Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics

revised

  • 111(4):908
FROM THE AMERICAN ACADEMY OF PEDIATRICS

Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents

Carol L. Wagner, Frank R. Greer and ; and the Section on Breastfeeding and Committee on Nutrition
Pediatrics November 2008, 122 (5) 1142-1152; DOI: https://doi.org/10.1542/peds.2008-1862
Carol L. Wagner
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Frank R. Greer
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • Comments
Loading
Download PDF

Abstract

Rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continues to be reported in the United States. There are also concerns for vitamin D deficiency in older children and adolescents. Because there are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase the risk of skin cancer, the recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed and older children and adolescents. It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. The current recommendation replaces the previous recommendation of a minimum daily intake of 200 IU/day of vitamin D supplementation beginning in the first 2 months after birth and continuing through adolescence. These revised guidelines for vitamin D intake for healthy infants, children, and adolescents are based on evidence from new clinical trials and the historical precedence of safely giving 400 IU of vitamin D per day in the pediatric and adolescent population. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer. The new data may eventually refine what constitutes vitamin D sufficiency or deficiency.

  • vitamin D
  • vitamin D deficiency
  • rickets
  • vitamin D requirements
  • infants
  • children
  • adolescents
  • 25-hydroxyvitamin D
  • vitamin D supplements

INTRODUCTION

This statement is intended to replace a 2003 clinical report from the American Academy of Pediatrics (AAP),1 which recommended a daily intake of 200 IU/day of vitamin D for all infants (beginning in the first 2 months after birth), children, and adolescents. The new recommended daily intake of vitamin D is 400 IU/day for all infants, children, and adolescents beginning in the first few days of life.

BACKGROUND

Rickets attributable to vitamin D deficiency is known to be a condition that is preventable with adequate nutritional intake of vitamin D.2–6 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.4,7–14 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.15

Rickets is an example of extreme vitamin D deficiency, with a peak incidence between 3 and 18 months of age. A state of deficiency occurs months before rickets is obvious on physical examination, and the deficiency state may also present with hypocalcemic seizures,16–18 growth failure, lethargy, irritability, and a predisposition to respiratory infections during infancy.16–22 In a retrospective review of children presenting with vitamin D deficiency in the United Kingdom,16 there were 2 types of presentations. The first was symptomatic hypocalcemia (including seizures) occurring during periods of rapid growth, with increased metabolic demands, long before any physical findings or radiologic evidence of vitamin D deficiency occurred. The second clinical presentation was that of a more chronic disease, with rickets and/or decreased bone mineralization and either normocalcemia or asymptomatic hypocalcemia. (For a more complete review of nutritional rickets and its management, please refer to the recent publication in Endocrinology and Metabolism Clinics of North America on the topic.23)

There are 2 forms of vitamin D: D2 (ergocalciferol, synthesized by plants) and D3 (cholecalciferol, synthesized by mammals). The main source of vitamin D for humans is vitamin D3 through its synthesis in the skin when UV-B in the range of 290 to 315 nm converts 7-dehydrocholesterol into previtamin D3. Through the heat of the skin, previtamin D3 is further transformed into vitamin D3, which then binds to the vitamin D–binding protein and is transported to the liver and converted to 25-hydroxyvitamin D (25-OH-D) by the action of 25-hydroxylase. 25-OH-D, the nutritional indicator of vitamin D, undergoes a second hydroxylation in the kidney and other tissues to become 1,25-dihydroxyvitamin D (1,25-OH2-D). Vitamin D is an important prehormone with active metabolites (25-OH-D and 1,25-OH2-D) that are involved in many metabolic processes beyond bone integrity and calcium homeostasis.24 More-detailed reviews of vitamin D physiology and metabolism are available from Hathcock et al,25 Holick,26 Webb,27 and Misra et al.23

It is important to note that measuring the concentration of 1,25-OH2-D instead of 25-OH-D for assessment of vitamin D status can lead to erroneous conclusions, because 1,25-OH2-D concentrations will be normal or even elevated in the face of vitamin D deficiency as a result of secondary hyperparathyroidism (see Table 1). Prevention of vitamin D deficiency and achieving adequate intake of vitamin D and calcium throughout childhood may reduce the risk of osteoporosis as well as other long-latency disease processes that have been associated with vitamin D–deficiency states in adults.28–31

View this table:
  • View inline
  • View popup
TABLE 1

Vitamin D Deficiency: Stages and Clinical Signs

The presence of vitamin D as a natural ingredient in food in most diets is limited, occurring in relatively significant amounts only in fatty fish and certain fish oils, liver and fat from aquatic mammals, and egg yolks of chickens fed vitamin D.32 In adults, new evidence suggests that vitamin D plays a vital role in maintaining innate immunity33 and has been implicated in the prevention of certain disease states including infection,34,35 autoimmune diseases (multiple sclerosis,28,33,36,37 rheumatoid arthritis38), some forms of cancer (breast, ovarian, colorectal, prostate),24,30,39–42 and type 2 diabetes mellitus.43–45 Results from prospective observational studies also suggest that vitamin D supplements in infancy and early childhood may decrease the incidence of type 1 diabetes mellitus.46–50

RECOMMENDED DAILY INTAKE OF VITAMIN D FOR INFANTS AND CHILDREN

In partnership with the Institute of Medicine, the National Academy of Sciences Panel for Vitamin D recommended in 1997 a daily intake of 200 IU vitamin D to prevent vitamin D deficiency in normal infants, children and adolescents.51 This recommendation was endorsed by the AAP in a previous clinical report.1 The National Academy of Sciences guidelines for infants were based on data primarily from the United States, Norway, and China, which showed that an intake of at least 200 IU/day of vitamin D prevented physical signs of vitamin D deficiency and maintained the concentration of 25-OH-D at or above 27.5 nmol/L (11 ng/mL).† These recommendations were made despite 50 years of clinical experience demonstrating that 400 IU of vitamin D (the concentration measured in a teaspoon of cod liver oil) not only prevented rickets but also treated it.52–55 Primarily on the basis of new information in adults linking other biomarkers (parathyroid hormone [PTH], insulin resistance, bone mineralization, and calcium absorption studies) to vitamin D deficiency, there is a growing concern that the previous recommendation of 200 IU/day as an adequate intake of vitamin D is not sufficient, even for infants and children.53,56–61

This new information has resulted in defining vitamin D deficiency in adults as a 25-OH-D concentration of <50 nmol/L and vitamin D insufficiency as a 25-OH-D concentration of 50 to 80 nmol/L.25,26,62–67 At the present time, however, consensus has not been reached with regard to the concentration of 25-OH-D to define vitamin D insufficiency for infants and children.66–69 Although there may not be a precise definition of what constitutes vitamin D insufficiency in infants and children, it is known that 200 IU/day of vitamin D will not maintain 25-OH-D concentrations at >50 nmol/L in infants, the concentration attributed to vitamin D sufficiency in adults.62,67,70–74 On the other hand, 400 IU/day of vitamin D has been shown to maintain serum 25-OH-D concentrations at >50 nmol/L in exclusively breastfed infants.73 It is also of note that liquid vitamins and vitamin D–only preparations available in the United States conveniently supply 400 IU/day, not 200 IU/day, in either drop or milliliter preparations.

SUNLIGHT EXPOSURE AND VITAMIN D

Historically, the main source of vitamin D has been via synthesis in the skin from cholesterol after exposure to UV-B light. Full-body exposure during summer months for 10 to 15 minutes in an adult with lighter pigmentation will generate between 10000 and 20000 IU of vitamin D3 within 24 hours; individuals with darker pigmentation require 5 to 10 times more exposure to generate similar amounts of vitamin D3.75–78 The amount of UV exposure available for the synthesis of vitamin D depends on many factors other than just time spent outdoors. These factors include the amount of skin pigmentation, body mass, degree of latitude, season, the amount of cloud cover, the extent of air pollution, the amount of skin exposed, and the extent of UV protection, including clothing and sunscreens.56,77,79–81 The Indoor Air Quality Act of 1989 reported that Americans spent an average of 93% of their time indoors,82 supporting the higher prevalence of lower 25-OH-D concentrations among adult Americans.83,84 More recently, vitamin D deficiency (as defined by concentrations of 25-OH-D < 25 nmol/L) among school-aged children and adolescents has been reported, reflecting modern-day lifestyle changes.3,6,9,58,85–96

The multitude of factors that affect vitamin D synthesis by the skin,27 the most important of which is degree of skin pigmentation, make it difficult to determine what is adequate sunshine exposure for any given infant or child.97–99 Furthermore, to limit exposure to UV light, the Centers for Disease Control and Prevention, with the support of many organizations including the AAP and the American Cancer Society, launched a major public health campaign in 1998 to increase public awareness about sunlight exposure and the risks of various skin cancers.100 Indirect epidemiologic evidence now suggests that the age at which direct sunlight exposure is initiated is even more important than the total sunlight exposure over a lifetime in determining the risk of skin cancer.101–105 Among dermatologists, there is active discussion about the risks and potential benefits of sun exposure and/or oral vitamin D supplementation97,99,106; however, the vast majority would agree with the current AAP guidelines for decreasing sunlight exposure, which include the advice that infants younger than 6 months should be kept out of direct sunlight. Although the AAP encourages physical activity and time spent outdoors, children's activities that minimize sunlight exposure are preferred, and when outdoors, protective clothing as well as sunscreens should be used.105 In following these guidelines, vitamin D supplements during infancy, childhood, and adolescence are necessary.

