Send letter to journal:
Re: Free vitamin D supplementation for every infant in Turkey

Dear Editor,

We read with interest the article by C S Zipitis, G A Markides and I L Swann concerning primary Care Trusts provide funds for vitamin D supplementation of Asian children for at least the first 2 years of life (1).

Nutritional rickets remains prevalent in developing regions of the world such as Africa, the Indian subcontinent, Asia and the Middle East, and ranks among the five most common diseases in children [2-4]. The prevalence of nutritional rickets in developed countries also appears to be rising [5-11].

In Turkey, nutritional rickets has long been among the leading diseases in childhood. Although the prevalence is not known, a recent study indicates that 6% of children under age 3 presenting to a general outpatient clinic were found to have nutritional rickets [12]. Maternal vitamin D deficiency is also endemic. Severe vitamin D deficiency was identified in 46 - 80% of pregnant women and nursing mothers in different regions of Turkey [13,14]. Similarly, almost half of the Turkish adolescent girls have varying degree of vitamin D deficiency [15].

Several life-style and environmental factors are likely responsible for the high prevalence of vitamin D deficiency in developing countries, as well as its resurgence in the developed world. . Inadequate exposure to sunlight is becoming more common as individuals spend more time indoors with access to television and computers, or actively avoid the outdoors because of concerns about pollution or the long-term effects of sun exposure on skin cancer. Cultural practices including traditional clothing (covered dress) for women and limited access to open space for pregnant and nursing women also limit adequate sunlight exposure [16]. In addition, there are increasing numbers of women breastfeeding and a decrease in the number of physicians routinely prescribing vitamin D supplementation for breastfed infants [17,18]. In the face of increasing reports of rickets, the American Academy of Pediatrics, the Department of Health’s committee on Medical Aspects of Food Policy in the UK and the European Society of Pediatric Endocrinology developed vitamin D intake guidelines for healthy infants, children and adolescents to prevent vitamin D deficiency and rickets. Daily supplementation of 200-400 IU vitamin D is recommended to all infants, particularly to those who are exclusively breastfed . There are, however, potential problems with the initiation and maintenance of vitamin D supplementation. These include limited public awareness, the cost of supplementation and limited access to health care. In 2003, the Bone Health Committee of Turkish Association of Pediatric Endocrinology issued a consensus document on vitamin D deficiency and its prevention in Turkey. The Turkish Medical Association facilitated its dissemination to all primary care providers. The consensus document defined two specific goals: 1) attain adequate vitamin D status for the whole population, particularly high risk groups such as infants, children, adolescents, pregnant and nursing women; 2) ensure early diagnosis and adequate treatment of nutritional rickets and osteomalacia. Proposed public health strategies to achieve these goals were: 1) develop a public awareness campaign to establish adequate sunlight exposure; 2) provide all infants with 400 IU/day vitamin D supplementation starting at birth; 3) educate primary care providers in the diagnosis and treatment of nutritional rickets and osteomalacia; 4) provide vitamin D supplementation to adolescent girls and women at risk, particularly those using traditional clothing (covered dress); 5) advocate for regulation mandating vitamin D enrichment of all dairy products. In 2004, the committee appealed to the Ministry of Health of Turkey to assume a leadership role in realizing these strategies. In May 2005, the Ministry of Health initiated a 5-year project coordinated by the General Directorate of Maternal Child Heath and Family Planning. This project will implement all the proposed strategies. A nationwide campaign has been launched to encourage the entire population, particularly pregnant and nursing women and infants, to have adequate sunlight exposure. A curriculum has been developed to train health care workers. The most significant step, however, is that the Ministry of Health will distribute vitamin D supplements to every newborn throughout infancy at no financial cost to families via its network of primary care units and maternal-child health centers. This should undoubtedly improve access to vitamin D supplementation and compliance with its use. We believe this initiative is a major step toward eliminating nutritional rickets in Turkey. It also is a unique opportunity to establish a model for populations in which vitamin D deficiency is a significant child health problem. Şükrü Hatun Abdullah Bereket Behzat Özkan Turgay Çoşkun Rıfat Köse Ali Süha Çalıkoğlu

References:

1. Zipitis CS, Markides GA , Swann IL. Vitamin D deficiency: prevention or treatment? Archives of Disease in Childhood 2006;91:1011-1014.

