new dietary reference intakes for calcium & vitamin d in children annual meeting... · 2015. 4....
TRANSCRIPT
1
Keli M. Hawthorne, MS, RD, LD Registered Dietitian, Pediatrics
Baylor College of Medicine
New Dietary Reference Intakes
for Calcium & Vitamin D
in Children
Keli M. Hawthorne, MS, RD, LD Registered Dietitian, Pediatrics
Baylor College of Medicine
…but really, mostly vitamin D
because that’s what we all want to
know about
Objectives
1. Understand new US guidelines for calcium and
vitamin D in healthy infants and children.
2. Learn to evaluate vitamin D status in children.
3. Examine current food sources of vitamin D and
ways to increase intakes in children's diets.
4. Appreciate risks of high dose vitamin D therapy and
limitations in current knowledge of vitamin D toxicity.
2
Disclosures
In the past, I have given CEU talks supported by the Texas Beef Council and the dairy industry
Rickets?
Sept 1931
Can’t please everyone of course
(Spokane)
3
Cures Everything?
History of vitamin D recommendations for children
Historically: 400 IU/day (tsp of cod liver oil) in “high risk” children.
1997 (IOM) and 2003 (AAP): 200 IU/day to prevent rickets (by 2 months of age, AAP) for all infants and children.
2008 AAP: 400 IU/day for all children beginning soon after birth
Strong pressure to revise government guidelines led to new IOM panel being formed in 2008.
2011: IOM new guidelines of 400-600 IU/day.
Globally, recommendations vary from none (India and others) with no milk fortification to 800 IU/day (Canadian Pediatric Society for infants in far north of Canada in Winter).
The language of dietary guidelines: Dietary Reference Intakes
Dietary Reference Intake (DRI): Daily nutrient recommendations based on age and gender; set at levels to decrease the risk of chronic disease
EAR - Estimated Average Requirement
RDA - Recommended Dietary Allowance
AI - Adequate Intake
UL - Tolerable Upper Intake Level
4
What are the DRIs?
Estimated Average Requirement (EAR)
Value to meet the needs of 50% of individuals.
Recommended Dietary Allowance (RDA)
Recommended daily levels of nutrients to meet the needs of almost all (97-98%) healthy individuals in a specific age and gender group.
Adequate Intake (AI)
Single value when not enough data or for use to reflect intake of breast-fed babies.
Tolerable Upper Intake Level (UL)
Maximum long-term intake that most likely won’t pose risks for health problems for almost all healthy people in that age and gender group. NOT a target intake. Derived based on pharmacological toxicity principles (No Adverse Effect Level, etc).
Dietary Reference Intake
The Estimated Average Requirement (EAR) is the intake at which the risk of inadequacy is 0.5 (50%) to an individual.
The Recommended Dietary Allowance (RDA) is the intake at which the risk of inadequacy is very small—only 0.02 to 0.03 (2% to 3%).
The Adequate Intake (AI) does not bear a consistent relationship to the EAR or the RDA because it is set without being able to estimate the average requirement. It is assumed that the AI is at or above the RDA if one could be calculated.
At intakes between the RDA and the Tolerable Upper Intake Level (UL), the risks of inadequacy and of excess are both close to 0. At intakes above the UL, the risk of adverse effects may increase.
Dietary Reference Intake
Effect of multiple days of observation on the apparent distribution of nutrient intake.
The mean is the same for both, but the percentage of individuals with intakes less than the Estimated Average Requirement (EAR) is overestimated by the 1-day observations. Adapted from NRC (1986); originally from Hegsted (1972).
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Improper Use of the DRIs
Mean nutrient intake of group is often compared to the RDA
Mean intakes ≥ RDA are assumed adequate Mean intakes < RDA are assumed deficient HOWEVER, this is not correct
Why improper?
If mean intakes ≥ RDA are assumed adequate, there may still be a large proportion of the group with inadequate intakes
If mean intakes < RDA are assumed deficient, there may still be individuals who have nutrient requirements below the RDA and therefore cannot be assumed to be deficient if intake is < RDA.