PREGNANCY, VITAMIN D, AND THE FETUS

The Institute of Medicine in 199751 and a Cochrane review in 2002107 concluded that there are few data available regarding maternal vitamin D requirements during pregnancy, despite the fact that maternal vitamin D concentrations largely determine the vitamin D status of the fetus and newborn infant. With restricted vitamin D intake and sunlight exposure, maternal deficiency may occur, as has been documented in a number of studies.107–113

Recent work has demonstrated that in men and nonpregnant women, oral vitamin D intake over a 4- to 5-month period will increase circulating 25-OH-D concentrations by approximately 0.70 nmol/L for every 40 IU of vitamin D ingested,114,115 which is consistent with earlier work performed in pregnant women. In those studies, as predicted by vitamin D kinetics, supplements of 1000 IU/day of vitamin D to pregnant women resulted in a 12.5 to 15.0 nmol/L increase in circulating 25-OH-D concentrations in both maternal and cord serum compared with nonsupplemented controls.108–110 Maternal 25-OH-D concentrations ranged from a mean of approximately 25 nmol/L at baseline to 65 ± 17.5 nmol/L at 230 days of gestation in the group of women who received 1000 IU of vitamin D per day during the last trimester. In comparison, 25-OH-D concentrations were 32.5 ± 20.0 nmol/L in the unsupplemented control group. These data suggest that doses exceeding 1000 IU of vitamin D per day are necessary to achieve 25-OH-D concentrations of >50 nmol/L in pregnant women.108–115 The significance of these findings for those who care for the pediatric population is that when a woman who has vitamin D deficiency gives birth, her neonate also will be deficient.

It is important to note that women with increased skin pigmentation or who have little exposure of their skin to sunlight are at a greater risk of vitamin D deficiency and may need additional vitamin D supplements, especially during pregnancy and lactation.71 In a study by van der Meer et al,116 >50% of pregnant women with darker pigmentation in the Netherlands were vitamin D deficient, as defined by a 25-OH-D concentration of <25 nmol/L.

Studies in human subjects have shown a strong relationship between maternal and fetal circulating (cord blood) 25-OH-D concentrations.117–120 With severe maternal vitamin D deficiency, the fetus may rarely develop rickets in utero and manifest this deficiency at birth.71 Supplementation with 400 IU of vitamin D per day during the last trimester of pregnancy has minimal effect on circulating 25-OH-D concentrations in the mother and her infant at term.112 An unsupplemented infant born to a vitamin D–deficient mother will reach a state of deficiency more quickly than an infant whose mother was replete during pregnancy.71

Adequate nutritional vitamin D status during pregnancy is important for fetal skeletal development, tooth enamel formation, and perhaps general fetal growth and development.121 There is some evidence that the vitamin D status of the mother has long-term effects on her infant. In a recent Canadian study by Mannion et al comparing growth parameters in newborn infants with the maternal intakes of milk and vitamin D during pregnancy, investigators found an association between vitamin D intake during pregnancy and birth weight but not infant head circumference or length at birth.122 With every additional 40 IU of maternal vitamin D intake, there was an associated 11-g increase in birth weight. Another study of the intrauterine effect of maternal vitamin D status revealed a significant association between umbilical cord 25-OH-D concentrations and head circumference at 3 and 6 months' postnatal age that persisted after adjustment for confounding factors.109,111 A study performed in the United Kingdom during the 1990s demonstrated that higher maternal vitamin D status during pregnancy was associated with improved bone-mineral content and bone mass in children at 9 years of age.123

Given the growing evidence that adequate maternal vitamin D status is essential during pregnancy, not only for maternal well-being but also for fetal development,71,122,124,125 health care professionals who provide obstetric care should consider assessing maternal vitamin D status by measuring the 25-OH-D concentrations of pregnant women. On an individual basis, a mother should be supplemented with adequate amounts of vitamin D3 to ensure that her 25-OH-D levels are in a sufficient range (>80 nmol/L).25,26,64,66,67 The knowledge that prenatal vitamins containing 400 IU of vitamin D3 have little effect on circulating maternal 25-OH-D concentrations, especially during the winter months, should be imparted to all health care professionals involved in the care of pregnant women.26,64,71,115

THE EFFECT OF MATERNAL VITAMIN D SUPPLEMENTATION DURING LACTATION ON THE VITAMIN D STATUS OF THE BREASTFED INFANT

The vitamin D content of human milk (parental vitamin D compound plus 25-OH-D) is related to the lactating mother's vitamin D status.71–74,126 In a lactating mother supplemented with 400 IU/day of vitamin D, the vitamin D content of her milk ranges from <25 to 78 IU/L.73,74,126–129 Infants who are exclusively breastfed but who do not receive supplemental vitamin D or adequate sunlight exposure are at increased risk of developing vitamin D deficiency and/or rickets.7,10–12,14,18,81,130 Infants with darker pigmentation are at greater risk of vitamin D deficiency,131 a fact explained by the greater risk of deficiency at birth132 and the decreased vitamin D content in milk from women who themselves are deficient.127

A small number of studies have examined the effect of higher maternal supplements of vitamin D on the 25-OH-D concentrations in breastfed infants. Supplements of 1000 to 2000 IU of vitamin D per day to nursing mothers have little effect on the breastfeeding infant's vitamin D status as measured by infant 25-OH-D concentrations.81,133,134 In 2 recent pilot studies that involved lactating women supplemented with high-dose vitamin D (up to 6400 IU/day), the vitamin D content of the mothers' milk increased to concentrations as high as 873 IU/L without any evidence of maternal vitamin D toxicity.73,74 The 25-OH-D concentrations in breastfed infants of mothers who received 6400 IU/day of vitamin D increased from a mean concentration of 32 to 115 nmol/L. These results compared favorably with infants receiving 300 to 400 IU of vitamin D per day, whose 25-OH-D concentrations increased from a mean of 35 to 107 nmol/L. Although vitamin D concentrations can be increased in milk of lactating women by using large vitamin D supplements, such high-dose supplementation studies in lactating women must be validated and demonstrated to be safe in larger, more representative populations of women across the United States. Recommendations to universally supplement breastfeeding mothers with high-dose vitamin D cannot be made at this time. Therefore, supplements given to the infant are necessary.

VITAMIN D SUPPLEMENTATION FOR BREASTFEEDING INFANTS

Although it is clear and incontrovertible that human milk is the best nutritive substance for infants during the first year,135–137 there has been concern about the adequacy of human milk in providing vitamin D.70,138 As such, the AAP published its 2003 vitamin D supplementation statement,1 recommending that all breastfed infants start to receive 200 IU of vitamin D per day within the first 2 months after delivery.

With improved understanding of the detrimental effects of insufficient vitamin D status before the appearance of rickets, studies in North America are continuing to examine the vitamin D status of children and appropriate 25-OH-D serum concentrations. A 2003 report of serum 25-OH-D status in healthy 6- to 23-month-old children in Alaska revealed that 11% had concentrations of <37 nmol/L and 20% had concentrations of 37 to 62 nmol/L.139,140 Thirty percent of the infants were still breastfeeding, and these infants were more likely to have serum 25-OH-D concentrations of <37 nmol/L. After this study, the Alaskan Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began an initiative to actively identify breastfeeding children and provide free vitamin supplements for them and a vitamin D fact sheet for their mothers. Another recent study by Ziegler et al141 assessed the vitamin D status of 84 breastfeeding infants in Iowa (latitude 41°N). In the 34 infants who received no supplemental vitamin D, 8 (23%) infants had a serum 25-OH-D concentration of <27 nmol/L at 280 days of age. Of these 8 low measurements, 7 were made in the winter months (November through April). Thus, at this time it is prudent to recommend that all breastfed infants be given supplemental vitamin D3.

The 2003 AAP statement recommended supplements of 200 IU of vitamin D per day to all breastfed infants within the first 2 months of life, after breastfeeding was well established.1 This was in agreement with a 1997 report from the Institute of Medicine.51 This report's recommendation of 200 IU/day was largely based on a study that showed that among breastfed infants in northern China supplemented with 100 or 200 IU of vitamin D per day, there were no cases of rickets.142 However, 17 of 47 infants and 11 of 37 infants receiving 100 or 200 IU of vitamin D per day, respectively, had serum concentrations of 25-OH-D at <27 nmol/L. Although corollary maternal serum concentrations were not measured, on the basis of vitamin D pharmacokinetics, maternal vitamin D status is assumed to have been abnormally low, thereby preventing adequate transfer of vitamin D in human milk. When the breastfeeding mother has marginal vitamin D status or frank deficiency, infant 25-OH-D concentrations are very low in unsupplemented infants, particularly in the winter months in latitudes further from the equator. It is clear that 25-OH-D concentrations of >50 nmol/L can be maintained in exclusively breastfed infants with supplements of 400 IU/day of vitamin D, which is the amount contained in 1 teaspoon of cod liver oil52,54 and for which there is historic precedence of safety and prevention and treatment of rickets.5,6,143

Thus, given the evidence that (1) vitamin D deficiency can occur early in life, especially when pregnant women are deficient, (2) 25-OH-D concentrations are very low in unsupplemented breastfeeding infants, particularly in the winter months when mothers have marginal vitamin D status or are deficient, (3) that the amount of sunshine exposure necessary to maintain an adequate 25-OH-D concentration in any given infant at any point in time is not easy to determine, and (4) serum 25-OH-D concentrations are maintained at >50 nmol/L in breastfed infants with 400 IU of vitamin D per day, the following recommendation is made: A supplement of 400 IU/day of vitamin D should begin within the first few days of life and continue throughout childhood. Any breastfeeding infant, regardless of whether he or she is being supplemented with formula, should be supplemented with 400 IU of vitamin D, because it is unlikely that a breastfed infant would consume 1 L (∼1 qt) of formula per day, the amount that would supply 400 IU of vitamin D.

FORMS OF VITAMIN D SUPPLEMENTS

There are 2 forms of vitamin D that have been used as supplements: vitamin D2 (ergocalciferol, which is plant derived) and vitamin D3 (cholecalciferol, which is fish derived). It has been shown that vitamin D3 has greater efficacy in raising circulating 25-OH-D concentrations under certain physiological situations.144 Most fortified milk products and vitamin supplements now contain vitamin D3. Vitamin D–only preparations are now available in the United States, in addition to the multivitamin liquids supplements, to provide the appropriate concentrations of 400 IU/mL (see Table 2). Some also contain 400 IU per drop, but such preparations must be prescribed with caution; explicit instruction and demonstration of use are essential because of the greater potential for a vitamin D overdose if several drops are administered at once.

