Growing pains? Optimizing Bone Health and Vitamin D

Vitamin DUgh. My tongue is still infused with metallic-like sweet flavor, and I’m starting to feel sick to my stomach. I really need a drink of water, and then I need some chocolate to eliminate this horrid sensation. No, I didn’t just bite my tongue or swallow a frog. I have just tried a dose of my son’s liquid vitamin which – needless to say at this point – we have long since discontinued. In the bottle it looks healthy and innocuous, and on the label it looks useful. But when the medicine led to us pinning our son down and him spitting up all over us with each attempt at dosing – thus covering me with a syrupy sweet goo – I was hesitant. And then . . .when it quickly changed my son from smelling like a lovely baby to smelling . . . .multivitaminerous . . . I stopped. I’ll admit it. I just plain gave up.

And then I willfully forgot about giving Vitamin D supplements to my son. This was against all recommendations from the medical profession. The American Academy of Pediatrics suggests that all children get 400 IU of Vitamin D daily and the Institute of Medicine recently increased this recommendation to 600 IU of Vitamin D daily. I thought – can it be such a big deal? Despite lower content in breast milk, Vitamin D from breast milk is more bioavailable, right? And my son gets plenty of time outside anyway – 5 to 10 minutes of arm and leg exposure to the sun is supposed to help the body produce around 3000 IU of Vitamin D – far that more Vitamin D than he needs, right?

Well, last week I attended a CME (continuing medical education) conference on bone health in children taught by CHOP Endocrinologist Dr. Andrew Calabria and I am back on the Vitamin D supplementation bandwagon. Why?

Adequate Vitamin D is essential to bone health

According to a study conducted in 2000 by Heaney et al, bone mass peaks between age 20 and 30 – after that time, it plateaus for some years, and then into a woman’s menopause and late adulthood – after the 50s, bone mass gradually declines and fractures increase (see image at figure6-2.gif on the Surgeon General’s report on bone health). Adults in the study who faced environmental deficiencies in childhood – including low levels of exercise and decreased calcium and vitamin D intake – had a lower peak bone mass in their adult life. Furthermore, they faced a higher fracture risk as they aged. I don’t know about you, but I want strong bones. And I want my child to have strong bones as an adult, too. And building those strong bones begins now. Once he is an adult, he will have only what he has already developed.

A low Vitamin D level is very common

The disease rickets helps us see just how low vitamin D levels can adversely affect bone growth, as the deficiency leads to “frontal bossing” – or a protuberance to the front of the skull, outward bowing of the legs, thickened wrists and knees, and thickened areas of the ribs. I see this disease occasionally in my patient population – especially in new immigrants to the United states.

But Vitamin D deficiency is not always so obvious. Studies have shown up to 50% of children to have blood levels of Vitamin D of less than 30 ng/mL, which is considered to be in the range of insufficiency (the deficiency level is <20). 50% is no inconsequential number, and this percentage occurred across geographic areas – from the warmest to the coolest latitudes. Not sure why this is occurring – are we overzealous with the sunscreen in the wamer areas? Are children not getting time outside? Regardless, know this – taking the time to intervene now when your children are young could have big implications for the future, so why not give a small amount of vitamin as a part of the investment you have already placed in your child?

How much Vitamin D does the body need?

Give your child enough vitamin D that the body can use it, but don’t go overboard. Unless recommended by your doctor for medical reasons, do not go out and buy ultra-concentrated vitamin D, which could cause toxicity. The magic amount recommended for children is 600 IU daily for children ages 1-10, and 800 IU daily for children above 10 years. This recommendations comes from studies that were conducted looking at doses of the vitamin and seeing which ones had an effect on the vitamin D levels in the body.  Heaney has suggested that even higher levels and amounts of vitamin D could be optimal, but I would recommend looking at AAP and IOM recommendations for starters.

What type of Vitamin D is best?

animals_life_197321I’d always prefer that people get their Vitamin D from the sun or from their diet. 5-10 minutes of exposure of the arms and legs to the sun can help the body produce 3000 IU of Vitamin D, but this all depends on your skin (darker skin produces less vitamin D), where you live, the season, and how much sunlight you get. Unfortunately, even surfers in Hawaii have been found to be vitamin D deficient! So the next route is food sources. Vitamin D is a fat-soluble vitamin found in oily fish and in cod liver oil (yum!).  A 3.5 ounce serving of such fish – including wild salmon (600-1000IU), sardines(250-600IU), or mackerel (250IU) all can provide children with significant amounts of vitamin D. But this is not something that little L eats every day. . . or any day. Fortified products such as milk or egg yolk usually only provide around 100IU per serving. Because it is so difficult to get enough vitamin D through the diet, you can also try medical supplements of vitamin D.

Vitamin D comes in two forms that you can purchase as a supplement – Vitamin D2 (ergocalciferol – in some supplements, plant based) and D3 (cholecalciferol, in supplements, usually animal based). Both are suitable, but the more “bioactive” Vitamin D is D3 – so keep that in mind for when you are the store – D3 is the one that will likely absorb better and is more likely to increase your child’s blood levels of Vitamin D. It is available in several formulations – single vitamin drops, multivitamin drops, and in small capsules which can be swallowed by older children. You can also purchase Vitamin D with Calcium  in tablets suitable for older children.

Brand recommendations?

I do not endorse any specific brand, but keep your eye out for what is available. Do not be fooled into the limits placed by your hometown pharmacy – you may find the right supplement at another pharmacy or online. When my son was first born, I thought the only options were Poly-vi-sol, D-vi-sol, and Tri-vi-sol, which each provide 400IU of Vitamin D per mL of medication. But as I have indicated to you, to some these taste pretty bad and they have ingredients that some mothers I know have not been happy with. As for me, even getting 1mL of medicine into my son’s mouth has been a challenge!

Imagine my surprise when I learned that there were vitamin D drops that were just that – a single tasteless drop without artificial flavorings or colors that you could put on the breast or in the baby’s mouth or bottle nipple, and like that get him 400 IU of vitamin D. So my order is in online for Vitamin D drops. These are available from several vendors in bottles with with 200 or 400IU of Vitamin D per drop. I’m excited to try giving my son Vitamin D in this formulation. I think we will have infinitely more success than I had with the multivitamin preparations through which I’ve slogged. If you go this route as I have, make sure you get the right formulation for your child –  ultra concentrated varieties of 2000 to 5000 IU per drop are more suitable for children who have vitamin deficiencies.

What about Calcium?

It is also important that your child gets calcium along with the Vitamin D. Both need to be present together to help bone health. A child needs between 700 and 1300 mg daily of calcium, and this can easily be obtained through commonly eaten items such as milk or yogurt (8 oz gives 300 mg) or natural cheese (1.5 oz gives 300 mg). For vegans calcium sources are a bit trickier but 8 oz of fortified orange juice, 6 oranges, or 6 ounces of tofu can each provide 300 mg of calcium. In this article I’ve focused more on the Vitamin D quandary since this seems to be the vitamin more difficult to come by.

If you have any questions or anything to contribute to the discussion please send them my way and I look forward to feedback! Thanks for reading!

 

References, Acknowledgements, and additional sources:

Thank you Dr. Calabria for an excellent and enlightening talk that has enhanced my doctoring and my parenting!

figure6-2.gif

http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

http://www.ncbi.nlm.nih.gov/pubmed/11256898

 

 

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A pediatrician. Now turned first-time mom. Venting and giving you all the wisdom I acquire over the days . . .

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