems. Studies have discovered that factors such as limited sunshine

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exposure, skin color, and inadequate intake of dietary and supplementation of vitamin D are
associated with vitamin D deficiency in children. Also, low levels of vitamin D in maternal blood
during pregnancy affect the neonatal blood resulting in vitamin D deficiency for mother and
baby. This problem has drawn attention to health professionals, and have encouraged researchers
to delve into the causes in order to find preventive measures to alleviate vitamin D deficiency in
order to improve childrens health.3

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References

1. Mitchell D. The relationship between vitamin D and cancer. Clin J Oncol Nurs [serial
online]. 2011;15(5):557-560.
The author describes how people obtain vitamin D. She explains that inadequate
levels of vitamin D endanger childrens lives and specifically affects their bones. The
author points out that geographical location influences inadequate vitamin D in children.
Although sunshine is the primary source of vitamin D, too much exposure poses high risk
of skin cancer.

2. O'Malley T, Heuberger R. Vitamin D status and supplementation in pediatric

gastrointestinal disease. J Spec Pediatr Nurs [serial online]. 2011;16(2):140-150.
doi:10.1111/j.1744-6155.2011.00280.x.

The authors of this article affirm that children with vitamin D deficiency easily
develop gastrointestinal diseases due to malabsorption. Vitamin D deficiency is caused by
so many factors, such as dysfunction of certain organs that decreases vitamin D
absorption. They suggest that vitamin D levels in children should be monitored and to
administer suitable treatment to achieve vitamin D adequacy in children.

3. Sahota JK, Shaw N. Preventing vitamin D deficiency in children in the UK. Nurse
Prescribing [serial online]. 2014;12(12):596-602.
This study informs its readers that vitamin D is very vital for healthy bones and
promotes quality health and growth. The study describes how vitamin D deficiency
causes growth retardation and other health related problems in children in the United
Kingdom. All health professionals should work together to fight against vitamin D
deficiency in children.
4. Patience S. Vitamin D deficiency in at-risk groups. Community Pract. 2013;86(3):38-40.

The article addresses the important role of vitamin D in the immune system. The
author asserts that vitamin D deficiency has a relationship between a mothers level of
vitamin D and that of her breastfeeding baby. The goal of the study is to help health

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professionals to monitor mothers and their babies who are at a high risk of vitamin D
deficiency.
5. Kazemi A, Sharifi F, Jafari N, Mousavinasab N. High prevalence of vitamin D deficiency
among pregnant women and their newborns in an Iranian population. J Womens Health
(15409996) [serial online]. 2009;18(6):835-839. doi:10.1089/jwh.2008.0954.

The authors of this article ascertain that vitamin D plays a vital role during
pregnancy and this can affect both the mother and the baby. The study was conducted to
examine the identification of vitamin D inadequacy in pregnancy and the problems
associated with maternal blood and neonate blood. The authors investigate the causes of
hypovitaminosis D and the measures for treating it.

6. Belal Said N. Vitamin D Deficiency in Critically Ill Children. IJCS [serial online].
2014;7(2):381-389.
This article is intended to inform its readers about the relationship between
vitamin D deficiency and health related problems in children. The article depicts the
importance of vitamin D in the body and the need to know its requirements, and how to
keep it within normal range. The author advises health professionals and parents to be
familiar with vitamin D and its health implications and recommends preventive measures.
7. Patience S. Promoting vitamin D uptake in infants and children. Br. J Midwifery [serial
online]. 2015;23:10-13.

The author of this article states that parents and health professionals are in a better
position to monitor vitamin D intake in children and infant,s and to identify those who are
at risk of vitamin deficiency in children. The author suggests that parents and health
professionals use supplementation to meet vitamin D requirements due to its essential
roles in the body. Also, the author describes how children are easily prone to vitamin D
deficiency and suggests steps for prevention.

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8. Lockyer V, Porcellato L, Gee I. Vitamin D deficiency and supplementation: are we failing
to prevent the preventable?. Community Pract [serial online]. 2011;84(3):23-26.

The authors affirm that rickets is a general health problem in the United Kingdom
because health professionals do not pay attention to recommendations for vitamin D
supplementation and preventive measures. The vision of the study is to determine the
level of understanding of community midwifery about vitamin D deficiency and
supplementation. The author advises health professionals to realize the prevalence of
vitamin deficiency among children and to follow recommendations for supplementations.
Health professionals need to educate families of the problem and effective preventive
measures to eradicate rickets in children.
9. Grasso D, Rafferty MA. Vitamin D: Implications of the Institute of Medicine report for
clinical practice. Am J Nurse Pract. 2012;16(1/2):35-40.
The primary goal of this article is to address the consequences surrounding
vitamin D deficiency and suggests precaution measures for primary care nurse
practitioners. The authors investigate if low levels of vitamin D are associated with health
related problems. They point out that vitamin D plays an essential role in calcium and
phosphorous absorption.
10. Prentice A. Standing on the shoulders of giants: Understanding calcium and vitamin D
requirements. Nutr Bull [serial online]. 2013;38(3):323-331. dOI: 10.1111/nbu.12043.

The author of this article tries to update the knowledge of the general public about
calcium and vitamin D. The author explains that calcium and vitamin D work
collaboratively in the body. The author explains that nutrition and bone health of mothers
affects their babies and that rickets in children is associated with low calcium and low
vitamin D. The article indicates that children suffering from rickets can be cured with
enough sunlight exposure.

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