View this table:
  • View inline
  • View popup
TABLE 2

Oral Vitamin D Preparations Currently Available in the United States (in Alphabetical Order)

The new vitamin D–only preparations are particularly appropriate for the breastfed infant who has no need for multivitamin supplements. The cost of purchase and administration of vitamin D either alone or in combination with vitamins A and C (as it is currently constituted) is minimal. Pediatricians and other health care professionals should work with the Special Supplemental Nutrition Program for Women, Infants, and Children clinics to make vitamin D supplements available for breastfeeding infants. Current preparations, assuming correct administration of dosage by caregivers, place the infant at little risk of overdosage and vitamin D toxicity, although this must be considered. Care must be taken by health care professionals to provide explicit instructions regarding the correct dosage and administration.145 Preparations that contain higher concentrations of vitamin D should only be prescribed in the setting of close surveillance of vitamin D status and for those who have such a demonstrated requirement (eg, those who suffer from fat malabsorption or who must chronically take antiseizure medication).

FORMULA-FED INFANTS AND VITAMIN D SUPPLEMENTS

All infant formulas sold in the United States must have a minimum vitamin D concentration of 40 IU/100 kcal (258 IU/L of a 20 kcal/oz formula) and a maximum vitamin D3 concentration of 100 IU/100 kcal (666 IU/L of a 20 kcal/oz formula).146 All formulas sold in the United States have at least 400 IU/L of vitamin D3.147 Because most formula-fed infants ingest nearly 1 L or 1 qt of formula per day after the first month of life, they will achieve a vitamin D intake of 400 IU/day. As mentioned earlier, infants who receive a mixture of human milk and formula also should get a vitamin D supplement of 400 IU/day to ensure an adequate intake. As infants are weaned from breastfeeding and/or formula, intake of vitamin D–fortified milk should be encouraged to provide at least 400 IU/day of vitamin D. Any infant who receives <1 L or 1 qt of formula per day needs an alternative way to get 400 IU/day of vitamin D, such as through vitamin supplements.

VITAMIN D SUPPLEMENTS DURING LATER CHILDHOOD AND ADOLESCENCE

As was mentioned earlier, there is active debate among vitamin D experts as to what constitutes vitamin D “sufficiency,” “insufficiency,” and “deficiency” in adults and children as defined by 25-OH-D serum concentrations.‡ Vitamin D deficiency is not limited to infancy and early childhood but covers the life span, with periods of vulnerability that mirror periods of accelerated growth or physiologic change. In fact, vitamin D deficiency in older children and adolescents continues to be reported worldwide.§ Recent studies of vitamin D status have shown that 16% to 54% of adolescents have serum 25-OH-D concentrations of ≤50 nmol/L.9,85–88,90,94,150–152 In 1 study that used the adult definition of insufficiency of a serum 25-OH-D concentration of <80 nmol/L, 73.1% of adolescents demonstrated values below this concentration.153 In examining the prevalence of vitamin D deficiency in adolescents, studies across North America have shown that serum 25-OH-D concentrations of <30 nmol/L occur in as few as 1% to as many as 17% of adolescents, depending on the subjects themselves and the latitude and season of measurement.3,86,87,151,152 All of these studies found black adolescents to have significantly lower 25-OH-D status than individuals who are not black. Although there have been no large series of adolescents with vitamin D–deficiency rickets, cases continue to occur.15

The inverse relationship of increasing PTH with decreasing 25-OH-D concentrations has been demonstrated in older children and adolescents.9,152 A study of vitamin D insufficiency in 6- to 10-year-old preadolescent black children in Pittsburgh, PA, revealed that serum PTH concentrations decreased with increasing serum 25-OH-D concentrations and reached a plateau when the serum 25-OH-D concentration was ≥75 nmol/L.150 In Boston, MA, Gordon et al152 found that 24.1% of healthy teenagers in their cross-sectional cohort were vitamin D deficient (25-OH-D concentration ≤ 37 nmol/L), of whom 4.6% were severely deficient (25-OH-D concentration ≤ 20 nmol/L) and 42% were vitamin D insufficient (25-OH-D concentration ≤ 50 nmol/L). There was an inverse correlation between serum 25-OH-D and PTH concentrations (R = −0.29). Concentrations of 25-OH-D also were related to season, ethnicity, milk and juice consumption, BMI, and physical activity, which were independent predictors of vitamin D status.

Similar results were found by Cheng et al89 in their cohort of pubertal and prepubertal Finnish girls. These investigators also found a significantly lower cortical volumetric bone-mineral density of the distal radius and tibial shaft in girls with vitamin D deficiency (as defined by 25-OH-D concentrations ≤ 25 nmol/L). These results are supported by the work of Viljakainen et al58 in their study of 212 Finnish early-adolescent (aged 11–12 years) girls who were randomly assigned to receive 0, 200, or 400 IU of vitamin D per day for 12 months. After 1 year, bone-mineral augmentation of the femur was 14.3% and 17.2% higher in the girls receiving 200 and 400 IU of vitamin D, respectively, compared with those in the placebo group.

The extent of vitamin D deficiency has been suggested by reports from other regions of the world, including children and adolescents living in northern Greece94 and Germany57 and adolescents in Beijing,153 Turkey,88 Finland,58 and Ireland.95 With lower 25-OH-D concentrations correlating with increased PTH concentrations, vitamin D deficiency could result in secondary hyperparathyroidism. This condition would deplete the bone of mineral, especially during periods of accelerated bone growth, and lead to long-term detrimental effects.

In evaluating bone mineralization as a function of vitamin D status in adolescents, several studies in the United States and Europe have demonstrated an unfavorable effect of lower 25-OH-D concentrations on bone health.58,89,154,155 Adolescent girls with serum 25-OH-D concentrations of >40 nmol/L have demonstrated increased radial, ulnar, and tibial bone-mineral densities,152 although studies have demonstrated inconsistent findings in other body sites.154 Additional studies are needed to identify the serum 25-OH-D status that promotes optimal bone health in older children and adolescents.

Although consuming 1 qt (32 oz) of vitamin D–fortified milk will provide 400 IU of vitamin D3 per day, it is clear that in the adolescent population, the intake of vitamin D–fortified milk is much less.155–157 In the United States, milk intake decreased by 36% among adolescent girls from 1977–1978 to 1994–1998.156 Fortified cereals (-cup dry) and 1 egg (yolk) will each provide approximately 40 IU of vitamin D3. Given the dietary practices of many children and adolescents, a dietary intake of 400 IU of vitamin D is difficult to achieve.157 Thus, for older children and adolescents, a daily multivitamin or vitamin D–only preparation containing 400 IU of vitamin D would be warranted. Additional studies are needed to evaluate what the optimal vitamin D status in older children and adolescents is and whether this level can be achieved consistently through diet and a vitamin D supplement of 400 IU/day.

Along with adequate vitamin D intake, dietary calcium intake to achieve optimal bone formation and modeling must be ensured.87 A dietary history is essential in assessing the adequacy of dietary intake for various vitamins, minerals, and nutrients, including vitamin D and calcium.3,91 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.158–161

SUMMARY GUIDELINES

To prevent rickets and vitamin D deficiency in healthy infants, children, and adolescents, a vitamin D intake of at least 400 IU/day is recommended. To meet this intake requirement, we make the following suggestions:

  1. Breastfed and partially breastfed infants should be supplemented with 400 IU/day of vitamin D beginning in the first few days of life. Supplementation should be continued unless the infant is weaned to at least 1 L/day or 1 qt/day of vitamin D–fortified formula or whole milk. Whole milk should not be used until after 12 months of age. In those children between 12 months and 2 years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or cardiovascular disease, the use of reduced-fat milk would be appropriate.163

  2. All nonbreastfed infants, as well as older children who are ingesting <1000 mL/day of vitamin D–fortified formula or milk, should receive a vitamin D supplement of 400 IU/day. Other dietary sources of vitamin D, such as fortified foods, may be included in the daily intake of each child.

  3. Adolescents who do not obtain 400 IU of vitamin D per day through vitamin D–fortified milk (100 IU per 8-oz serving) and vitamin D–fortified foods (such as fortified cereals and eggs [yolks]) should receive a vitamin D supplement of 400 IU/day.

  4. On the basis of the available evidence, serum 25-OH-D concentrations in infants and children should be ≥50 nmol/L (20 ng/mL).

  5. Children with increased risk of vitamin D deficiency, such as those with chronic fat malabsorption and those chronically taking antiseizure medications, may continue to be vitamin D deficient despite an intake of 400 IU/day. Higher doses of vitamin D supplementation may be necessary to achieve normal vitamin D status in these children, and this status should be determined with laboratory tests (eg, for serum 25-OH-D and PTH concentrations and measures of bone-mineral status). If a vitamin D supplement is prescribed, 25-OH-D levels should be repeated at 3-month intervals until normal levels have been achieved. PTH and bone-mineral status should be monitored every 6 months until they have normalized.

  6. Pediatricians and other health care professionals should strive to make vitamin D supplements readily available to all children within their community, especially for those children most at risk.

