The Importance of Vitamin D Supplementation in Children: Evidence and Recommendations

The alarming prevalence of vitamin D deficiency among American children has prompted significant concern from health organizations, leading to new recommendations. In the United States, 50% of children ages 1 to 5 and 70% of children ages 6 to 11 have vitamin D deficiency (Chauhan et al., 2023). Factors contributing to this deficiency include limited sun exposure, dietary insufficiency, and socioeconomic disparities, which disproportionately affect minority populations (Lautenbacher et al., 2016).

In light of these concerning statistics, the Endocrine Society has issued new guidelines in 2024 recommending that all children should receive vitamin D supplementation, either through fortified foods or a supplement. This recommendation is driven by evidence linking vitamin D deficiency to various health issues, including increased risk of nutritional rickets and respiratory infections. The guidelines emphasize the importance of proactive measures to ensure adequate vitamin D levels, particularly given the documented prevalence of deficiency and insufficiency among children.(The Endocrine Society., 2024).

The American Academy of Pediatrics has long advocated for vitamin D supplementation, suggesting a daily intake of 400 IU for infants and 600 IU for older children. However, compliance with these recommendations remains a challenge, as many children do not meet the recommended dietary allowance for vitamin D. The new guidelines from the Endocrine Society aim to address these gaps by reinforcing the necessity of supplementation, particularly in light of the seasonal variations that exacerbate deficiency rates during winter months (Sarau, 2024).

The Role of Vitamin D in Children’s Health

Vitamin D deficiency in children has been linked to several health problems, including:

Rickets: A condition characterized by soft and weak bones, leading to deformities and growth disturbances.
Osteomalacia: Softening of the bones, which can cause pain and increase the risk of fractures.
Increased Risk of Infections: Low vitamin D levels can impair immune function, making children more susceptible to respiratory infections and other illnesses.
Delayed Growth and Development: Vitamin D plays a role in bone health and overall growth; deficiency may hinder proper growth patterns.
Autoimmune Diseases: Some studies suggest that low vitamin D levels may be linked to an increased risk of autoimmune conditions, such as type 1 diabetes.
Mood Disorders: There is emerging evidence linking vitamin D deficiency to mood disorders, including depression and anxiety in children.
Dental Problems: Insufficient vitamin D can affect dental health, leading to issues like tooth decay and enamel defects.
Atopy: Insufficient vitamin D has been linked with poorly controlled asthma, eczema and allergies.

Recommendations from the Endocrine Society

According to the Endocrine Society’s 2024 guidelines, it is suggested that healthcare providers recommend empiric vitamin D supplementation for children and adolescents aged 1 to 18 years to prevent nutritional rickets and potentially lower the risk of respiratory tract infections. This supplementation may include a daily intake of fortified foods, vitamin D formulations, or supplements (pills or drops).

In the trials included in the Endocrine Society’s systematic review, the vitamin D dosages ranged from 300 to 2000 IU daily. The estimated median vitamin D dosage used in these studies was 811 IU daily. The estimated weighted average dosages were 1203 IU per day for any respiratory infection outcome and 1473 IU per day for the lower respiratory tract infection outcome.

See below for a link to their recommendation and supporting evidence:

Endocrine Society Vitamin D Recommendations

Safety of Vitamin D Supplements in Children

Vitamin D supplements are widely regarded as safe for children when taken at recommended dosages. The American Academy of Pediatrics advises a daily intake of 400 IU for infants and a minimum of 600 IU for children, while some may require higher doses if they are deficient. Additionally, recent guidelines from the Endocrine Society indicate that the average effective dose across various studies is approximately 800 IU per day, although specific recommendations may vary.

It is crucial to avoid excessive vitamin D intake. Consuming excess Vitamin D can lead to toxicity, resulting in hypercalcemia. Symptoms of vitamin D toxicity may include nausea, vomiting, weakness, polydipsia, and renal complications.

Vitamin D supplementation through Diet

Getting sufficient vitamin D through a well-balanced diet can effectively eliminate the need for supplementation. When children receive adequate vitamin D from their diet and, when appropriate, from sun exposure, they can maintain healthy levels without the need for additional supplements. Prioritizing dietary sources is one approach to ensure optimal vitamin D status, although it has its practical challenges.

