Calcium and Vitamin D from Infancy to Adolescence

 

Dr. Anuradha Vaman Khadilkar, MD (Paediatrics), DCH (London)
Deputy Director, Hirabai Cowasji Jehangir Medical Research Institute (HCJMRI), Jehangir Hospital, Pune.
Dr. Vaman Khadilkar , MD, DNB, MRCP(UK), DCH (London)
Consultant Pediatric & Adolescent Endocrinologist , Jehangir Hospital, Pune and Bombay Hospital, Mumbai

Calcium and vitamin D are critical for musculosketal health. One of the main actions of Vitamin D is for the absorption of calcium. The calcium that is absorbed is deposited in bones; bones act as a reservoir for calcium, and when there is a decrease in the serum calcium levels, bones are leached of calcium to maintain serum calcium concentrations for bodily functions.

While both calcium and vitamin D are important during the whole life cycle, deficiency of calcium and vitamin D during growing years can result in rickets or osteomalacia. Vitamin D deficiency has been described in India in all age groups, from infancy to adolescence. Cultural practices, a diet low in calcium and high in phytates , lack of fortification with vitamin D, as well as genetic factors such as increased 25(OH)D-24-hydroxylase (this degrades 25(OH)D to inactive metabolites), environmental pollution etc. are some of the reasons proposed for vitamin D deficiency in Indian children. Together with these factors, a change in lifestyle with sedentary behavior in children with reduced sunlight exposure increases the tendency for vitamin D deficiency. Further, premature babies and children with renal, hepatic disorders, malabsorptive states, etc. are at an increased risk for vitamin D deficiency.

Low intakes of dietary calcium, especially milk calcium, are common in Indian children.  Further, high amounts of phytates and oxalates in the diet hamper calcium absorption and the low calcium to phorphorous ratio in Indian diets results in poor absorption of calcium.

Thus, given the high prevalence of vitamin D deficiency in the Indian population (30-90%), the Indian Academy of Pediatrics has published guidelines for prevention and treatment of vitamin D and calcium deficiency in children and adolescents.

For the prevention of rickets in premature infants, 400 IU of vitamin D and 150-220 mg/kg of calcium, and in neonates, 400 IU of vitamin D and 200 mg of calcium daily have been recommended. For prevention of rickets and hypocalcemia in infants (after neonatal period) upto 1 year of age, and from 1-18 years, 400 IU and 600 IU vitamin D/day and 250-500 mg/day and 600-800 mg/day of calcium, respectively, have been recommended. For treatment of rickets in premature neonates, infants upto 1 year and from 1-18 years, 1000 IU, 2000 IU and 3000-6000 IU of vitamin D daily, respectively, and elemental calcium of 70-80 mg/kg/day in premature neonates and 500-800 mg daily for all children over that age are recommended. Larger doses of vitamin D have been prescribed from 3 months to 18 years of age as 60,000 IU/week for 6 weeks. Age appropriate doses of calcium and vitamin D have been advised for maintenance post therapy. Minimum treatment for vitamin D and calcium deficiency is advised for 3 months. If there are no radiological and biochemical signs of healing after 3 months, the patient may need to be investigated for non- nutritional rickets

Vitamin D3 (cholecalciferol) has been reported to have greater efficacy in raising 25(OH)D concentrations; most supplements available thus contain D3. Most calcium supplements contain calcium carbonate, though preparations with gluconate and citrate are also available. Calcium carbonate contains the highest amount of elemental calcium (40%) compared to other preparations (gluconate, citrate). Thus, given the lower price and higher amount of elemental calcium, it should be the first choice.

As a long-term policy, fortifying staple foods, which may be consumed by the at-risk segments of the population, with calcium and vitamin D is the solution to calcium and vitamin D deficiency. Till the time this can be implemented, supplementation of infants with 400 IU, and children and adolescents with 600 IU daily and higher doses for at-risk groups, with adequate calcium intake for prevention of deficiency, is necessary.

References

Prevention and Treatment of Vitamin D and Calcium Deficiency in Children and Adolescents:

  • Indian Academy of Pediatrics (IAP) Guidelines. From Indian Academy of Pediatrics ‘Guideline for Vitamin D and Calcium in Children’ Committee, Khadilkar A, Khadilkar V, Chinnappa J, Rathi N, Khadgawat R, Balasubramanian S, Parekh B, Jog P. Indian Pediatr. 2017 Jul 15;54(7):567-573.
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