COMMITTEE ON NUTRITION, 2007–2008

*Frank R. Greer, MD, Chairperson

Jatinder J.S. Bhatia, MD

Stephen R. Daniels, MD, PhD

Marcie B. Schneider, MD

Janet Silverstein, MD

Nicolas Stettler, MD, MSCE

Dan W. Thomas, MD

LIAISONS

Donna Blum-Kemelor, MS, RD

US Department of Agriculture

Laurence Grummer-Strawn, PhD

Centers for Disease Control and Prevention

Rear Admiral Van S. Hubbard, MD, PhD

National Institutes of Health

Valerie Marchand, MD

Canadian Paediatric Society

Benson M. Silverman, MD

US Food and Drug Administration

STAFF

Debra L. Burrowes, MHA

SECTION ON BREASTFEEDING EXECUTIVE COMMITTEE, 2007–2008

Arthur J. Eidelman, MD, Policy Committee Chairperson

Ruth A. Lawrence, MD, Chairperson

Lori B. Feldman-Winter, MD

Jane A. Morton, MD

Audrey J. Naylor, MD, DrPH

Lawrence M. Noble, MD

Laura R. Viehmann, MD

*Carol L. Wagner, MD

LIAISONS

Jatinder J.S. Bhatia, MD

Committee on Nutrition

Alice Lenihan, MPH, RD, LDN

National Association of WIC Directors

Sharon Mass, MD

American College of Obstetrics and Gynecology

Julie Wood, MD

American Academy of Family Physicians

STAFF

Lauren Barone, MPH

Footnotes

  • All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaf.rmed, revised, or retired at or before that time.

  • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

  • ↵* Lead Authors

  • ↵† Universal units of measure for 25-OH-D and 1,25-OH2-D are nmol/L. Conversion to ng/mL is made by dividing the value expressed in nmol/L by 2.496. Thus, 80 nmol/L becomes 32 ng/mL.

  • ↵‡ Refs 6,9,56,64,66,67,94,132, and 148–150.

  • ↵§ Refs 9,57,58,85–89,94–96, and 150–154.

AAP—American Academy of Pediatrics • 25-OH-D—25-hydroxyvitamin D • 1,25-OH2-D—1,25-dihydroxyvitamin D • PTH—parathyroid hormone

