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› IN PRACTICE
2 Journal of Health Visiting › June 2014 › Volume 2 Issue 6
© 2014 MA Healthcare Ltd
Identifying vitamin D deciency and
recommendations for at-risk groups
› Abstract
In recent years there has been an increase in identication
of vitamin D deciency in infants and children in the UK,
particularly in black and minority ethnic groups. Vitamin
D is essential for bone health and deciency can lead to
rickets. Sunlight is the primary source of vitamin D but, in
the UK, ultraviolet radiation is not strong enough to produce
adequate levels of vitamin D. As food sources are limited,
supplementation is necessary for most people, particularly
groups at high risk of deciency. Health visitors have a
role in raising awareness of the importance of vitamin D
and promoting supplementation among pregnant and
breastfeeding women and infants and children under 5.
Key words
› Vitamin D › Rickets › Deficiency › Diet › Nutrition › Sunlight
› Supplements › Bone health › Breastfeeding › Pregnancy › Weaning
Kathy Cowbrough
Consultant Dietitian and Nutritionist,
Retford, Nottinghamshire
e: kathy.cowbrough@virgin.net
Vitamin D is a topic that has been
highlighted by health professionals,
scientists, government, industry and
the general public increasingly over
the past few decades (Cashman and Kiely, 2011).
The rising interest is due partly to the increased
identication of vitamin D deciency in infants,
young children and adolescents in the UK
(Kehler et al, 2013) and particularly black and
minority ethnic groups, especially those of Afro-
Caribbean and South Asian origin (Shaw and
Pal, 2002).
But does the high level of interest mean the
advice to families has become clearer and the
deciencies are being addressed? Recent years
have seen guidance on vitamin D from the
Chief Medical Ofcer (Davies, 2013) and the
National Institute for Health and Care Excellence
(NICE, 2011), a consensus statement (British
Association of Dermatologists et al, 2010) and
review of requirements (Institute of Medicine,
2011; Cashman and Kiely, 2014). However,
some health professionals remain unsure of
what to recommend to families (Feeding for Life
Foundation, 2011). A report of a survey of health
professionals, presented at the Royal College of
Paediatrics and Child Health (RCPCH) conference
in 2011 (Jain et al, 2011), found that 71% of UK
parents surveyed trusted health professionals
to provide informed advice on vitamin D, yet
77% of parents were unaware of vitamin D
recommendations and 35% stated that they had
never received information about their child’s
specic needs (Vitamin D Mission, 2014).
In adults, vitamin D deciency can contribute
to the development of osteoporosis and fractures
(National Radiological Protection Board (NRPB),
2002). There has also been recent interest in the
potential role vitamin D plays in the prevention
of non-skeletal disorders such as autoimmune
disease, cancer, mental health problems and
cardiovascular disease, although these links
are not conclusive (British Association of
Dermatologists et al, 2010).
This article will consider the importance of
vitamin D as a public health issue, emphasising
the prevention of deciency and insufciency in
pregnancy and the 0–5 age group. It will consider
why we need vitamin D, sources, causes of
deciency, groups at high risk, supplementation
and the role health visitors can play in raising
awareness and highlighting recommendations.
Why do we need vitamin D?
Vitamin D is essential for bone health. It is
required to absorb calcium and phosphorus into
the body and regulate the movement of these
minerals in and out of the skeleton, ensuring
strong bones. Although vitamin D is classed as an
essential nutrient, it is actually a hormone and can
be manufactured in the body.
In comparison with other essential nutrients,
specic requirement levels for vitamin D are
complicated because it can be manufactured by
the body. In the UK, reference nutrient intake
(RNI) levels for vitamin D have been set for those
population groups most at risk of deciency:
› IN PRACTICE
Journal of Health Visiting › June 2014 › Volume 2 Issue 6 3
© 2014 MA Healthcare Ltd
infants, pregnant women and the elderly. The RNI
is dened as being two standard deviations above
the estimated average requirement and is therefore
the intake amount that will satisfy the needs of
97.5% of the population (Department of Health
(DH), 1991). The RNI is therefore not the same as
the average nutrient requirement.