THEREFORE,
Use EAR if you are looking at groups
Use RDA if you are looking at an individual
Calcium DRIs by Life Stage (old vs new)
Life Stage Group 1997 AI (mg) 2011 EAR (mg) 2011 RDA (mg)
0-6 mo 210 210 (AI) --
7-12 mo 270 270 (AI) --
1-3 yr 500 500 700
4-8 yr 800 800 1000
9-13 yr 1300 1100 1300
14-18 yr 1300 1100 1300
19-30 yr 1000 800 1000
31-50 yr 1000 800 1000
51-70 yr Males 1200 800 1000
51-70 yr Females 1200 1000 1200
71+ yr 1200 1000 1200
Vitamin D DRIs by Life Stage (old vs new)
Life Stage Group 1997 AI (IU) 2011 EAR (IU) 2011 RDA (IU)
0-6 mo 200 400 (AI) --
7-12 mo 200 400 (AI) --
1-3 yr 200 400 600
4-8 yr 200 400 600
9-13 yr 200 400 600
14-18 yr 200 400 600
19-30 yr 200 400 600
31-50 yr 200 400 600
51-70 yr Males 400 400 600
51-70 yr Females 400 400 700
71+ yr 600 400 800
These seemed reasonable, but…..
6
So, how much vitamin D do children need?
Vitamin D Metabolism
7
Vitamin D: infants
2008 AAP and Pediatric Endocrine Society and 2011 IOM recommend 400 IU/day consistent with nearly 100 years of evidence of its effectiveness in preventing rickets.
Fundamental wording distinction:
AAP “all infants soon after birth” and for formula fed infants who do not consume 1 L of formula
IOM DRI reflects average intake over first year of life
AI used by IOM due to lack of data on outcomes at different 25-OHD levels in infants and historical evidence that 400 IU is effective.
Vitamin D infants: formula-fed
Infant Formula Act: 40 to 100 IU/100 kcal (27 to 67 IU/100 mL). Every formula bottle must be in that range at usual dilutions.
Usual US formulas have 60 IU/100 kcal (40 IU/100 mL), but due to overages, average content is about 75 IU/100 kcal (50 IU/100 mL).
First two months of life infants may typically receive 600-800 mL/day (240-320 IU/day) by label claim or 300-400 IU/day by average analysis of actual content.
Some suggest that all formula-fed infants get a vitamin D supplement until at 1 liter. Some babies never reach 1 L of formula intake nor is that a necessary goal.
How much vitamin D is needed?
Siafarikis et al, Arch Dis Child 2010 (online)
Breast-fed infants in Germany, no seasonal
variation in results. 250 IU daily is plenty.
But endpoint was 25-OHD level of uncertain
interpretation.
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So, should we supplement formula-fed babies?
Supplementing formula-fed babies (several million babies/yr at $50-100/baby) would be costly with no evidence of benefit.
About 300 IU/day in first weeks is close enough to save a few hundred million dollars.
Supplements not really needed for formula fed babies.
Vitamin D: Breastfed babies
Give 400 IU/day as a single dropper. Do not use high concentration drops (AAP and FDA 2010).
Can give from first week of life as D alone, multivitamins (tri or poly), or as multivitamins and iron (use for < 2500 g or < 37 weeks gestation at birth).
Change to multivitamins with Fe at 4 months (AAP 2010).
Give to partially breast-fed until fully weaned.
The real world
Perrine et al, Pediatrics, April 2010
9
Why is vitamin D not given to BF infants?
Pediatricians:
In the South we have sun!!
Cut-off for winter sun is south of Atlanta – some
controversy about this.
Old ideas of vitamin D sufficiency die hard.
Families:
No clinical problem apparent to families.
Concern about spitting, dislike of vitamins. It’s a hassle.
Cost: not available on public assistance. One 50 mL
bottle is about $8 or about 18 cents/day.
Mixed messages from advocacy groups and
pediatricians.
What should a child’s vitamin D level be?
Misra et al. for LWPES, Pediatrics 2008
10
Serum 25-OHD concentrations: IOM 2011
“Committee concluded that serum 25OHD levels of 16 ng/ml (40
nmol/liter) cover the requirements of approximately half the
population, and levels of 20 ng/ml (50 nmol/liter) cover the
requirements of at least 97.5% of the population.”