REFERENCES

  1. ↵
    Gartner LM, Greer FR; American Academy of Pediatrics, Section on Breastfeeding Medicine and Committee on Nutrition. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics.2003;111 (4):908– 910
    OpenUrlAbstract/FREE Full Text
  2. ↵
    McCollum EV, Simmonds N, Becket JE, Shipley PG. Studies on experimental rickets. XXI. An experimental demonstration of the existence of a vitamin, which promotes calcium deposition. J Biol Chem.1922;53 (8):219– 312
    OpenUrl
  3. ↵
    Moore C, Murphy MM, Keast DR, Holick M. Vitamin D intake in the United States. J Am Diet Assoc.2004;104 (6):980– 983
    OpenUrlCrossRefPubMed
  4. ↵
    Thacher TD, Fischer PR, Strand MA, Pettifor JM. Nutritional rickets around the world: causes and future directions. Ann Trop Paediatr.2006;26 (1):1– 16
    OpenUrlCrossRefPubMed
  5. ↵
    Park EA. The therapy of rickets. JAMA.1940;115 :370– 379
    OpenUrlCrossRef
  6. ↵
    Rajakumar K, Thomas SB. Reemerging nutritional rickets: a historical perspective. Arch Pediatr Adolesc Med.2005;159 (4):335– 341
    OpenUrlCrossRefPubMed
  7. ↵
    Mylott BM, Kump T, Bolton ML, Greenbaum LA. Rickets in the Dairy State. WMJ.2004;103 (5):84– 87
    OpenUrlPubMed
  8. Pettifor JM. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr.2004;80 (6 suppl):1725S– 1729S
    OpenUrlAbstract/FREE Full Text
  9. ↵
    Pettifor JM. Rickets and vitamin D deficiency in children and adolescents. Endocrinol Metab Clin North Am2005;34 (3):537– 553, vii
    OpenUrlCrossRefPubMed
  10. ↵
    Kreiter SR, Schwartz RP, Kirkman HN, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr.2000;137 (2):153– 157
    OpenUrlCrossRefPubMed
  11. Pugliese MT, Blumberg DL, Hludzinski J, Kay S. Nutritional rickets in suburbia. J Am Coll Nutr.1998;17 (6):637– 641
    OpenUrlPubMed
  12. ↵
    Sills IN, Skuza KA, Horlick MN, Schwartz MS, Rapaport R. Vitamin D deficiency rickets: reports of its demise are exaggerated. Clin Pediatr (Phila).1994;33 (8):491– 493
    OpenUrlFREE Full Text
  13. Ward LM. Vitamin D deficiency in the 21st century: a persistent problem among Canadian infants and mothers. CMAJ.2005;172 (6):769– 770
    OpenUrlFREE Full Text
  14. ↵
    Weisberg P, Scanlon K, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr.2004;80 (6 suppl):1697S– 1705S
    OpenUrlAbstract/FREE Full Text
  15. ↵
    Schnadower D, Agarwal C, Oberfield SE, Fennoy I, Pusic M. Hypocalcemic seizures and secondary bilateral femoral fractures in an adolescent with primary vitamin D deficiency. Pediatrics.2006;118 (5):2226– 2230
    OpenUrlAbstract/FREE Full Text
  16. ↵
    Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Arch Dis Child.2004;89 (8):781– 784
    OpenUrlAbstract/FREE Full Text
  17. Hatun S, Ozkan B, Orbak Z, et al. Vitamin D deficiency in early infancy. J Nutr.2005;135 (2):279– 282
    OpenUrlAbstract/FREE Full Text
  18. ↵
    Binet A, Kooh SW. Persistence of vitamin D-deficiency rickets in Toronto in the 1990s. Can J Public Health.1996;87 (4):227– 230
    OpenUrlPubMed
  19. Najada AS, Habashneh MS, Khader M. The frequency of nutritional rickets among hospitalized infants and its relation to respiratory diseases. J Trop Pediatr.2004;50 (6):364– 368
    OpenUrlAbstract/FREE Full Text
  20. Stearns G, Jeans PC, Vandecar V. The effect of vitamin D on linear growth in infancy. J Pediatr.1936;9 (1):1– 10
    OpenUrlCrossRef
  21. Pawley NJ, Bishop N. Prenatal and infant predictors of bone health: the influence of vitamin D. Am J Clin Nutr. 2004;80 (6 suppl):1748S– 1751S
  22. ↵
    Molgaard C, Michaelsen KF. Vitamin D and bone health in early life. Proc Natl Acad Sci U S A. 2003;62 (4):823– 828
    OpenUrl
  23. ↵
    Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M, on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122 (2):398– 417
    OpenUrlAbstract/FREE Full Text
  24. ↵
    Holick MF. Vitamin D: Importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr.2004;79 (3):362– 371
    OpenUrlAbstract/FREE Full Text
  25. ↵
    Hathcock JN, Shao A, Vieth R, Heaney RP. Risk assessment for vitamin D. Am J Clin Nutr. 2007;85 (1):6– 18
    OpenUrlAbstract/FREE Full Text
  26. ↵
    Holick MF. Vitamin D deficiency. N Engl J Med.2007;357 (3):266– 281
    OpenUrlCrossRefPubMed
  27. ↵
    Webb AR. Who, what, where and when: influences on cutaneous vitamin D synthesis. Prog Biophys Mol Biol.2006;92 (1):17– 25
    OpenUrlCrossRefPubMed
  28. ↵
    Willer CJ, Dyment DA, Sadovnick AD, Rothwell PM, Murray TJ, Ebers GC. Timing of birth and risk of multiple sclerosis: population based study. BMJ.2005;330 (7483):120
    OpenUrlAbstract/FREE Full Text
  29. Kamen DL, Cooper GS, Bouali H, Shaftman SR, Hollis BW, Gilkeson GS. Vitamin D deficiency in systemic lupus erythematosus. Autoimmun Rev.2006;5 (2):114– 117
    OpenUrlCrossRefPubMed
  30. ↵
    Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Serum 25(OH)D and colon cancer: eight-year prospective study. Lancet.1989;2 (8673):1176– 1178
    OpenUrlPubMed
  31. ↵
    Giovannucci E, Liu Y, Rimm EB, et al. Prospective study of predictors of vitamin D status and cancer incidence and mortality in men. J Natl Cancer Inst.2006;98 (7):451– 459
    OpenUrlAbstract/FREE Full Text
  32. ↵
    Institute of Medicine. Calcium, vitamin D, and magnesium. In: Subcommittee on Nutritional Status and Weight Gain During Pregnancy, ed. Nutrition During Pregnancy. Washington, DC: National Academy Press; 1990:318– 335
  33. ↵
    Liu PT, Stenger S, Li H, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science.2006;311 (5768):1770– 1773
    OpenUrlAbstract/FREE Full Text
  34. ↵
    Rehman PK. Sub-clinical rickets and recurrent infection. J Trop Pediatr.1994;40 (1):58
    OpenUrlPubMed
  35. ↵
    Martineau AR, Wilkinson RJ, Wilkinson KA, et al. A single dose of vitamin D enhances immunity to mycobacteria. Am J Respir Crit Care Med.2007;176 (2):208– 213
    OpenUrlCrossRefPubMed
  36. ↵
    Hayes CE. Vitamin D: a natural inhibitor of multiple sclerosis. Proc Nutr Soc.2000;59 (4):531– 535
    OpenUrlCrossRefPubMed
  37. ↵
    Munger KL, Zhang SM, O'Reilly E, et al. Vitamin D intake and incidence of multiple sclerosis. Neurology.2004;62 (1):60– 65
    OpenUrlAbstract/FREE Full Text
  38. ↵
    Merlino LA, Curtis J, Mikuls TR, Cerhan JR, Criswell LA, Saag KG. Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study. Arthritis Rheum.2004;50 (1):72– 77
    OpenUrlCrossRefPubMed
  39. ↵
    Garland FC, Garland CF, Gorham ED, Young JE. Geographic variation in breast cancer mortality in the United States: a hypothesis involving exposure to solar radiation. Prev Med.1990;19 (6):614– 622
    OpenUrlCrossRefPubMed
  40. Lefkowitz ES, Garland CF. Sunlight, vitamin D, and ovarian cancer mortality rates in US women. Int J Epidemiol.1994;23 (6):1133– 1136
    OpenUrlAbstract/FREE Full Text
  41. Grant WB. An ecologic study of dietary and solar ultraviolet-B links to breast carcinoma mortality rates. Cancer.2002;94 (1):272– 281
    OpenUrlCrossRefPubMed
  42. ↵
    Grant WB. An estimate of premature cancer mortality in the US due to inadequate doses of solar ultraviolet-B radiation. Cancer.2002;94 (6):1867– 1875
    OpenUrlCrossRefPubMed
  43. ↵
    Chiu K, Chu A, Go VL, Soad MF. Hypovitaminosis D is associated with insulin resistance and beta cell dysfunction. Am J Clin Nutr.2004;79 (5):820– 825
    OpenUrlAbstract/FREE Full Text
  44. Pittas AG, Dawson-Hughes B, Li T, et al. Vitamin D and calcium intake in relation to type 2 diabetes in women. Diabetes Care.2006;29 (3):650– 656
    OpenUrlAbstract/FREE Full Text
  45. ↵
    Ford ES, Ajani UA, McGuire LC, Liu S. Concentrations of serum vitamin D and the metabolic syndrome among U.S. adults. Diabetes Care.2005;28 (5):1228– 1230
    OpenUrlFREE Full Text
  46. ↵
    The EURODIAB Substudy 2 Study Group. Vitamin D supplement in early childhood and risk for type 1 (insulin-dependent) diabetes mellitus. Diabetologia.1999;42 (1):51– 54
    OpenUrlCrossRefPubMed
  47. Hyppönen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet.2001;358 (9292):1500– 1503
    OpenUrlCrossRefPubMed
  48. Harris SS. Vitamin D in type 1 diabetes prevention. J Nutr.2005;135 (2):323– 325
    OpenUrlAbstract/FREE Full Text
  49. Shehadeh N, Shamir R, Berant M, Etzioni A. Insulin in human milk and the prevention of type 1 diabetes. Pediatr Diabetes.2001;2 (4):175– 177
    OpenUrlCrossRefPubMed
  50. ↵
    Fronczak CM, Baron AE, Chase HP, et al. In utero dietary exposures and risk of islet autoimmunity in children. Diabetes Care.2003;26 (12):3237– 3242
    OpenUrlAbstract/FREE Full Text
  51. ↵
    Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board, Institute of Medicine. Calcium, phosphorus, magnesium, vitamin D and fluoride. In: Dietary Reference Intakes. Washington, DC: National Academy Press; 1997:250– 287
  52. ↵
    Marriott W, Jeans P. Infant Nutrition: A Textbook of Infant Feeding for Students and Practitioners of Medicine. 3rd ed. St Louis, MO: Mosby; 1941
  53. ↵
    American Academy of Pediatrics, Committee on Nutrition. The prophylactic requirement and the toxicity of vitamin D. 1963;31 (3):512– 525
  54. ↵
    Davison W. The Compleat Pediatrician: Practical, Diagnostic, Therapeutic and Preventive Pediatrics. For the Use of Medical Students, Interns, General Practitioners, and Pediatricians. Durham, NC: Duke University Press; 1943
  55. ↵
    Aldrich C, Aldrich M. Babies Are Human Beings: An Interpretation of Growth. New York, NY: Macmillan Company; 1938
  56. ↵
    Roth DE, Martz P, Yeo R, Prosser C, Bell M, Jones AB. Are national vitamin D guidelines sufficient to maintain adequate blood levels in children? Can J Public Health.2005;96 (6):443– 449
    OpenUrlPubMed
  57. ↵
    Sichert-Hellert W, Wenz G, Kersting M. Vitamin intakes from supplements and fortified food in German children and adolescents: results from the DONALD study. J Nutr.2006;136 (5):1329– 1333
    OpenUrlAbstract/FREE Full Text
  58. ↵
    Viljakainen HT, Natri AM, Kärkkäinen MM, et al. A positive dose-response effect of vitamin D supplementation on site-specific bone mineral augmentation in adolescent girls: a double-blinded randomized placebo-controlled 1-year intervention. J Bone Miner Res.2006;21 (6):836– 844
    OpenUrlCrossRefPubMed
  59. Canadian Paediatric Society, Health Canada; Dietitians of Canada. Breastfeeding and Vitamin D. Ottawa, Ontario, Canada: Canadian Paediatric Society; 2003
  60. Dobrescu MO, Garcia AC, Robert M. Rickets. CMAJ.2006;174 (12):1710
    OpenUrlFREE Full Text
  61. ↵
    Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T, Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr.2006;84 (1):18– 28
    OpenUrlAbstract/FREE Full Text
  62. ↵
    Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of vitamin D status. Osteoporosis Int.2005;16 (7):713– 716
    OpenUrlCrossRefPubMed
  63. El-Hajj Fuleihan E, Nabulsi M, Tamim H, et al. Effect of vitamin D replacement on musculoskeletal parameters in school children: a randomized controlled trial. J Clin Endocrinol Metab.2006;91 (2):405– 412
    OpenUrlCrossRefPubMed
  64. ↵
    Vieth R, Bischoff-Ferrari H, Boucher BJ, et al. The urgent need to recommend an intake of vitamin D that is effective [published correction appears in Am J Clin Nutr. 2007;86 (3):809] . Am J Clin Nutr. 2007;85(3):649–650
    OpenUrlFREE Full Text
  65. Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: an important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol.2007;103 (3–5):631– 634
    OpenUrlCrossRefPubMed
  66. ↵
    Hollis BW. Circulating 25-hydroxyvitamin D levels indicative of vitamin sufficiency: implications for establishing a new effective DRI for vitamin D. J Nutr. 2005;135 (2):317– 322
  67. ↵
    Hollis BW, Wagner CL, Kratz A, Sluss PM, Lewandrowski KB. Normal serum vitamin D levels. Correspondence. N Engl J Med.2005;352 (5):515– 516
    OpenUrlCrossRefPubMed
  68. ↵
    Heaney RP, Dowell MS, Hale CA, Bendich A. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr. 2003;22 (2):142– 146
    OpenUrlCrossRefPubMed
  69. ↵
    Need AG. Bone resorption markers in vitamin D insufficiency. Clin Chim Acta.2006;368 (1–2):48– 52
    OpenUrlCrossRefPubMed
  70. ↵
    Greer FR, Marshall S. Bone mineral content, serum vitamin D metabolite concentrations and ultraviolet B light exposure in infants fed human milk with and without vitamin D2 supplements. J Pediatr.1989;114 (2):204– 212
    OpenUrlCrossRefPubMed
  71. ↵
    Hollis BW, Wagner CL. Assessment of dietary vitamin D requirements during pregnancy and lactation. Am J Clin Nutr.2004;79 (5):717– 726
    OpenUrlAbstract/FREE Full Text
  72. Basile LA, Taylor SN, Wagner CL, Horst RL, Hollis BW. The effect of high-dose vitamin D supplementation on serum vitamin D levels and milk calcium concentration in lactating women and their infants. Breastfeed Med.2006;1 (1):32– 35
    OpenUrl
  73. ↵
    Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month follow-up pilot study. Breastfeed Med.2006;1 (2):59– 70
    OpenUrlCrossRefPubMed
  74. ↵
    Hollis BW, Wagner CL. Vitamin D requirements during lactation: High-dose maternal supplementation as therapy to prevent hypovitaminosis D in both mother and nursing infant. Am J Clin Nutr.2004;80 (6 suppl):1752S– 1758S
    OpenUrlAbstract/FREE Full Text
  75. ↵
    Holick MF, MacLaughlin JA, Clark MB, et al. Photosynthesis of vitamin D3 in human skin and its physiologic consequences. Science.1980;210 (4466):203– 205
    OpenUrlAbstract/FREE Full Text
  76. Kimlin MC, Schallhorn KA. Estimations of the human “vitamin D” UV exposure in the USA. Photochem Photobiol Sci.2004;3 (11–12):1067– 1070
    OpenUrlCrossRefPubMed
  77. ↵
    Matsuoka LY, Wortsman J, Haddad JG, Kolm P, Hollis BW. Racial pigmentation and the cutaneous synthesis of vitamin D. Arch Dermatol. 1991;127 (4):536– 538
    OpenUrlCrossRefPubMed
  78. ↵
    Matsuoka LY, Wortsman J, Hollis BW. Suntanning and cutaneous synthesis of vitamin D3. J Lab Clin Med.1990;116 (1):87– 90
    OpenUrlPubMed
  79. ↵
    Matsuoka LY, Wortsman J, Dannenberg MJ, Hollis BW, Lu Z, Holick MF. Clothing prevents ultraviolet-B-radiation-dependent photosynthesis of vitamin D3. J Clin Endocrinol Metab.1992;75 (4):1099– 1103
    OpenUrlCrossRefPubMed
  80. Matsuoka LY, Wortsman J, Hollis BW. Use of topical sunscreen for the evaluation of regional synthesis of vitamin D3. J Am Acad Dermatol.1990;22 (5 pt 1):772– 775
    OpenUrlPubMed
  81. ↵
    Ala-Houhala M. 25(OH)D levels during breast-feeding with or without maternal or infantile supplementation of vitamin D. J Pediatr Gastroenterol Nutr. 1985;4 (2):220– 226
    OpenUrlPubMed
  82. ↵
    US Environmental Protection Agency. Report to Congress on Indoor Air Quality. Volume II: Assessment and Control of Indoor Air Pollution: US Environmental Protection Agency: Washington, DC; 1989. Report EPA 400-1-89-001C
  83. ↵
    Nesby-O'Dell S, Scanlon KS, Cogswell ME, et al. Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: Third National Health and Nutrition Examination Survey: 1988–1994. Am J Clin Nutr.2002;76 (1):187– 192
    OpenUrlAbstract/FREE Full Text
  84. ↵
    Scanlon KS. Vitamin D expert panel meeting, October 11–12, Atlanta, Georgia: final report. Available at: www.cdc.gov/nccdphp/dnpa/nutrition/pdf/Vitamin_D_Expert_Panel_Meeting.pdf. Accessed July 24, 2008
  85. ↵
    Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone.2002;30 (5):771– 777