Sources of vitamin D
About 90% of our vitamin D comes from sunlight
(Scientic Advisory Committee on Nutrition
(SACN), 2007). When the skin is exposed to
the ultraviolet B (UVB) contained in sunlight,
it converts 7-dehydrocholesterol in the deep
epidermal layers of the skin to the provitamin
cholecalciferol (vitamin D3). Cholecalciferol
is transported to the liver and converted to
25-hydroxyvitamin D (25(OH)D). This is then
metabolised in the kidney to the active form
1,25-dihydroxyvitamin D (1,25(OH)2D) or
calcitriol (De Luca, 2004; Infant and Toddler
Forum, 2012).
The amount of UVB radiation needed to make
sufcient vitamin D depends on certain factors,
such as skin colour: people with fair complexions
need only 10% of the sunlight exposure required
by those with darker skin (Dawson-Hughes, 2004).
There are some dietary sources of vitamin D
(Table 1). Small amounts are found in oily sh
(sardines, salmon, mackerel, pilchards and tuna)
and even smaller amounts in egg yolk and red
meat. Some foods, such as margarine, infant
formula and some breakfast cereals, are fortied
with vitamin D (SACN, 2003). Foods contain
cholecalciferol (vitamin D3) and ergocalciferol
(vitamin D2), which are biologically inactive;
when they are eaten and absorbed they are
transported to the liver and follow the same
metabolic pathway as vitamin D3 from sunlight.
Sunlight
Exposure to UVB radiation in sunlight is the
most efcient way to boost vitamin D supply.
More vitamin D is made in direct sunlight than
in the shade or on a cloudy day (British Dietetic
Association, 2013). However, there are several
factors that affect exposure and can therefore
have an impact on the body’s production of
vitamin D. Environmental factors include
(Institute of Medicine, 2011; Health Council of the
Netherlands, 2012):
Latitude: people living above 52° North (in
the UK, this is approximately the latitude of
Table 1. Vitamin D in food
Food: portion size for toddlers* Amount of vitamin D
Micrograms (μg) International units (IU)
2–3 tbsp (45 g) sardines (canned in tomato sauce) 3.6 144
2–3 tbsp (45 g) grilled salmon 3.2 128
2–3 tbsp (45 g) tuna (canned in oil) 1.35 54
1 egg (60 g) 1.1 44
½–1 slice cooked lamb 0.18 7
Fortified foods
100–120 ml infant formula for children <1 year 1.2 48
100–120 ml infant formula for children >1 year 1.9 76
100–120 ml follow-on formula 1.4 56
30 ml evaporated milk 1.2 48
3–6 heaped tbsp (18 g) fortified breakfast cereal 0.7 28
1 tsp (5 g) margarine 0.4 16
* Household spoons vary in size: tablespoons (tbsp) are about 15 ml and teaspoons (tsp) are about 5 ml
Source: Food Standards Agency (2002); Infant and Toddler Forum (2012)
» Exposure to UVB radiation in sunlight is
the most efficient way to boost vitamin D
supply. However, there are several factors
that affect production of vitamin D. «
› IN PRACTICE
4 Journal of Health Visiting › June 2014 › Volume 2 Issue 6
© 2014 MA Healthcare Ltd
Birmingham) are unable to produce sufcient
vitamin D from October to March (Pearce and
Cheetham, 2010)
Prevailing weather conditions and the level of air
pollution (Hosseinpanah et al, 2010)
Time of year: in the UK, ultraviolet light is only
strong enough to make vitamin D on exposed
skin in the middle of the day (around 11am–
3pm) from April to September (British Dietetic
Association, 2013)
Personal characteristics e.g. skin pigmentation
(people with darker skin manufacture less
vitamin D) and age (the skin of older people is
less able to absorb vitamin D from sunlight)
Physical exposure to sunlight e.g. amount of
time spent outside, attire, use of sunscreen.