“Serum concentrations of 25OHD above 30 ng/ml (75 nmol/liter)
are not consistently associated with increased benefit, and risks
have been identified for some outcomes at 25OHD levels above 50
ng/ml (125 nmol/liter).”
“The Committee finds that the prevalence of vitamin D inadequacy
in the North American population has been overestimated by some
groups due to the use of inappropriate cut-points for these
categories that greatly exceed the levels identified in this report.”
Ross CM et al, JCEM 2011
U-shaped curve?
Visser et al, AJCN, 2006.
Mortality
risk in
elderly
Marker of vitamin D: Serum 25-OHD
Oct. 2009
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Vitamin D status of children
Mansbach et al. Pediatrics, Nov 2009:124:1404
We can change the world!
http://www.aruplab.com/guides/ug/tests/0080379.jsp
Accessed Jan. 13, 2011
Another view
www.vitamindcouncil.org
60 caps: 5000 IU
for $35.
compared to
generic about $3-
4.
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Measuring 25-OHD levels
Routine 25-OHD measurement not addressed by IOM, no evidence of value in healthy children.
Serum 25-OHD monitoring in preterm infants?
“Close monitoring of vitamin D status through each change in parenteral and enteral feedings must occur to assure adequate vitamin D status of these [preterm] infants” (Taylor et al., NeoReviews 2009).
“Routine measurement of serum 25-OHD levels in premature infants is not supported by currently available clinical research. No studies have related serum 25-OHD level in these infants to specific clinical outcomes.” (IOM 2011)
Risk/benefit and cost considerations on both an individual basis and public health basis should be considered in evaluating need for 25-OHD levels in any group.
Vitamin D supplementation and bone density in healthy children
Cochrane review (Winzenberg et al, Nov. 2010): No overall benefit. Very small effect in those with 25-OHD < 14 ng/mL.
Authors conclusions “These results do not support vitamin D supplementation to improve bone density in healthy children with normal vitamin D levels, but suggest that supplementation of deficient children may be clinically useful.
Note that deficient is defined by review < 14 ng/mL and that RDA of 600 IU/day will bring > 97.5% of the population of children to a level above 20 ng/mL.
How much calcium and vitamin D are children in the United States
consuming now?
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What We Eat in America, NHANES: Calcium
Mean Amount of Calcium Consumed per Individual
0
200
400
600
800
1000
1200
1400
2-5 years,
Males
2-5 years,
Females
6-11
years,
Males
6-11
years,
Females
12-19
years,
Males
12-19
years,
Females
Gender and Age Group
Calc
ium
(m
g/d
ay)
What We Eat in America, NHANES: Calcium
Mean Amount of Calcium Consumed per Individual
(EAR inserted for Gender and Age Groups)
0
200
400
600
800
1000
1200
1400
2-5 years,
Males
2-5 years,
Females
6-11
years,
Males
6-11
years,
Females
12-19
years,
Males
12-19
years,
Females
Gender and Age Group
Calc
ium
(m
g/d
ay)
1-3yo: 500 mg
4-8yo: 800 mg 4-8yo: 800 mg
9-13yo: 1100 mg 9-13 & 14-18yo: 1100 mg
What We Eat in America, NHANES: Calcium
Mean Amount of Calcium Consumed per Individual
0
200
400
600
800
1000
1200
1400
1600
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Race/Ethnicity and Age
Calc
ium
(m
g/d
ay)
2-5 Years 6-11Years 12-19 Years
1-3 Years: 500 mg
4-8 Years: 800 mg 4-8 Years: 800 mg
9-13 Years: 1100 mg 14-18 Years: 1100 mg
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What We Eat in America, NHANES: Vitamin D
Mean Amount of Vitamin D Consumed per Individual
0
50
100
150
200
250
300
2-5 years,
Males
2-5 years,
Females
6-11
years,
Males
6-11
years,
Females
12-19
years,
Males
12-19
years,
Females
Gender and Age Group
Vit
am
in D
(IU
/day)
What We Eat in America, NHANES: Vitamin D
Mean Amount of Vitamin D Consumed compared to EAR
0
100
200
300
400
500
2-5 years,
Males
2-5 years,
Females
6-11
years,
Males
6-11
years,
Females
12-19
years,
Males
12-19
years,
Females
Gender and Age Group
Vit
am
in D
(IU
/day) 1-3 & 4-8yo: 400 IU 4-8 & 9-13yo: 400 IU 9-13 & 14-18yo: 400 IU
What We Eat in America, NHANES: Vitamin D
Mean Amount of Vitamin D Consumed by Individuals
0
100
200
300
400
500
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Non
-Hispa
nic W
hite
Non
-Hispa
nic Black
Mex
ican
Am
erican
All Hispa
nic
Race/Ethnicity and Age
Vit
am
in D
(IU
/day)
2-5 Years 6-11 Years 12-19 Years
1-3, 4-8 yo: 400 IU 4-8, 9-13 yo: 400 IU 9-13, 14-18 yo: 400 IU
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DRI values for 1-18 years of age
RDA of 600 IU/day likely meets needs of most teens.