    OpenUrlCrossRefPubMed
  86. ↵
    Harkness LS, Cromer BA. Vitamin D deficiency in adolescent females. J Adolesc Health.2005;37 (1):75
    OpenUrlPubMed
  87. ↵
    Harkness LS, Bonny AE. Calcium and vitamin D status in the adolescent: key roles for bone, body weight, glucose tolerance, and estrogen biosynthesis. J Pediatr Adolesc Gynecol.2005;18 (5):305– 311
    OpenUrlCrossRefPubMed
  88. ↵
    Olmez D, Bober E, Buyukgebiz A, Cimrin D. The frequency of vitamin D insufficiency in healthy female adolescents. Acta Paediatr.2006;95 (10):1266– 1269
    OpenUrlCrossRefPubMed
  89. ↵
    Cheng S, Tylavsky F, Kroger H, et al. Association of low 25-hydroxyvitamin D concentrations with elevated parathyroid hormone concentrations and low cortical bone density in early pubertal and prepubertal Finnish girls. Am J Clin Nutr.2003;78 (3):485– 492
    OpenUrlAbstract/FREE Full Text
  90. ↵
    Tylavsky FA, Ryder KA, Lyytikäinen A, Cheng S. Vitamin D, parathyroid hormone, and bone mass in adolescents. J Nutr.2005;135 (11):2735S– 2738S
    OpenUrlAbstract/FREE Full Text
  91. ↵
    DeBar LL, Ritenbaugh C, Aickin M, et al. A health plan-based lifestyle intervention increases bone mineral density in adolescent girls. Arch Pediatr Adolesc Med.2006;160 (12):1269– 1276
    OpenUrlCrossRefPubMed
  92. El-Hajj Fuleihan GH, Nabulsi M, Choucair M, et al. Hypovitaminosis D in healthy schoolchildren. Pediatrics.2001;107 (4). Available at: www.pediatrics.org/cgi/content/full/107/4/e53
  93. Marwaha RK, Tandon N, Reddy DR, et al. Vitamin D and bone mineral density status of healthy schoolchildren in northern India. Am J Clin Nutr.2005;82 (2):477– 482
    OpenUrlAbstract/FREE Full Text
  94. ↵
    Lapatsanis D, Moulas A, Cholevas V, Soukakos P, Papadopoulou Z, Challa A. Vitamin D: a necessity for children and adolescents in Greece. Calcif Tissue Int.2005;77 (6):348– 355
    OpenUrlCrossRefPubMed
  95. ↵
    Hill TR, Flynn A, Kiely M, Cashman KD. Prevalence of suboptimal vitamin D status in young, adult and elderly Irish subjects. Ir Med J.2006;99 (2):48– 49
    OpenUrlPubMed
  96. ↵
    Primary vitamin D deficiency in children. Drug Ther Bull.2006;44 (2):12– 16
    OpenUrlAbstract/FREE Full Text
  97. ↵
    Grant WB, Garland C, Holick MF. Comparisons of estimated economic burdens due to insufficient solar ultraviolet irradiance and vitamin D and excess solar UV irradiance for the United States. Photochem Photobiol.2005;81 (6):1276– 1286
    OpenUrlCrossRefPubMed
  98. Reichrath J. The challenge resulting from positive and negative effects of sunlight: how much solar UV exposure is appropriate to balance between risks of vitamin D deficiency and skin cancer? Prog Biophys Mol Biol.2006;92 (1):9– 16
    OpenUrlCrossRefPubMed
  99. ↵
    Wolpowitz D, Gilchrest BA. The vitamin D questions: how much do you need and how should you get it? J Am Acad Dermatol.2006;54 (2):301– 317
    OpenUrlCrossRefPubMed
  100. ↵
    National Coalition for Skin Cancer Prevention. The National Forum for Skin Cancer Prevention in Health, Physical Education, Recreation and Youth Sports. Reston, VA: American Association for Health Education; 1998
  101. ↵
    Marks R, Jolley D, Lectsas S, Foley P. The role of childhood exposure to sunlight in the development of solar keratoses and non-melanocytic skin cancer. Med J Aust.1990;152 (2):62– 66
    OpenUrlPubMed
  102. Autier P, Dore JF. Influence of sun exposures during childhood and during adulthood on melanoma risk. EPIMEL and EORTC Melanoma Cooperative Group. Int J Cancer.1998;77 (4):533– 537
    OpenUrlCrossRefPubMed
  103. Westerdahl J, Olsson H, Ingvar C. At what age do sunburn episodes play a crucial role for the development of malignant melanoma. Eur J Cancer.1994;30A (11):1647– 1654
    OpenUrlCrossRefPubMed
  104. Gilchrest BA, Eller MS, Geller AC, Yaar M. The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med.1999;340 (17):1341– 1348
    OpenUrlCrossRefPubMed
  105. ↵
    American Academy of Pediatrics, Committee on Environmental Health. Ultraviolet light: a hazard to children. Pediatrics.1999;104 (2 pt 1):328– 333
    OpenUrlFREE Full Text
  106. ↵
    Lucas R, Ponsonby AL. Considering the potential benefits as well as adverse effects of sun exposure: can all the potential benefits be provided by oral vitamin D supplementation? Prog Biophys Mol Biol.2006;92 (1):140– 149
    OpenUrlCrossRefPubMed
  107. ↵
    Mahomed K, Gulmezoglu AM. Vitamin D supplementation in pregnancy [Cochrane review]. In: The Cochrane Library. Oxford, United Kingdom: Update Software; 2002
  108. ↵
    Mallet E, Gugi B, Brunelle P, Henocq A, Basuyau JP, Lemeur H. Vitamin D supplementation in pregnancy: a controlled trial of two methods. Obstet Gynecol.1986;68 (3):300– 304
    OpenUrlCrossRefPubMed
  109. ↵
    Brooke OG, Brown IRF, Bone CDM, et al. Vitamin D supplements in pregnant Asian women: effects on calcium status and fetal growth. Br Med J.1980;280 (6216):751– 754
    OpenUrlAbstract/FREE Full Text
  110. ↵
    Maxwell JD, Ang L, Brooke OG, Brown IRF. Vitamin D supplements enhance weight gain and nutritional status in pregnant Asians. Br J Obstet Gynaecol.1981;88 (10):987– 991
    OpenUrlPubMed
  111. ↵
    Brooke OG, Butters F, Wood C. Intrauterine vitamin D nutrition and postnatal growth in Asian infants. Br Med J (Clin Res Ed).1981;283 (6298):1024
    OpenUrlCrossRefPubMed
  112. ↵
    Cockburn F, Belton NR, Purvis RJ, et al. Maternal vitamin D intake and mineral metabolism in mothers and their newborn infants. Br Med J.1980;281 (6232):11– 14
    OpenUrlAbstract/FREE Full Text
  113. ↵
    Delvin EE, Salle L, Glorieux FH, Adeleine P, David LS. Vitamin D supplementation during pregnancy: effect on neonatal calcium homeostasis. J Pediatr.1986;109 (2):328– 334
    OpenUrlCrossRefPubMed
  114. ↵
    Vieth R, Chan PCR, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level (LOAEL). Am J Clin Nutr.2001;73 (2):288– 294
    OpenUrlAbstract/FREE Full Text
  115. ↵
    Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J Clin Nutr.2003;77 (1):204– 210
    OpenUrlAbstract/FREE Full Text
  116. ↵
    van der Meer IM, Karamali NS, Boeke AJ. High prevalence of vitamin D deficiency in pregnant non-Western women in the Hague, Netherlands. Am J Clin Nutr.2006;84 (2):350– 353
    OpenUrlAbstract/FREE Full Text
  117. ↵
    Bouillon R, Van Baelen H, DeMoor D. 25-Hydroxy-vitamin D and its binding protein in maternal and cord serum. J Clin Endocrinol Metab.1977;45 (4):679– 684
    OpenUrlCrossRefPubMed
  118. Bouillon R, Van Assche FA, Van Baelen H, Heyns W, DeMoor P. Influence of the vitamin D-binding protein on serum concentrations of 1,25(OH)2D. J Clin Invest. 1981;67 (3):589– 596
  119. Markestad T, Aksnes L, Ulstein M, Aarskog D. 25-Hydroxyvitamin D and 1,25-dihydroxy vitamin D of D2 and D3 origin in maternal and umbilical cord serum after vitamin D2 supplementation in human pregnancy. Am J Clin Nutr.1984;40 (5):1057– 1063
    OpenUrlAbstract/FREE Full Text
  120. ↵
    Hollis BW, Pittard WB. Evaluation of the total fetomaternal vitamin D relationships at term: evidence for racial differences. J Clin Endocrinol Metab.1984;59 (4):652– 657
    OpenUrlCrossRefPubMed
  121. ↵
    Hollis BW, Wagner CL. Nutritional vitamin D status during pregnancy: reasons for concern. CMAJ.2006;174 (9):1287– 1290
    OpenUrlFREE Full Text
  122. ↵
    Mannion C, Gray-Donald K, Koski K. Association of low intake of milk and vitamin D during pregnancy with decreased birth weight. CMAJ.2006;174 (9):1273– 1277
    OpenUrlAbstract/FREE Full Text
  123. ↵
    Javaid MK, Crozier SR, Harvey NC, et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study [published correction appears in Lancet. 2006;367(9521):1486]. Lancet.2006;367 (9504):36– 43
    OpenUrlCrossRefPubMed
  124. ↵
    Hyppönen E. Vitamin D for the prevention of preeclampsia? A hypothesis. Nutr Rev.2005;63 (7):225– 232
    OpenUrlCrossRefPubMed
  125. ↵
    Moncrieff M, Fadahunsi TO. Congenital rickets due to maternal vitamin D deficiency. Arch Dis Child.1974;49 (10):810– 811
    OpenUrlFREE Full Text
  126. ↵
    Specker BL, Tsang RC, Hollis BW. Effect of race and diet on human milk vitamin D and 25(OH)D. Am J Dis Child. 1985;139 (11):1134– 1137
    OpenUrlCrossRefPubMed
  127. ↵
    Cancela L, LeBoulch N, Miravet L. Relationship between the vitamin D content of maternal milk and the vitamin D status of nursing women and breastfed infants. J Endocrinol.1986;110 (1):43– 50
    OpenUrlAbstract/FREE Full Text
  128. Hollis BW, Roos B, Draper HH, Lambert PW. Vitamin D and its metabolites in human and bovine milk. J Nutr.1981;111 (7):1240– 1248
    OpenUrlAbstract/FREE Full Text
  129. ↵
    Greer FR, Hollis BW, Cripps DJ, Tsang RC. Effects of maternal ultraviolet B irradiation on vitamin D content of human milk. J Pediatr.1984;105 (3):431– 433
    OpenUrlCrossRefPubMed
  130. ↵
    Daaboul J, Sanderson S, Kristensen K, Kitson H. Vitamin D deficiency in pregnant and breast-feeding women and their infants. J Perinatol.1997;17 (1):10– 14
    OpenUrlPubMed
  131. ↵
    Kreiter S. The reemergence of vitamin D deficiency rickets: the need for vitamin D supplementation. AMB News Views Newsl.2001;7 :1– 5
    OpenUrl
  132. ↵
    Basile LA, Taylor SN, Wagner CL, Quinones L, Hollis BW. Neonatal vitamin D status at birth at latitude 32 degrees 72′: evidence of deficiency. J Perinatol.2007;27 (9):568– 571
    OpenUrlCrossRefPubMed
  133. ↵
    Saadi H, Dawodu A, Afandi B, Zayed R, Benedict S, Nagelkerke N. Efficacy of daily and monthly high-dose calciferol in vitamin D-deficient nulliparous and lactating women. Am J Clin Nutr.2007;85 (6):1565– 1571
    OpenUrlAbstract/FREE Full Text
  134. ↵
    Ala-Houhala M, Koskinen T, Terho A, Koivula T, Visakorpi J. Maternal compared with infant vitamin D supplementation. Arch Dis Child.1986;61 (12):1159– 1163
    OpenUrlAbstract/FREE Full Text
  135. ↵
    Kramer M, Kakuma R. The Optimal Duration of Exclusive Breastfeeding: A Systematic Review. Geneva, Switzerland: World Health Organization; 2002
  136. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics.2005;115 (2):496– 506
    OpenUrlAbstract/FREE Full Text
  137. ↵
    Chantry C, Howard C, Auinger P. Full breastfeeding duration and associated decrease in respiratory tract Infection in US Children. Pediatrics.2006;117 (2):425– 432
    OpenUrlAbstract/FREE Full Text
  138. ↵
    Greer FR. Issues in establishing vitamin D recommendations for infants and children. Am J Clin Nutr.2004;80 (6 suppl):1759S– 1762S
    OpenUrlAbstract/FREE Full Text
  139. ↵
    Gessner BD, deSchweinitz E, Petersen KM, Lewandowski C. Nutritional rickets among breast-fed black and Alaska Native children. Alaska Med.1997;39 (3):72– 74, 87
    OpenUrlPubMed
  140. ↵
    Gessner BD, Plotnik J, Muth PT. 25-Hydroxyvitamin D levels among healthy children in Alaska. J Pediatr.2003;143 (4):434– 437
    OpenUrlCrossRefPubMed
  141. ↵
    Ziegler EE, Hollis BW, Nelson SE, Jeter JM. Vitamin D deficiency in breastfed infants in Iowa. Pediatrics.2006;118 (2):603– 610
    OpenUrlAbstract/FREE Full Text
  142. ↵
    Ho ML, Yen HC, Tsang RC, Specker BL, Chen XC, Nichols BL. Randomized study of sunshine exposure and serum 25 (OH)D in breast-fed infants in Beijing, China. J Pediatr.1985;107 (6):928– 931
    OpenUrlCrossRefPubMed
  143. ↵
    Mozolowski W. Jedrzej Sniadecki (1768–1883) on the cure of rickets. Nature.1939;143 (January 21):121
    OpenUrl
  144. ↵
    Armas L, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab.2004;89 (11):5387– 5391
    OpenUrlCrossRefPubMed
  145. ↵
    Barrueto F Jr, Wang-Flores HH, Howland MA, Hoffman RS, Nelson LS. Acute vitamin D intoxication in a child. Pediatrics.2005;116 (3). Available at: www.pediatrics.org/cgi/content/full/116/3/e453
  146. ↵
    Assessment of nutrient requirements for infant formulas. J Nutr.1998;128 (11 suppl):i– iv, 2059S–2293S
    OpenUrlPubMed
  147. ↵
    Tsang R, Zlotkin S, Nichols B, Hansen J. Nutrition During Infancy: Principles and Practice. 2nd ed. Cincinnati, OH: Digital Education Publishing; 1997
  148. ↵
    Hanley DA, Davison KS. Vitamin D insufficiency in North America. J Nutr. 2005:135 (2)332– 337
    OpenUrlAbstract/FREE Full Text
  149. Whiting SJ, Calvo MS. Overview of the proceedings from Experimental Biology 2005 Symposium: Optimizing Vitamin D Intake for Populations With Special Needs: Barriers to Effective Food Fortification and Supplementation. J Nutr. 2006;136 (4):1114– 1116
    OpenUrlFREE Full Text
  150. ↵
    Rajakumar K, Fernstrom JD, Janosky JE, Greenspan SL. Vitamin D insufficiency in preadolescent African-American children. Clin Pediatr (Phila).2005;44 (8):683– 692
    OpenUrlAbstract/FREE Full Text
  151. ↵
    Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone health in children and young adults: a reevaluation of the evidence. Pediatrics.2005;115 (3):736– 743
    OpenUrlAbstract/FREE Full Text
  152. ↵
    Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med.2004;158 (6):531– 537
    OpenUrlCrossRefPubMed
  153. ↵
    Du X, Greenfield H, Fraser DR, Ge K, Trube A, Wang Y. Vitamin D deficiency and associated factors in adolescent girls in Beijing. Am J Clin Nutr.2001;74 (4):494– 500
    OpenUrlAbstract/FREE Full Text
  154. ↵
    Abrams SA, Griffin IJ, Hawthorne KM, Gunn SK, Gundberg CM, Carpenter TO. Relationships among vitamin D levels, parathyroid hormone, and calcium absorption in young adolescents. J Clin Endocrinol Metab.2005;90 (10):5576– 5581
    OpenUrlCrossRefPubMed
  155. ↵
    Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B. Positive association between 25(OH)D levels and bone mineral density: a population-based study of younger and older adults. Am J Med.2004;116 (9):634– 639
    OpenUrlCrossRefPubMed
  156. ↵
    Greer FR, Krebs NF, American Academy of Pediatrics, Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics. 2006;117 :578– 585
    OpenUrlAbstract/FREE Full Text
  157. ↵
    Bowman SA. Beverage choices of young females: changes and impact on nutrient intakes. J Am Diet Assoc. 2002;102 :1234
    OpenUrlCrossRefPubMed
  158. ↵
    Fisher JO, Mitchell DC, Smiciklas-Wright H, Mannino ML, Birch LL. Meeting calcium recommendations during middle childhood reflects mother-daughter beverage choices and predicts bone mineral status. Am J Clin Nutr. 2004;79 :698– 706
    OpenUrlAbstract/FREE Full Text
  159. Aris RM, Merkel PA, Bachrach LK, et al. Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab. 2005;90 :1888– 1896
    OpenUrlCrossRefPubMed
  160. Mikati MA, Dib L, Yamout B, Sawaya R, Rahi AC, Fuleihan Gel-H. Two randomized vitamin D trials in ambulatory patients on anticonvulsants. Impact on bone. Neurology. 2006;67 :2005– 2014
    OpenUrlAbstract/FREE Full Text
  161. ↵
    Valsamis HA, Arora SK, Labban B, McFarlane SI. Antiepileptic drugs and bone metabolism. Nutr Metab (Lond). 2006;3 :36
    OpenUrlCrossRefPubMed
  162. ↵
    Martínez J, Bartoli F, Recaldini E, Lavanchy L, Bianchetti M. A taste comparison of two different liquid colecalciferol (vitamin D3) preparations in healthy newborns and infants. Clin Drug Investig.2006;26 (11):663– 665
    OpenUrlCrossRefPubMed
  163. ↵
    Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122 (1):198– 208
    OpenUrlAbstract/FREE Full Text
  • Copyright © 2008 by the American Academy of Pediatrics
PreviousNext
Back to top