2. Bereket A. Rickets in developing countries. Endocr Dev. 2003;6:220 -232.

3. Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V. High prevalence of vitamin D deficiency among pregnant women and their newborns in northern India. Am J Clin Nutr. 2005 May;81(5):1060-1064.

4. Wharton B, Bishop N. Rickets. Lancet. 2003; 25;362:1389-1400.

5. Kreiter SR, Schwartz RP, Kirkman HN, Jr., Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr 2000; 137:153-157.

6. Shah M, Salhab N, Patterson D, Seikaly MG. Nutritional rickets still afflict children in north Texas. Tex Med 2000; 96:64-68.

7. Welch TR, Bergstrom WH, Tsang RC. Vitamin D-deficient rickets: the reemergence of a once-conquered disease. J Pediatr 2000; 137:143-145.

8. Wright A, Schanler R. The resurgence of breastfeeding at the end of the second millennium. J Nutr 2001; 131:421S-425S.

9. Tomashek KM, Nesby S, Scanlon KS, Cogswell ME, Powell KE, Parashar UD, Mellinger-Birdsong A, Grummer-Strawn LM, Dietz WH. Nutritional rickets in Georgia. Pediatrics 2001; 107:E45.

10. DeLucia MC, Mitnick ME, Carpenter TO. Nutritional rickets with normal circulating 25-hydroxyvitamin D: a call for reexamining the role of dietary calcium intake in North American infants. J Clin Endocrinol Metab. 2003; 88: 3539-45.

11. Ward LM. Vitamin D deficiency in the 21st century: a persistent problem among Canadian infants and mothers. CMAJ. 2005 15;172:769-770.

12. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes: National Academy of Sciences and Food and Nutrition Board. Washington, D.C., National Academy Press, 1997.

13. Ozkan B, Buyukavci M, Aksoy H, Tan H, Akdag R. Incidence of rickets among 0 to 3 year old children in Erzurum. Cocuk Sagligi ve Hastaliklari Dergisi 1999; 42:389-396.

14. Andiran N, Yordam N, Ozon A. Risk factors for vitamin D deficiency in breast-fed newborns and their mothers. Nutrition 2002; 18:47-50.

15. Pehlivan I, Hatun S, Aydogan M, Babaoglu K, Gokalp AS. Maternal vitamin D deficiency and vitamin D supplementation in healthy infants. Turk J Pediatr 2003;45:315-320.

16. Hatun S, Islam O, Cizmecioglu F, Kara B, Babaoglu K, Berk F, Gokalp AS. Subclinical vitamin d deficiency is increased in adolescent girls who wear concealing clothing. J Nutr. 2005 Feb;135(2):218-22.

17. Davenport ML, Uckun A, Calikoglu AS. Pediatrician patterns of prescribing vitamin supplementation for infants: do they contribute to rickets? Pediatrics. 2004; 113: 179-80.

Send letter to journal:
Re: Vit D deficiecy; Preventive measure usually more cost effective.

Dear Editor,

We read with interest the article by C S Zipitis, G A Markides and I L Swann regarding the cost of prevention and treatment of vitamin D deficiency [1]. We agree with the proposal that local authorities should provide funds to supplement vitamin D in ‘at risk’ ethnic minority groups.

Similar to Burnley, Oldham has a large Asian community of 20.8%. Between December 2002 and March 2004, we identified 9 cases of vitamin D deficiency. Out of these 9 patients 8 were of Asian origin.Six presented with hypocalcaemic symptoms (seizures, carpopedal spasms/cramps) and three presented with signs of rickets.

All patients responded well to treatment with Vitamin D. Three children also received oral calcium supplements.

A recent study on the prevalence of rickets in adults in the UK [2] showed a high prevalence of vitamin D deficiency (24%) in inner city Birmingham. One in 3 Asians were deficient. No data are available on the prevalence in children in the UK. Our experience and that of others [3] shows a growing number of vitamin D deficient patients. Looking at both financial and health implications we support the introduction of supplemental vitamin D to at risk populations as the most cost effective measure.

References:

1. Zipitis CS, Markides GA, Swann IL. Vitamin D deficiency: prevention or treatment? Archives of Disease in childhood 2006;91: 1011- 1014

2. Ford L, Graham V, Wall A, Berg J.Vitamin D concentrations in an UK inner-city multicultural outpatient population. Ann Clin Biochem. 2006;43(pt6): 468-473

3. Mughal MZ. Resurgence of vitamin D deficieny rickets in the UK. Osteoporosis Review 2005;13(1): 10-13.