In adolescents, may have some greater risk with 600 IU/day RDA of not reaching 25-OHD of 20 ng/mL in more than 2.5% of population.
Clinical concerns of this are unclear.
Intake of 800 IU/day provides some margin, especially for dark-skinned population and those with no sun exposure.
DRI values did not address obese children specifically, nor did they address children with chronic illnesses.
No evidence that 25-OHD levels 40-80 ng/mL are dangerous in children, but limited data.
I’m hungry – what’s there to eat?
Common food sources of vitamin D
Food Serving Vitamin D IU/serving
Cod Liver Oil 1 Tbsp 1,360
Salmon (cooked) 3 oz 795
Milk 8 fl oz 100
Ca & Vit D fortified Orange Juice 8 fl oz 100
Sardines, canned in oil 2 each 46
Egg 1 whole 25
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Irradiated mushrooms: 400 IU vit D / 3 oz
Jasinghe et al. Br J Nutr. 2005 Jun;93(6):951-5. Bioavailability of vitamin D2
from irradiated mushrooms: an in vivo study.
Proven to make stronger bones in rats!
One Size Does Not Fit All: MARGARINE
Brand of Margarine (as of May 13, 2011)
Calcium
mg / Tbsp
Vitamin D IU / Tbsp
Land O’ Lakes® 0 0
Brummel & Brown® 0 0
Benecol® 0 0
Promise Fat Free® 0 0
Country Crock® spreadable butter and sticks 0 0
Country Crock® Honey Spread or Cinnamon Spread 100 0
Promise Buttery® Spread and Light Buttery Spread 0 60
Promise Active® Light Spread 0 60
Country Crock® Original, Light, and Churn Style 0 60
Country Crock® Calcium and Vitamin D 100 80
One Size Does Not Fit All: YOGURT
Brand of Yogurt (as of May 13, 2011)
Serving in
Container
Calcium mg/serv
Vitamin D
IU/serv
Dannon Activia® Light 6 oz 150 0
Brown Cow Farm® (all varieties) 8 oz 250 0
Dannon® Fruit on the Bottom 6 oz 250 0
Yoplait Kids® ("Calcium & Vitamin D for strong bones") 3 oz 200 20
Dannon Dan-o-nino® 1.76 oz 200 24
Yoplait Gogurt® 2.25 oz 100 40
Yoplait Trix® yogurt ("Ca & Vit D for strong bones") 4 oz 100 40
Dannon Danimals Smoothie® 3.1 oz 250 40
Dannon Activia® 5.75 oz 150 60
Dannon Danimals Crush Cup® Strawberry 4 oz 150 60
Stonyfield Greek® 6 oz 400 80
Stonyfield YoKids® 4 oz 200 100
Stonyfield Super Smoothie® 10 oz 400 100
Stonyfield Yo-baby® 4 oz 250 100
Lifeway ProBugs® - cultured smoothie (gooberry pie) 5 oz 300 100
Stonyfield Yo-baby® drinkable 6 oz 400 100
Yoplait Original® Strawberry 6 oz 500 200
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One Size Does Not Fit All: CEREAL
Brand of Cereal (as of May 13, 2011)
Serving
Size
Calcium
mg / serv
Vitamin D
IU / serv
Special K® (original) ¾ c (30g) 0 0
General Mills Raisin Nut Bran® ¾ c (49g) 20 0
Kashi Go Lean® ¾ c (39g) 60 0
Quaker Life (original)® ¾ c (32g) 100 0
General Mills Fiber One® ½ c (30g) 100 0
Kellogg’s Raisin Bran Crunch® 1 c (53g) 0 40
Special K® (vanilla almond) ¾ c (30g) 0 40
Post Raisin Bran® 1 c (59g) 20 40
Kellogg’s Raisin Bran® (original) 1 c (59g) 20 40
Kellogg’s Raisin Bran Extra® 1 c (49g) 20 40
General Mills Trix® 1 c (32g) 100 40
General Mills Lucky Charms® ¾ c (27g) 100 40
General Mills Cheerios® (all varieties) ¾ c (28g) 100 40
Total Whole Grain® (all Total varieties) ¾ c (30g) 1000 100
One Size Does Not Fit All: BREAD
