October 14, 2008 — The American Academy of Pediatrics (AAP) has issued updated guidelines for vitamin D intake in infants, children, and teens to prevent rickets and vitamin D deficiency. The new recommendations were posted in the October 13 Early Release issue and will be published in the November 5 print issue of Pediatrics.

The recommendations were also presented at the American Academy of Pediatrics 2008 National Conference and Exhibition in Boston, Massachusetts.

The updated guidelines replace a 2003 AAP clinical report, which recommended a daily intake of 200 IU per day of vitamin D for all infants, from the first 2 months after birth, as well as for children and adolescents. The new recommendations call for a daily intake of 400 IU per day of vitamin D for all infants, children, and adolescents beginning in the first few days of life.

"Rickets attributable to vitamin D deficiency is known to be a condition that is preventable with adequate nutritional intake of vitamin D," write Carol L. Wagner, MD, Frank R. Greer, MD, and the AAP Section on Breastfeeding and Committee on Nutrition. "Despite this knowledge, cases of rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continue to be reported in the United States and other Western countries, particularly with exclusively breastfed infants and infants with darker skin pigmentation. Rickets, however, is not limited to infancy and early childhood, as evidenced by cases of rickets caused by nutritional vitamin D deficiency being reported in adolescents."

The primary natural source of vitamin D is from skin synthesis from cholesterol after exposure to UVB light. Natural dietary sources of vitamin D are limited, and the amount of sunshine exposure sufficient for the cutaneous synthesis of vitamin D is not easily determined for a given individual. Furthermore, that amount of sunshine exposure may increase the risk for skin cancer. Therefore, the AAP has revised its 2003 recommendations to ensure adequate vitamin D status to include all infants, including those who are exclusively breast-fed, as well as older children and adolescents.

All infants and children, including adolescents, should have a minimal daily intake of 400 IU of vitamin D beginning soon after birth, according to these revised guidelines. The current recommendation for healthy infants, children, and adolescents is based on findings from new clinical trials as well as on the historical precedent of safely administering 400 IU of vitamin D per day in the pediatric and adolescent populations. Furthermore, ingestion of 400 IU of vitamin D daily appears to treat as well as to prevent rickets.

New data suggest that vitamin D has a potential role in maintaining innate immunity and in reducing the risk for certain chronic diseases including diabetes and cancer. This new evidence may eventually change the definition of vitamin D sufficiency or deficiency. Currently, vitamin D insufficiency in adults is defined as a level of 25-hydroxyvitamin D of 50 to 80 nmol/L and vitamin D deficiency as a level less than 50 nmol/L.

Specific recommendations to ensure that healthy infants, children, and adolescents meet the required vitamin D intake of at least 400 IU per day are as follows:

1. Beginning in the first few days of life, breast-fed and partially breast-fed infants should be supplemented with 400 IU per day of vitamin D, and this should be continued unless the infant is weaned to at least 1 L per day or 1 quart per day of vitamin D–fortified formula or whole milk. Vitamin D levels in breast milk range from less than 25 to 78 IU/L, putting exclusively breast-fed infants at greater risk for vitamin D deficiency.

Whole milk should not be given until the infant is at least 1 year old. Use of reduced-fat milk between ages 12 months and 2 years is appropriate in those children for whom overweight or obesity is a concern or for those with a family history of obesity, dyslipidemia, or cardiovascular disease.

2. A vitamin D supplement of 400 IU per day is indicated for all non–breast-fed infants and for older children who are consuming less than 1000 mL per day of vitamin D–fortified formula or milk. The daily intake of each child may include other dietary sources of vitamin D, such as fortified foods.

3. A vitamin D supplement of 400 IU per day is indicated for adolescents who do not ingest 400 IU of vitamin D per day from vitamin D–fortified milk (100 IU per 8-oz serving) and vitamin D–fortified foods (such as fortified cereals and egg yolks).

4. Serum concentrations of 25-hydroxyvitamin D in infants and children should be at least 50 nmol/L (20 ng/mL), based on the available evidence.

5. Despite ingesting 400 IU per day, children at increased risk for vitamin D deficiency, such as those with chronic fat malabsorption and those chronically treated with antiepileptic drugs, may continue to be vitamin D deficient. Children with dark skin pigmentation require 5 to 10 times longer to generate vitamin D₃ from sunlight exposure.

Children in these groups may require higher doses of vitamin D supplementation to achieve normal vitamin D status, which should be evaluated with laboratory tests for concentrations of serum 25-hydroxyvitamin D and parathyroid hormone and measures of bone mineral status. When a vitamin D supplement is prescribed, 25-hydroxyvitamin D levels should be monitored every 3 months, and parathyroid hormone and bone mineral status should be monitored every 6 months, until levels normalize.

6. Pediatricians and other healthcare professionals should ensure that vitamin D supplements are readily available to all children in their community, especially to those who are at greatest risk.

Pregnant and lactating women who are vitamin D deficient may expose their offspring to a higher risk for vitamin D deficiency after birth and during lactation, and their vitamin D status should therefore be monitored. Although insufficient vitamin D intake in pregnant women adversely affects fetal skeletal development, tooth enamel formation, and general fetal growth, universal recommendations for high-dose vitamin D supplementation during pregnancy are not currently available.

"Along with adequate vitamin D intake, calcium intake to achieve optimal bone formation and modeling must be ensured," the guidelines authors conclude. "A dietary history is essential in assessing the adequacy of dietary intake for various vitamins, minerals, and nutrients, including vitamin D and calcium. Children and adolescents at increased risk of developing rickets and vitamin D deficiency, including those with increased skin pigmentation, decreased sunlight exposure, chronic diseases characterized by fat malabsorption (cystic fibrosis, etc), and those who require anticonvulsant medications (which induce cytochrome P450 and other enzymes that may lead to catabolism of vitamin D) may require even higher doses than 400 IU/day of vitamin D."

As with other AAP clinical reports, these guidelines automatically expire in 5 years unless reaffirmed, revised, or retired at or before that time. The recommendations in these guidelines are intended to prescribe an exclusive course of treatment or to serve as a standard of medical care. Variations in management considering individual patient circumstances may be appropriate.

Pediatrics. Published online October 13, 2008. 2008;122:1142-1152.

Clinical Context

Pearls for Practice

• Vitamin D supplementation at 400 IU per day should begin within the first few days of life and is especially recommended in breast-fed children, and supplementation may be higher for children with additional risk factors.
• Adolescents who do not consume adequate vitamin D in their diet should have an intake of 400 IU of vitamin D supplements daily.

CME/CE Test