Addressing the supplementation needs of
the under 5s
Vitamin D Briefing 19 March 2012
Royal National Orthopaedic Hospital
Dr Robert Moy
Retired Senior Lecturer in Child Health
College of Medical and Dental Sciences
University of Birmingham
High prevalence of vitamin D deficiency in
children 1.5 to 2.5 years
Blood level of 25 hydroxyvitamin D <25 nmol/l
• White children
1%
• Bangladeshi children
20%
• Indian children
25%
• Pakistani children
34%
Lawson M. BMJ 1998;317:10-11
National Diet and Nutrition Survey 1995
Low Vitamin D status in pregnant women
• National Diet and Nutrition Survey 1995
– 28% females 19-24 years 25(OH)D < 25 nmol/l
– 50% ethnic minorities
• 160 non white pregnant women in South Wales 2002
– 50% 25(OH)D level < 20 nmol/l
• 198 white pregnant women in Southampton 2008
– 18% 25(OH)D level < 27.5 nmol/l
• pregnant Asian women in Birmingham 2011
20% 25(OH)D level < 15 nmol/l
Datta S et al. Brit J Obstetrics 2002;109:905-8
Gale C et al. Eur J Clin Nutr 2008;62:68-77
Caused by: 1. Limited sunlight exposure
•
>90% of vitamin D derived from UVB light
through photosynthesis of 7 dehydrocholesterol
in the skin
•
Fair skinned persons: 20-30 minutes on
face/forearms at midday in summer 2-3 times
per week
•
Pigmented skin persons: 2-10 times exposure
or frequency required
•
Oct to April inadequate UVB at UK latitude 5055º north
•
SF15 blocks 99% of skin synthesis
Pearce S Cheetham T.
Diagnosis and management of vitamin D deficiency. BMJ 2010;340:142-7
2. UK diet profoundly lacking in vitamin D
• Oily fish (trout, salmon, mackerel, herring, sardine,
anchovy, tuna) and fish oils (5-10 µg/100g)
• Egg yolk (5µg/100g)
• Red meat (1µg/100g)
• Breast milk (0.07µg/100ml)
Fortified sources
• Fortified breakfast cereals (3-8µg/100g)
• Margarine (7.5µg/100g)
• Formula (1.2µg/100ml)
SACN Update on Vitamin D 2007
Recent dietary evidence: NDNS 2008-2010
• Reference Nutrient Intake children 1.5 to 3 years
7 µg/day
• Average daily intake of vitamin D 1.9 µg/day
(27% of RNI)
• Only 7% toddlers taking any vitamin supplement
• Mean dietary intake of all other vitamins above
RNI
Bates B et al. National Diet and Nutrition Survey 2008/09-2009/10
Bridging the gap by
vitamin D supplementation
“ vitamin D intake cannot be met from the diet alone (or
usual sunlight exposure) and can only be guaranteed by
supplementation”
BUT
“there is concern that supplementation is being
overlooked or not implemented by health professionals
and the general public”
SACN Update on vitamin D 2007
Supplementation through welfare schemes
1940 Welfare
Food Scheme
1970 Welfare
Food Scheme
• Dried milk
• Cod liver oil
• Orange juice
• Dried eggs
• Vitamin drops
• Targeted programme
• Families in special
circumstances
1988 Welfare Food
Scheme
2006 Launch of
Healthy Start
•Targeted to families in
receipt of income support
and Job seekers allowance
•Milk tokens: Cow’s milk or
infant formula
•Vitamin supplements for
pregnant women and
children under 5 years
•Targeted to pregnant
women and families in
receipt of benefits or
pregnant women under
the age of 18
•Free milk fruit, vegetables
and vitamins for women
and children under 5
Vitamin D supplementation in 1950s
Vitamin D supplementation campaign
1979-1981
Promotion of vitamin D drops
to the Asian community
• posters and leaflets
• radio and TV
• video tapes
• Asian newspapers
• places of worship
• Asian GPs
• Community leaders
COMA recommendations for vitamin D
supplementation 1998
•
ALL pregnant women and breast feeding mothers should take a vitamin D
supplement
•