Brand of Bread (as of May 13, 2011)
Calcium
Mg / slice
Vitamin D IU / slice
Nature’s Own® 100% Whole Grain 0 0
Nature’s Own® 100% Honey Wheat 0 0
Sara Lee Hearty & Delicious® 100% Whole Wheat 20 0
Mrs. Baird’s® 100% Whole Wheat 20 0
Nature’s Own® 100% Whole Wheat 40 0
Mrs. Baird’s® White 40 0
Pepperidge Farm® 100% Whole Wheat 40 0
Orowheat® 100% Whole Wheat 60 0
WonderKids® 200 24
Sara Lee Soft & Smooth Plus® 100% Whole Wheat w/ Calcium & Vit D 125 30
Sara Lee® White with Calcium & Vit D 125 30
Sara Lee Soft & Smooth Plus® Whole Grain White 125 30
Sara Lee® 100% Whole Wheat with Calcium & Vit D 125 30
Nature’s Own® Whole Grain White 100 40
Mrs. Baird’s® Whole Grain White 150 60
Gotta read those food labels
Calcium
% Daily Value for Calcium = 1000 mg (20% = 200 mg)
Vitamin D
% Daily Value for Vitamin D = 400 IU (10% = 40 IU)
1 mg vitamin D = 40 IU
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Don’t focus too much on one nutrient
How to get to 600 IU/day?
Diet: 1 L milk has 400 IU. Few kids drink that.
Fortified foods extremely variable. Yogurts, juices range from 0-200 IU/serving.
Cereals and other foods vary. Daily Value (DV) is 400 IU.
So “Good Source” is 40 IU and “Excellent Source” is 80 IU/serving.
Natural sources in fish are limited for most kids.
Be cautious of high dose supplements.
Sample Menus
What are the best and easiest ways to increase calcium and vitamin D intake among children?
19
Sample Menu: 6 year old child Meal Calcium (mg) Vitamin D (IU)
Breakfast: 1 biscuit
1 Tbsp jam
1 banana
4 fl oz orange juice
38
0
0
0
7
0
0
0
Lunch: 2 slices bread
2-3 oz deli turkey meat
1 slice provolone cheese
1 snack bag chips
6 fl oz water
0
0
212
0
0
0
0
6
0
0
Afternoon Snack: 1 oz bag potato chips
1 pouch Capri-Sun
8
6
0
0
Dinner: ½ cup spaghetti noodles
½ cup spaghetti sauce with meat
1 small slice garlic bread
6 fl oz skim milk
1 small brownie
5
34
15
225
14
0
3
3
86
8
TOTAL 557 mg/day 113 IU/day
Sample Menu: 6 year old child (Revised)
Meal Calcium (mg) Vitamin D (IU)
Breakfast: ¾ cup Cheerios
½ cup skim milk
1 banana
4 fl oz Ca & Vit D fortified orange juice
100
150
0
150
40
50
0
50
Lunch: 2 slices whole grain white bread
2-3 oz deli turkey meat
1 slice provolone cheese
1 snack bag chips
8 fl oz chocolate skim milk
300
50
212
0
300
100
0
6
0
100
Afternoon Snack: 6 oz Yoplait Original Yogurt
1 pouch Capri-Sun
500
6
200
0
Dinner: ½ cup spaghetti noodles
½ cup spaghetti sauce with meat
1 small slice garlic bread
8 fl oz skim milk
1 small brownie
5
34
15
300
14
0
3
3
100
8
TOTAL 2,136 mg/day 660 IU/day
Sample Menu: 14 year old Teenage Girl Meal Calcium (mg) Vitamin D (IU)
Breakfast: 1 Quaker chewy granola bar 5 0
Lunch: 2 slices Mrs. Baird’s white bread
3 oz deli turkey
1 oz bag potato chips
1 banana
1 pudding cup
12 fl oz soda
76
8
8
5
58
7
0
3
0
0
0
0
Afternoon Snack: ½ bag microwave popcorn
1 pouch Capri-Sun
3
6
0
0
Dinner: 2 slices pepperoni pizza
20 fl oz soda
1 brownie
335
12
14
17
0
8
TOTAL 527 mg/day 28 IU/day
20
Sample Menu: 14 year old Teenage Girl (Revised)
Meal Calcium (mg) Vitamin D (IU)
Breakfast: 1 Nutri-grain granola bar
8 fl oz Calcium & Vit D fortified orange juice
200
300
0
100
