Recommendations for nutritional rickets announced

New consensus recommendations for the management of nutritional rickets include universal vitamin D supplementation during the first year of life.

This should have the same priority for public health as vaccinations, Wolfgang Högler (Birmingham Children’s Hospital, UK) told delegates at the European Society of Paediatric Endocrinology (ESPE) meeting in Dublin, Ireland.

The advised dose is 400 IU per day, which Högler stressed is safe regardless of children’s endogenous levels and is part of the reason they advise universal supplementation: “If you start to subcategorise everyone, it’s just a mess.”

Supplementation should be continued beyond the first year in children with risk factors for vitamin D deficiency, which include:

  • Being young or in a period of rapid growth
  • Exclusively breastfed without supplementation
  • Limited sun exposure for geographical or cultural reasons
  • Recent immigration and dark skin
  • Mother with vitamin D insufficiency
  • Restrictive diet, including low calcium

The recommendations were initiated by ESPE, but the consensus group of 33 experts included those from fields including epidemiology, nutrition and public health.

Another major recommendation is for vitamin D and calcium fortification of staple and complementary foods in high-risk populations, and the promotion and subsidisation of indigenous sources of calcium.

Högler noted that although rickets is “becoming increasingly prevalent and a global public health concern”, it may be just the “tip of the iceberg”, indicative of widespread vitamin D deficiency. This is partly a matter of geography, he said, with people living more than 34o North or South exposed to a “vitamin D winter”, but also results from cultural factors such as diet and use of veils. Immigrant or refugee groups who move north or south from equatorial regions are therefore at particularly high risk of rickets, said Högler.

The consensus group also hopes to establish systematic assessment of the prevalence of rickets, including mandatory reporting in low-prevalence countries.

When rickets is detected, vitamin D should be given for at least 12 weeks, at doses ranging from 2000 IU in infants younger than 3 months to 6000 IU in children older than 12 years, and a daily calcium intake of at least 500 mg should also be ensured. A single, larger dose is also possible where needed in children older than 3 months, with vitamin D3 advised in this instance due to its longer half-life.

Högler said that the full written recommendations are in progress and will be submitted for publication at the end of 2014.

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