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Clinical Review

Diagnosis and management of vitamin D deficiency

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.b5664 (Published 11 January 2010) Cite this as: BMJ 2010;340:b5664

Re: Diagnosis and management of vitamin D deficiency

Mega dose vitamin D supplementation in children in developing countries.

Sir,

Vitamin D deficiency has now been accepted as one of the major nutrition problems among children and is of paramount importance. The estimate that 70 – 100% children in the Indian subcontinent have vitamin D deficiency is not an exaggeration.( 1,2,3) In India alone the numbers would be overwhelming.There are three major approaches to the control of this problem: 1) improvement in sun exposure to ensure adequate intake of vitamin D; 2) fortification of foods with vitamin D; and 3) periodic administration of large doses of the vitamin D. No significant research has been carried out in developing countries on developing these intervention programmes and evaluating their impact on the large scale. Although the goal of controlling the forms of malnutrition may be difficult to attain, it is not unrealistic as far as vitamin D deficiency is concerned, provided that the knowledge now in hand is applied. Of the various measures available, the massive dose vitamin D programme could be regarded as a safe and potentially effective intervention to prevent vitamin D deficiency.

Studies to see the effect of vitamin D supplementation starting at two years of age, six monthly, by giving mega dose of 1,80000 International units each time (equivalent to 1000 iu / day) Assessing vitamin D levels at 5 years of age in this population of children and compared to those children who never received any supplement of vitamin D could potentially be a starting point to suggest to policy makers that mega vitamin D supplementation is a safe and effective method to counteract the menace of vitamin D deficiency which is endemic in countries like India. The effectiveness of periodic large dosing of the vitamin needs to be demonstrated. Such a study would lay to rest any scepticism about the efficacy of this method, and demonstrate for the first time that proper distribution of massive doses of vitamin D (1,80000 I U) can bring about a significant reduction in the incidence of vitamin D deficiency, and that periodic large dosing of vitamin D is conceptually simple. However, the operational aspects of a programme should receive much attention as otherwise any programme will be marred. For the delivery of vitamin D to the community: medical approach which offers treatment for children with rickets and, targeted approach which covers high risk groups are already in place. However, a universal system in which all preschool children are given the doses could be the most appropriate for a developing country like ours - ie covering all children and the first two components can be incorporated into the universal system.

Targeted delivery can reach only a minority of the “at risk” population. But a universal approach may be more successful. It is true that the absorption of vitamin D is incomplete in cases of giardiasis, which is very much prevalent in children. Although the most rational method to control this problem would be to treat giardiasis and consequent fat malabsorption, this does not mean that those infected with giardia do not benefit from therapeutic doses of vitamin D. Though the absorption may be lower, a child would still benefit from the amount absorbed. Vitamin D deficiency is a disease with a primary nutritional solution. Women play a crucial role in maintaining vitamin D nutrition of their children through breastfeeding. No concerted education campaigns seem to have been taken up to control vitamin D deficiency. For the prophylaxis programme to be effective, it should be aimed at the widest coverage of population which is at risk, and this should be done at minimum cost and with maximum community participation. We have an estimated 120 million preschool children in India as per the statistics published in Dec 2013 on the link www.unicef.org/infobycountry/india_statistics.html. Hence, local coverage cannot be expected to make a significant dent in the problem. It is here, perhaps, that the international agencies like WHO and UNICEF can contribute significantly by meeting the supply requirements.

References
1. Van Schoor, N.M.; Lips, P. Worldwide Vitamin D Status. Best Pract. Res. Clin. Endocrinol. Metab.2011, 25, 671–680, doi:10.1016/j.beem.2011.06.007.
2. Mithal, A.; Wahl, D.A.; Bonjour, J.P.; Burckhardt, P.; Dawson-Hughes, B.; Eisman, J.A.; El-Hajj Fuleihan, G.; Josse, R.G.; Lips, P.; Morales-Torres, J.; et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009, 20, 1807–1820, doi:10.1007/s00198-009-0954-6.
3. Van der Meer, I.M.; Middelkoop, B.J.; Boeke, A.J.; Lips, P. Prevalence of vitamin D deficiency among Turkish, Moroccan, Indian and sub-Sahara African populations in Europe and their countries of origin: An overview. Osteoporos. Int. 2011, 22, 1009–1021, doi:10.1007/s00198-010-1279-1.

Competing interests: No competing interests

13 June 2016
PUSHPENDRA MAGON
professor in department of pediatrics
none
punjab institute of medical sciences , jalandhar
PIMS medical college and hospital ,Garha road,Jalandhar