Here’s a list of foods rich in vitamin D and the approximate amounts needed to achieve 800 IU per day:

Several barriers can prevent children from obtaining enough vitamin D through their diet, which should be taken into consideration:

Limited Food Options: Many common dietary sources of vitamin D, such as fatty fish, fortified dairy products, and egg yolks, may not be staples in every child’s diet, especially if they are picky eaters or have dietary restrictions.
Cultural Dietary Practices: Cultural preferences and dietary habits can influence food choices, potentially leading to insufficient intake of vitamin D-rich foods.
Nutritional Awareness: Many parents may not be aware of the importance of vitamin D or which foods are good sources, resulting in inadequate dietary planning.
Health Conditions: Certain medical conditions or dietary restrictions (like lactose intolerance or veganism) can limit access to natural sources of vitamin D.
Economic Factors: Access to a variety of nutritious foods can be constrained by economic limitations, making it difficult for some families to afford vitamin D-rich options.
Sun Exposure: In addition to diet, vitamin D is synthesized in the skin through sun exposure. Factors like living in northern latitudes, use of sunscreen, or limited outdoor activities can further impact overall vitamin D levels.

Addressing these barriers through education, access to fortified foods, and promoting a balanced diet can help improve vitamin D intake among children.

Discussion with Parents when Recommending a Dietary Supplement

Dosage: Ensure that the supplement provides an appropriate amount of vitamin D based on age and specific needs.
Form: It is advisable to choose vitamin D3 (cholecalciferol) over D2 (ergocalciferol), as D3 is more effective at raising and maintaining vitamin D levels in the bloodstream.
Supplement Type: Vitamin D is available in various forms including liquid, gummies, chewables, and pills. While gummies are popular, they often contain high sugar levels and can stick to teeth, potentially increasing the risk of dental issues. If gummies are advised, it’s important to discuss good dental practices, including flossing.
Purity and Quality: Choose supplements that are third-party tested for quality and free from harmful additives or contaminants.
Dietary Restrictions: Consider any allergies or dietary restrictions (e.g., vegetarian or vegan) when selecting a supplement.

Conclusion

Given the evidence supporting the importance of vitamin D for bone health, immune function, and overall well-being, healthcare professionals should consider the Endocrine Society’s 2024 recommendations for empiric supplementation with fortified foods or a supplement. By promoting sufficient vitamin D intake, healthcare providers can enhance health outcomes for children both now and in the future.

References

Cole, C. R., et al. (2010). “25-Hydroxyvitamin D Status of Healthy, Low-Income, Minority Children in Atlanta, Georgia.” *Pediatrics*, doi:10.1542/peds.2009-1928.
Lautenbacher, S., et al. (2016). “Vitamin D and pulmonary function in obese asthmatic children.” *Pediatric Pulmonology*, doi:10.1002/ppul.23485.
Radhakishun, Y., et al. (2014). “Efficacy and Tolerability of a High Loading Dose (25,000 IU Weekly) Vitamin D3 Supplementation in Obese Children with Vitamin D Insufficiency/Deficiency.” *Hormone Research in Paediatrics*, doi:10.1159/000362236.
Sarau, M., et al. (2024). “Exploring the Preventive Potential of Vitamin D against Respiratory Infections in Preschool-Age Children: A Cross-Sectional Study.” *Nutrients*, doi:10.3390/nu16111595.
Freishtat RJ, Iqbal SF, Pillai DK, Klein CJ, Ryan LM, Benton AS, Teach SJ: High prevalence of vitamin D deficiency among inner city-African-American youth with asthma in Washington, D.C. J Pediatr 2010;156:948–952.
Joshi M, Uday S. Vitamin D Deficiency in Chronic Childhood Disorders: Importance of Screening and Prevention. Nutrients. 2023 Jun 19;15(12):2805. doi: 10.3390/nu15122805. PMID: 37375708; PMCID: PMC10302516.
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