There is a need to reconcile the requirement for
sun exposure to produce vitamin D with the need
to protect skin from ultraviolet radiation that can
cause skin damage and cancers (Box 1).
Vitamin D deciency
Vitamin D insufciency is common in the UK.
The level of 25(OH)D in the blood is the best
indicator of vitamin D status. There is consensus
that levels below 25 nmol/l (10 ng/ml) qualify as
‘decient’ (SACN, 2007; Pearce and Cheetham,
2010) because the severe bone disorders of rickets
and osteomalacia can occur below these levels
(NRPB, 2002; Ashwell et al, 2010). Some authorities
state that a 25(OH)D level of 50 nmol/l (20 ng/ml)
represents a ‘sufcient’ level, based on bone health
ndings (Institute of Medicine, 2011).
Groups considered to be at a higher risk of
vitamin D deciency are (Need et al, 1993; Shaw
and Pal, 2002; SACN, 2003; RCPCH, 2012; Kehler
et al, 2013; Bates et al, 2014):
Babies and young children, and children and
adolescents who spend little time outside
Pregnant women and breastfeeding mothers
Breastfed babies whose mothers are lacking in
vitamin D
People over 65 years old
People with darker skin tones; people of Asian,
African, Afro-Caribbean and Middle Eastern
descent living in the UK or other northern
climates.
Infants and children aged 6 months to 3 years
are particularly vulnerable to vitamin D depletion
because of their rapid bone growth, along with
the fact that some may have limited exposure to
sunlight. There is evidence that under-5s of Asian
origin are more likely to have lower vitamin D
status than children of other ethnicities (Kwan
et al, 2007). There is some inconsistency in
recommendations regarding the age at which
children are no longer considered at high risk of
deciency. DH recommendations are based on
advice from SACN (2007), which states that: ‘For
Box 1. Vitamin D and the ‘sun safe’ message
Concern over the balance between having sucient sun exposure to produce
vitamin D, and over-exposure leading to burning of the skin and an increased
risk of skin cancer, has led to some confusion in public health messages.
A consensus from seven UK health organisations—the British Association
of Dermatologists, Cancer Research UK, Diabetes UK, the Multiple Sclerosis
Society, the National Heart Forum (now called the UK Health Forum), the
National Osteoporosis Society and the Primary Care Dermatology Society
(British Association of Dermatologists et al, 2010)—along with existing vitamin
D guidance (Infant and Toddler Forum, 2012) suggests:
e amount of time spent in the sun that is required for skin to make
enough vitamin D is dierent for every person
Short daily periods of sun exposure without sunscreen during the summer
months (April to October) are enough for most people to make sucient
vitamin D. Evidence suggests that the most eective time of day for vitamin
D production is between 11am and 3pm
A ‘short period’ in the sun means a matter of minutes—the time required
varies depending on clothing, the amount of shade and how much time
people typically spend outside. e consensus report does not specify a
time but states that ‘regularly going outside for a matter of minutes around
the middle of the day without sunscreen should be enough’ and is ‘less than
the time it takes to start going red or burn’
e larger the area of skin that is exposed to sunlight, the more chance there
is of making enough vitamin D before starting to burn
People with darker skin will need to spend longer in the sun to produce the
same amount of vitamin D as those with lighter skin
Box 2. Recognising signs of vitamin D deficiency
In adults, signs of vitamin D deficiency include bone pain and tenderness
as a result of a condition called osteomalacia. A national survey of adults
showed that 21.7% of women of child-bearing age have low vitamin D levels
(Bates et al, 2014). e rate is higher in women with dark-pigmented skins; a
survey from Wales reported that about 50% of pregnant women with dark-
pigmented skins have low vitamin D levels (Datta et al, 2002).