Advertising Disclaimer »

In this issue

Pediatrics
Vol. 122, Issue 5
November 2008
  • Table of Contents
  • Index by author
View this article with LENS
PreviousNext
Email Article

Thank you for your interest in spreading the word on American Academy of Pediatrics.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
(Your Name) has sent you a message from American Academy of Pediatrics
(Your Name) thought you would like to see the American Academy of Pediatrics web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Request Permissions
Article Alerts
Log in
You will be redirected to aap.org to login or to create your account.
Or Sign In to Email Alerts with your Email Address
Citation Tools
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
Carol L. Wagner, Frank R. Greer
Pediatrics Nov 2008, 122 (5) 1142-1152; DOI: 10.1542/peds.2008-1862

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
Carol L. Wagner, Frank R. Greer
Pediatrics Nov 2008, 122 (5) 1142-1152; DOI: 10.1542/peds.2008-1862
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Print
Download PDF
Insight Alerts
  • Table of Contents

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • BACKGROUND
    • RECOMMENDED DAILY INTAKE OF VITAMIN D FOR INFANTS AND CHILDREN
    • SUNLIGHT EXPOSURE AND VITAMIN D
    • PREGNANCY, VITAMIN D, AND THE FETUS
    • THE EFFECT OF MATERNAL VITAMIN D SUPPLEMENTATION DURING LACTATION ON THE VITAMIN D STATUS OF THE BREASTFED INFANT
    • VITAMIN D SUPPLEMENTATION FOR BREASTFEEDING INFANTS
    • FORMS OF VITAMIN D SUPPLEMENTS
    • FORMULA-FED INFANTS AND VITAMIN D SUPPLEMENTS
    • VITAMIN D SUPPLEMENTS DURING LATER CHILDHOOD AND ADOLESCENCE
    • SUMMARY GUIDELINES
    • COMMITTEE ON NUTRITION, 2007–2008
    • LIAISONS
    • STAFF
    • SECTION ON BREASTFEEDING EXECUTIVE COMMITTEE, 2007–2008
    • LIAISONS
    • STAFF
    • Footnotes
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • Comments

Related Articles

  • Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake
  • PubMed
  • Google Scholar

Cited By...