ALL infants should receive vitamin supplements unless they are having >
500 ml of fortified infant formula daily
•
Breast fed babies may delay supplements until 6 months if there mother
was in “good vitamin status” during pregnancy
•
Children over 1 year should have vitamins unless their diet is “diverse and
plentiful” and have exposure to sunlight
•
Children at high risk should take supplements until age 5 years eg living
in north of UK, from Asian/Islamic families, poor eaters, restricted or
exclusion diets, born with poor vitamin stores
Department of Health: Nutrition and Bone Health 1998
NICE guidance PH 11: Maternal and Child
Nutrition 2008
• Recommends Healthy Start vitamins for all children 6
months to 4 years and for all pregnant women eligible for
the Healthy Start scheme
• Recommends health professionals should promote
vitamin D supplements for all those not eligible for
Healthy Start, especially for pregnant women with limited
sun exposure, of south Asian, African, Caribbean or
Middle Eastern descent
NICE PH11 2008. Improving the nutrition of pregnant and
breastfeeding mothers and children in low income households
Chief Medical Officers’ letter 2 Feb 2012
ALL pregnant and breastfeeding women
require 10µg vitamin D daily
ALL infants and children aged 6 months to
5 years need 7-8.5µg daily
Breast fed infants whose mothers did not
take vitamin D in pregnancy require vitamin
D drops from age one month
Infants receiving > 500ml formula do NOT
require additional vitamin D
65 years+ not exposed to much sun should
take 10µg daily
Bridging the Gap by vitamin D supplementation
Current UK vitamin supplements for children
A
D
C
B
Minerals
IU
µg
mg
Healthy Start
700
7.5
20
-
-
Abidec
1333
10
40
+
-
Dalivit
5000
10
50
+
-
Haliborange
200
3.25
25
+
-
Well Kid
400
5
40
+
++
1µg vitamin D equivalent to 40 International Units
What is optimal vitamin D supplementation
for young children ?
• UK Reference Nutrient Intake: 7 - 8.5 µg/day up to 3 years
• USA: doubled recommended minimum intake from 5 to 10µg from soon after
birth (based on prevention of deficient blood level <50 nmol/l)
• Canada: recommends 20µg
north of latitude 55º October-April
(3 times vitamin D content of
Healthy Start drops)
Wagner C. Pediatrics 2008;122:1142-52
Importance of maternal vitamin D status
• Maternal vitamin D status determines neonatal vitamin D
status
• Poor maternal vitamin D status adversely affects fetal and
infant skeletal growth and bone ossification and tooth
enamel formation
• Inadequate vitamin D in breast milk to meet infant’s needs
unless mother and infant are exposed to sunlight
• Emphasises need for supplementation for pregnant and
lactating women
Specker BL. Am J Clin Nutr 1994;59:S484-91
Thomas S.
BMJ Open 2011;1:e000236
UNICEF UK Baby Friendly Initiative 21/12/2011
Vitamin supplements for pregnant and
lactating women
C
D
Folic acid
Healthy Start
70mg
10µg
400µg
Pregnacare
70mg
10µg
400µg
Is the current vitamin D supplementation
dosage in pregnancy and lactation adequate ?
1. Conclusion of RCT of 10µg, 50µg or 100µg vitamin D supplementation from
first trimester of pregnancy
100µg vitamin D is safe and most effective in achieving vitamin D sufficiency
in all women (defined as 25(OH)D >80nmol/l) (ie 10 times USA/UK
recommended dose )
2. Conclusion of RCT of 50µg or 100µg vitamin D supplementation of lactating
women
100µg is safe and ensures adequate vitamin D status of mother and nursing
infant
Current recommendations for vitamin D supplementation with 10µg:
“irrelevant”, “inconsequential” “ useless” !