In infants and children, deficiency can cause muscle weakness and
twitching (tetany), rickets and bone deformities. It is important that
health visitors are able to identify signs of vitamin D deficiency in children
and ensure that suspicions are investigated so that those children receive
appropriate treatment. e main signs are skeletal malformation (e.g.
bowed legs) with bone pain or tenderness and muscle weakness, lethargy
and irritability (RCPCH, 2012). According to the Diet and Nutrition Survey
of Infants and Young Children, undertaken in 2011, 6% of infants aged 5–11
months and 2% of those aged 12–18 months had vitamin D levels below
the reference (Lennox et al, 2013).
› IN PRACTICE
Journal of Health Visiting › June 2014 › Volume 2 Issue 6 5
© 2014 MA Healthcare Ltd
4 to 65 year olds, it is assumed that the action of
summer sunlight will provide adequate vitamin
D status, except for specic at risk groups who are
not exposed to sufcient sunlight’ (SACN, 2007:
10). However, a letter to health professionals
from the Chief Medical Ofcers of England,
Wales, Northern Ireland and Scotland included
‘infants and young children under 5 years of
age’ in its list of people at high-risk of vitamin D
deciency (Davies et al, 2012: 2). While ofcial
recommendations refer to children under 3, it
may be appropriate to consider children under
5 to be part of this at-risk group. A new SACN
report on vitamin D, expected in 2014, may help
to clarify this aspect of the recommendations.
One reason why infants are at risk of deciency
is that there is little vitamin D in breast milk,
particularly if the mother has a deciency.
However, given the signicant advantages of
breastfeeding, mothers should be discouraged
from ceasing to breastfeed over concern about
vitamin D levels. Breastfed babies can be given
Ta b l e 2 . R e f e r e n c e n u t r i e n t i n t a k e s f o r v i t a m i n D i n t h e U K
Age group Vitamin D requirement (daily) Meeting the requirement
Micrograms
(μg)
International
units (IU)
All pregnant women and
breastfeeding women
10 400 A daily supplement is necessary to ensure the mother’s requirements
for vitamin D are met and that the baby is born with enough stores
of vitamin D for the first few months of its life. Breast milk contains
only small amounts of vitamin D, and these levels are even lower in
vitamin D-deficient mothers
Babies 0–6 months
(breastfed)
8.5 340 If the mother has not taken vitamin D supplements throughout her
pregnancy, the baby may need to receive drops containing vitamin
D from 1 month of age. e recommended daily supplement is
7.5 μg/300 IU
Babies 0–6 months
(formula-fed)
8.5 340 Infant formula is fortified with vitamin D so formula-fed babies will
not need vitamin drops until they are receiving less than 500 ml
of infant formula per day. e recommended daily supplement is
7.5 μg/300 IU
Children 6 months
to 3 years
7280 All babies and children aged 6 months to 3 years should be given
a daily supplement of 7–8.5 μg, unless they are drinking more than
500 ml of fortified formula milk. Some sources suggest the range of
children at high risk of deficiency is up to 5 years (Davies et al, 2012);
a new SACN report due in 2014 may help to clarify this
4–64 years No requirement set is group ought to get enough vitamin D from sun and food, but
for those with dark skin pigmentation or who are confined inside or
cover up when outside, a 10 μg supplement is recommended
People aged 65+ 10 400 Older people have a reduced ability to make vitamin D through their
skin and often have less exposure to sunlight, so daily supplements
are recommended
Source: DH (1991); SACN (2007); Bates et al (2014)
vitamin D supplements as drops by mouth.
Health professionals should be aware of the
signs of vitamin D deciency (Box 2). In infancy
and childhood, deciency typically presents with
bone deformity (rickets) or hypocalcaemia. In
2012, the RCPCH reported that rates of rickets had
risen fourfold in the past 15 years (RCPCH, 2012).
National Diet and Nutrition Surveys show that
few toddlers and women of childbearing age in
the UK meet their RNI through food alone, and
will only attain their RNI when taking adequate
vitamin D supplements (Gregory et al, 1995; Bates
et al, 2014).