  • Pearls & Oy-sters: Focal hypocalcemic seizures secondary to severe vitamin D deficiency/rickets
  • Neonatal Hypocalcemia in the Infant of a Diabetic Mother
  • Adherence to Vitamin D Intake Guidelines in the United States
  • Vitamin D in Children: Can We Do Better?
  • Population-specific sequence and expression differentiation in Europeans
  • Vitamin D During Pregnancy and Infant Growth: A Long Shot
  • Question 2: Vitamin D intake for preterm infants: how much do they really need?
  • Vitamin Excess and Deficiency
  • Vitamin D, the placenta and early pregnancy: effects on trophoblast function
  • Updates in Infant Nutrition
  • Suboptimal vitamin D status in Korean adolescents: a nationwide study on its prevalence, risk factors including cotinine-verified smoking status and association with atopic dermatitis and asthma
  • Vitamin D deficiency in adolescents in a tier 4 psychiatric unit
  • Trends in the Diagnosis of Vitamin D Deficiency
  • Maternal Preferences for Vitamin D Supplementation in Breastfed Infants
  • High-Dose Monthly Maternal Cholecalciferol Supplementation during Breastfeeding Affects Maternal and Infant Vitamin D Status at 5 Months Postpartum: A Randomized Controlled Trial
  • Response to commentary by D Roth
  • Vitamin D Status and Dental Caries
  • Maternal postpartum high-dose vitamin D3 supplementation (6400 IU/day) or conventional infant vitamin D3 supplementation (400 IU/day) lead to similar vitamin D status of healthy exclusively/fully breastfeeding infants by 7 months of age
  • Maternal Vitamin D Supplementation for Breastfeeding Infants
  • The predictive value of serum 25-hydroxyvitamin D and dietary intake during adolescence: timing matters
  • Maternal Vitamin D Supplementation for Breastfeeding Infants: Will it Work?
  • Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial
  • Vitamin D Deficiency in School-Age Children Is Associated with Sociodemographic and Lifestyle Factors
  • Improved Vitamin D Supplementation in Hospitalized Breastfed Infants Through Electronic Order Modification and Targeted Provider Education
  • Rapid Normalization of Vitamin D Levels: A Meta-Analysis
  • Consumption of non-cow's milk beverages and serum vitamin D levels in early childhood
  • Vitamin D in the Newborn, Part I: Assessment of Status and Deficiency Risk Factors
  • Vitamin D in the Newborn, Part II: Bases for Current Dietary Recommendations in Term and Preterm Neonates
  • Dental Complications of Rickets in Early Childhood: Case Report on 2 Young Girls
  • NICU Follow-up: Medical and Developmental Management Age 0 to 3 Years
  • Vitamin D status of early preterm infants and the effects of vitamin D intake during hospital stay
  • Trial of Daily Vitamin D Supplementation in Preterm Infants
  • Higher Vitamin D Intake in Preterm Infants Fed an Isocaloric, Protein- and Mineral-Enriched Postdischarge Formula Is Associated with Increased Bone Accretion
  • Is vitamin D deficiency an underreported issue in refugee health?: Two cases of infants presenting with vitamin D-deficiency rickets
  • Osteopenia in preterm infants
  • Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants
  • Vitamin D status of exclusively breastfed infants aged 2-3 months
  • The Change in Plasma 25-Hydroxyvitamin D Did Not Differ between Breast-Fed Infants That Received a Daily Supplement of Ergocalciferol or Cholecalciferol for 3 Months
  • The Relationship Between Cow's Milk and Stores of Vitamin D and Iron in Early Childhood
  • Vitamin D Status of Exclusively Breastfed 4-Month-Old Infants Supplemented During Different Seasons
  • Vitamin D Deficiency in Critically Ill Children
  • Vitamin D Deficiency in Critically Ill Children: A Roadmap to Interventional Research
  • The Association of Vitamin D Status With Pediatric Critical Illness
  • Efficacy of Fat-Soluble Vitamin Supplementation in Infants With Biliary Atresia
  • MECHANISMS IN ENDOCRINOLOGY: Vitamin D and fertility: a systematic review
  • Impact of Maternal Nutritional Status on Human Milk Quality and Infant Outcomes: An Update on Key Nutrients
  • Maternal Vitamin D Status: Effect on Milk Vitamin D Content and Vitamin D Status of Breastfeeding Infants
  • Question 2 What is the ideal dose of vitamin D supplementation for term neonates?
  • Breastfeeding and the Use of Human Milk
  • Care of the Well Newborn
  • 25-Hydroxyvitamin D Levels and Vitamin D Deficiency in Children with Rheumatologic Disorders and Controls
  • Vitamin D: A D-Lightful Solution for Health
  • New Insights About Infant and Toddler Skin: Implications for Sun Protection
  • Preventable but no strategy: vitamin D deficiency in the UK
  • Vitamin D and Diabetes
  • Vitamin D Status in Abused and Nonabused Children Younger Than 2 Years Old With Fractures
  • Vitamin D requirements in adolescents: what is the target?
  • Dietary Guidelines for Calcium and Vitamin D: A New Era
  • Ultraviolet Radiation: A Hazard to Children and Adolescents
  • Ultraviolet Radiation: A Hazard to Children and Adolescents
  • Randomised controlled trial analysing supplementation with 250 versus 500 units of vitamin D3, sun exposure and surrounding factors in breastfed infants
  • Cord-Blood 25-Hydroxyvitamin D Levels and Risk of Respiratory Infection, Wheezing, and Asthma
  • An Inflection Point of Serum 25-Hydroxyvitamin D for Maximal Suppression of Parathyroid Hormone Is Not Evident from Multi-Site Pooled Data in Children and Adolescents
  • Vitamin D Status of Inuit Preschoolers Reflects Season and Vitamin D Intake
  • Vitamin D Insufficiency in Children With Epilepsy
  • Predictors of vitamin D status and its association with parathyroid hormone in young New Zealand children
  • Maternal Serum 25-Hydroxyvitamin D Concentrations Are Associated with Small-for-Gestational Age Births in White Women
  • Vitamin D Status Is Modestly Associated with Glycemia and Indicators of Lipid Metabolism in French-Canadian Children and Adolescents
  • Adherence to Vitamin D Recommendations Among US Infants
  • Widespread Vitamin D Deficiency in Urban Massachusetts Newborns and Their Mothers
  • 25-Hydroxyvitamin D Status of Healthy, Low-Income, Minority Children in Atlanta, Georgia
  • Incorporating Type 1 Diabetes Prevention Into Clinical Practice
  • Diagnosis and management of vitamin D deficiency
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods
  • Potential Interactions of Vitamins With Medications
  • Vitamin D Needs of Preterm Infants
  • Vitamin D: An Evidence-Based Review
  • Defining Vitamin D Deficiency in Children: Beyond 25-OH Vitamin D Serum Concentrations
  • Vitamin D Levels in Subjects With and Without Type 1 Diabetes Residing in a Solar Rich Environment
  • Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004
  • US Vitamin Use: Too Much By Too Many
  • Dietary Reference Intakes for vitamin D: justification for a review of the 1997 values
  • Vitamin D Recommendations: They Change Again!
  • Google Scholar

More in this TOC Section

  • Ethical Considerations in Pediatricians’ Use of Social Media
  • 2021 Recommendations for Preventive Pediatric Health Care
  • Recommended Childhood and Adolescent Immunization Schedule: United States, 2021
Show more From the American Academy of Pediatrics

Similar Articles

Subjects

  • Endocrinology
    • Metabolic Disorders
    • Endocrinology
  • AAP Policy Collections by Authoring Entities
    • Committee on Nutrition
  • Journal Info
  • Editorial Board
  • Editorial Policies
  • Overview
  • Licensing Information
  • Authors/Reviewers
  • Author Guidelines
  • Submit My Manuscript
  • Open Access
  • Reviewer Guidelines
  • Librarians
  • Institutional Subscriptions
  • Usage Stats
  • Support
  • Contact Us
  • Subscribe
  • Resources
  • Media Kit
  • About
  • International Access
  • Terms of Use
  • Privacy Statement
  • FAQ
  • AAP.org
  • shopAAP
  • Follow American Academy of Pediatrics on Instagram
  • Visit American Academy of Pediatrics on Facebook
  • Follow American Academy of Pediatrics on Twitter
  • Follow American Academy of Pediatrics on Youtube
  • RSS
American Academy of Pediatrics

© 2021 American Academy of Pediatrics