Lunch: 2 slices Mrs. Baird’s Whole Grain White
3 oz deli turkey
1 oz bag potato chips
1 banana
1 pudding cup
8 fl oz skim milk
400
8
8
5
58
300
80
3
0
0
0
100
Afternoon Snack: ½ bag microwave popcorn
8 fl oz skim milk
3
300
0
100
Dinner: 2 slices pepperoni pizza
20 fl oz soda
1 brownie
335
12
14
17
0
8
After Dinner: 6 oz Yoplait Original Yogurt 500 200
TOTAL 2443 mg/day 608 IU/day
Other non-bone benefits? Lots of association studies, very few trials
Immune – Type 1 DM?
Despite claims, no real evidence, especially in US.
Data on asthma are conflicting and no controlled trials.
Autism/Other neurological outcomes?
No real data – available data are ambiguous at best.
Anti-infectious, esp. influenza?
Maybe – esp. TB. Influenza data is limited
Cancer?
No data in children.
Cardiovascular?
No data in children.
Prevention of prematurity?
One study, not yet published. Need large trials
Influenza
• Japanese children
• 6-15 yrs of age
• Supplemented with
1200 IU/d Vit D3
• Urashima et al,
AJCN, May
2010:91:1255-60.
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Significant effect overall for Influenza A, not B or overall influenza. Wide Confidence intervals.
Subgroup analysis confusing and inconsistent
Substantial dropouts probably invalidate study
No vitamin D levels!!
Preliminary evidence, needs confirmation, large trials, varying doses with monitoring of levels
A couple of other issues
Obese children have lower serum 25-OHD. Unclear if this is a true deficiency and what is cause and effect.
Evidence that vitamin D OR calcium are major factors in weight regulation is questionable.
Vitamin D2 is probably comparable to D3 at moderate daily doses. May be less so at high intermittent doses.
Controversy about both safety and efficacy of intermittent high dose vitamin D – e.g. 200,000 units every 6 month. Not really recommended any more in children. May have very high acute levels and may not be as effective as daily or weekly dosing.
Vitamin D Fortified Sunscreen
200 IU in 1 oz available
Only 1 brand on market now
“Ocean Potion”
Fortified with Vitamin D3
No published studies
22
Conclusions
Controlled trials to identify vitamin D needs of children are
limited at best. Most of literature is “association” studies with
strong publication and other biases.
Research needs include short and long-term outcomes of
various intakes/25-OHD levels.
There are no compelling data establishing any single
“insufficient” 25-OHD level in children. 25-OHD > 20 ng/mL
consistent with available data.
“The plural of anecdote is not data.”
Conclusions
Breast-fed babies need their vitamin D drops.
Healthy kids need to get reasonable amounts of calcium and vitamin D. Dairy or other fortified foods are best sources, but may need small supplements such as are found in MVIs for children.
Beware of high dose supplements.
Do not buy into idea that chronic illnesses in children are vitamin D-related or treatable until reliable evidence says they are.
Can always try higher doses on an individual child, generally staying to UL values.
No role currently identified for routine monitoring of 25-OHD in healthy children.
Vitamin D Containing
Beer