At present, there are no dietary requirements
for vitamin D set for people aged 4–64 years; it is
assumed that people in this group do not require
a dietary source of vitamin D provided they are
exposed to sunlight in the summer months (DH,
1991). Table 2 shows the RNI for vitamin D in
various groups, and how these requirements
can be met through sun exposure, diet and
supplementation.
› IN PRACTICE
6 Journal of Health Visiting › June 2014 › Volume 2 Issue 6
© 2014 MA Healthcare Ltd
Supplementation
As a result of low UVB levels in sunlight and
the fact that only around 10% of required
vitamin D comes from dietary sources, most
people in the UK should take supplements to
ensure adequate intake of vitamin D (Bates et
al, 2014). In particular, people in groups at high
risk of vitamin D deciency should be offered
information on suitable supplements.
Health visitors, midwives and early years
professionals should advise parents to check that
the supplements they take or give to their children
contain enough vitamin D to meet requirements
(as set out in Table 2). Healthy Start vitamins
contain the amount advised by the DH and all
families who qualify should be advised on using
them (McFadden et al, 2014). However, provision
of Healthy Start vitamins varies widely across
the country.
Supplements containing vitamin D are
available over the counter in some shops, and
health visitors should be aware of where to
obtain suitable vitamin D supplements for
pregnant and breastfeeding mothers, infants
and young children. Vitamin D toxicity is
uncommon and usually only affects people
who have been taking vitamin D supplements
well above the recommended dosage for several
months (NHS Choices, 2013). However, parents
should be advised to give their toddlers only
one supplement containing vitamin D, at the
recommended dose once per day (Infant and
Toddler Forum, 2012).
Conclusion
The increased rates of rickets and vitamin D
deciency in recent years suggest that there is a
need to raise awareness of the importance of this
essential nutrient. Health visitors are in a position
to advise pregnant women and parents of young
children on diet, supplementation and safe sun
exposure, and to direct them to resources (Box 3)
website to gain more information. JHV
This article has been subject to peer review.
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Health visitors who wish to learn more about vitamin D may find the
following websites useful:
Infant and Toddler Forum: Fact Sheet 4.7, Preventing vitamin D deficiency in
toddlers, is available at http://tinyurl.com/ly9zt3h
NHS Choices: Practitioners may wish to signpost parents to the useful
summary of guidance around sun exposure with regard to vitamin D intake
at http://tinyurl.com/NHSvitDsun
Royal National Orthopaedic Hospital NHS Trust: is website has a section
on frequently asked questions about Vitamin D in childhood, at www.rnoh.
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Vitamin D Mission: is project, which aims to raise awareness of the
importance of vitamin D, oers accessible information for both parents and
health professionals. See www.vitamindmission.co.uk
Key points
Vitamin D is essential for bone health
Sunlight is the most important source of vitamin D, which cannot be
supplied by diet alone
Vitamin D insuciency is common in the UK population, and infants and
children aged 6 months to 3 years are particularly vulnerable
Vitamin D deficiency typically presents with bone deformity (rickets) or
hypocalcaemia in infancy and childhood, and a resurgence of rickets has
been reported in many cities in the UK
Risk factors include skin pigmentation, use of sunscreen or concealing
clothing, being elderly or being housebound
During winter months in the UK, there is not enough UVB for vitamin D
synthesis and people rely on tissues stores, supplements and dietary sources
Vitamin D supplements and fortified foods can help to maintain sucient
levels of vitamin D, particularly in people at risk of deficiency
Health professionals should familiarise themselves with current
supplementation recommendations for at-risk groups
Health visitors have a key role in advising families on the importance of
vitamin D and how to safely obtain it from sunlight, food and supplements
› IN PRACTICE
Journal of Health Visiting › June 2014 › Volume 2 Issue 6 7
© 2014 MA Healthcare Ltd
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