Hollis B Wagner C. Am J Clin Nutr 2004;80:S175-8
Hollis B et al. J Bone and Mineral Research 2011;26:2341-57
Launched 2006
Department of Health: Scientific Review of
the Welfare Food Scheme 2002
Is the Healthy Start vitamin supplementation
programme working?
• Only those on benefits are eligible
• Many families at risk not covered by Healthy Start
• Estimated uptake of scheme:
80% of those eligible
• Uptake of vitamins very low:
2.7% children
4.0% women
• Significant problems with supplement supply and availability
Department of Health Healthy Start unit statistics available to PCTs
Feeding for Life Foundation survey of HCPs
• 51% are either not sure or are unaware of the UK Health
Departments’ supplementation recommendations
• 46% of those who are aware of the recommendations
don’t know which vitamins are recommended daily
• 56% don’t discuss the importance of vitamin
supplementation with all parents
The Feeding for Life Foundation survey was carried out by Opinion Health between
3rd to 13th October 2011, completed online with a sample of 155 healthcare
professionals and 1001 parents
Feeding for Life Foundation survey of parents
• 74% are not aware of the UK Health Department
recommendations
• 65 % of those aware of the recommendation do not
know which vitamins are recommended daily
The Feeding for Life Foundation survey was carried out by Opinion Health between
3rd to 13th October 2011, completed online with a sample of 155 healthcare
professionals and 1001 parents
Vitamin D deficiency in Heart of
Birmingham PCT
• 20% Healthy Start eligibility of pregnant women
• 75% of births to ethnic minority women with dark skin
• increasing use of modest Islamic dress
• no UV light at latitude 52 degrees in winter
• frequent cases of rickets and neonatal hypocalcaemic
seizures
HoB PCT vitamin D supplementation
• FREE Healthy Start Vitamin D tablets for ALL pregnant
women 2nd and 3rd trimesters
• FREE Healthy Start Vitamin D tablets for one year for
ALL post natal women (breast feeding or not)
• FREE Healthy Start Vitamin drops for ALL children from
2 weeks up to 4 years
• First bottle of Healthy Start drops provided by Health
Visitors at Primary (New Baby) visit
• Subsequent supplies from Health Centres, Sure Start,
pharmacists
• Universal untargeted approach
HoB public awareness about vitamin D
• Posters and leaflets in languages
• Community radio
• Shopkeepers
• Logo on shopping bags, trolley discs
• Baby T shirts, sun hats
HoB vitamin D programme outcomes
• Increased public awareness:
heard of vitamin D
specific knowledge
61% to 89%
21% to 79%
• Increased professional awareness:
• Increased uptake of supplements:
children: 7% to 17%
women: 4% to 17 %
• Decreased cases:
2006: 29 cases (incidence: 120/100,000)
2010: 12 cases
(49/100,000)
What are the issues ?
• In general vitamin deficiency is not really a problem for the
majority of children in UK
• EXCEPT for vitamin D especially in ethnic minority families
• Lack of Health Care Professional awareness about
supplementation
• Poor awareness about vitamin D among parents
• Healthy Start not covering all at risk families
• Very limited uptake of Healthy Start vitamin supplements
• Overly cautious approach to sunlight exposure
• Limited vitamin D food fortification
Bridging the gap in vitamin D status
• Advocacy for a new integrated public health policy aimed at
the elimination of rickets through:
Supplementation of pregnant and lactating women and
young children with an adequate dosage of vitamin D
Enhanced food fortification eg milk
• Improved awareness of Health Care Professionals
• Increased parental awareness
Acknowledgement:
Feeding for Life Foundation
•
An education initiative that aims to enhance knowledge and expertise in
early nutrition through training, research, raising awareness and
collaborative working
•
It’s education programme is led by a group of experts in child health and is
aimed at supporting health professionals and early-years practitioners
working with infants and toddlers
•
The Feeding for Life Foundation is supported by Cow & Gate but is a nonpromotion initiative which reflects and complements their continued
commitment to improving early nutrition as a way of influencing future health
outcomes.