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Vitamin D Deficiency

By
Dr.M. Sravanthi
Intern 2K9 Batch
Overview
Brief Note on Vitamin D
Vitamin D Deficiency
Epidemiology
Prevention
Control
Diagnosis
Treatment
Vitamin D Deficiency with reference to Rickets
in MIMS

Introduction

Vitamin D is a fat soluble vitamin. It is also known as
sunshine vitamin or antirachitic vitamin.
Two forms of vitamin D
Vitamin D2 or Ergocalciferol(Present in Plants)
Vitamin D3 or Cholecalciferol ( Present in Animals )
The natural form of Vitamin D(Cholecalciferol or
vitamin D3) is formed in the skin by action of UV light
on 7-dehydrocholesterol(metabolite of cholesterol).
It plays an important role in metabolism of calcium
and phosphorous and maintaining proper bone
structure.


Recommended Dietary Allowance of
Vitamin D
Daily requirement of vitamin D is 400IU or
10g of cholecalciferol.
The RDA in infants is 5g ( 200IU ) per day and
children 10g ( 400IU ) per day.
In pregnancy 10g of vitamin D per day
In countries with good sun light ( Like India )
the RDA is 200IU or 5mg.
Sources of Vitamin D
Sunlight
Fish Oils
Egg Yolk
Butter
Cereals
Cheese
Fortified Milk
Metabolism
Metabolism and Absorption
Functions of Calcitriol
Increases internal absorption of calcium and
phospate
Essential for bone formation
In minimizing the excretion of Ca and Ph
through kidney by enhancing absorption

Epidemiology of Vitamin D Deficiency
worldwide
Vitamin D Deficiency status
When do you call it as Vitamin D
deficiency ?
Measurement of 25(OH) vitamin D serum
levels best reflects the vitamin D status of an
individual.
Normal levels 25 (OH) vitamin D are in the range
of 30 to 80 ng/mL (75 to 200 nmol/L).
Concentrations < 12 to 20 ng/mL (30 to 50
nmol/L) are considered deficient.
Levels > 150 ng/mL (374 nmol/L) are considered
toxic.
Vitamin D deficiency consequences
It causes Rickets in children




Osteomalacia in adults


Both are characterized by
defective mineralization

Rickets
A lack of adequate mineralization of growing bones
results in rickets.
This results in soft and pliable bones and delay in heat
formation.
The weight bearing bones are bent to form bow legs.
In India nutritional rickets is widely prevalent.
In most of the developed countries nutritional rickets
was eradicated by fortification of milk or direct
administration of Vitamin D.
Statistics in MIMS in 2013 Overall 5 cases have been
detected in paediatric ward.

Causes of Rickets
Vitamin D Deficiency
Classical Lack of sunlight exposure
GI Diseases Malabsorption
Failure of 1,25 vit D synthesis
Chronic renal failure Kidney damage
Vitamin D resistant rickets type1
Vitamin D receptor defects
Vitamin D resistant rickets type2
Defects in phosphate metabolism

Signs and Symptoms of Rickets
Skeletal Deformity

Bowed Legs ( genu varum )
in toddlers


Knock Knee ( genu valgum )
in older children

Signs and Symptoms of Rickets
Craniotabes ( Soft skull )
Spinal and pelvis deformities
Growth disturbances
Costochodral swelling ( rickety rosary or rachitic
rosary )
Harrisons grove, double malleoli due to
metaphyseal hyperplasia
Bone pain or tenderness and muscle weakness
and dental problems


Radiological Changes
Loss of normal zone of calcification adjacent to metaphysis.
Frayed appearance with widening of growth plate due to lack
of calcification of metaphyseal bone.
Splaying and cupping of metaphysis due to stress on
uncalcified bone.
Reduction in bone density





Diagnosis
Values below 10g/ml are indicative of
deficiency
An increase plasma level of 1,25 ( OH )
2
D3
indicates deficient intake of calcium and
phosphorus.
Blood levels of 25 ( OH ) D3 are decreased in
rickets.
Serum alkaline phosphate is elevated.


Treatment
Vitamin D is administered orally in single dose of
6,00,000IU or over 10 days(6,00,000IU daily for
10days)
Followed by a maintainence dose of 400IU/day
and oal calcium supplements(50-75mg/kg/day)
Patients with D deficiency rickets show evidence
of radiological healing within 4wks
If no healing occurs with 2megas doses of vit d
patient should be evaluated for refractory rickets

Vitamin D Resistant Rickets
It is of two types
Type 1 and Type 2
Clinical features are similar to infantile rickets and
the diagnosis is usually first suspected when
patient fails to respond to vitamin D
supplements.
Type 1 is treated by active vitamin D
supplementation and calcium supplementation.
Type 2 is extremely difficult to treat as it responds
less to vitamin D supplementation.



Prevention and Control of Vitamin D
Deficiency
Proper sunlight exposure
Using vitamin D3 for the treatment and prevention of vitamin D deficiency .
For infants and toddlers aged 01 yr who are vitamin D deficient, treatment with
2000 IU/d of vitamin D3 , or with 50,000 IU of vitamin D3 once weekly for 6 wk to
achieve a blood level of 25(OH)D above 30 ng/ml, followed by maintenance
therapy of 4001000 IU/d
For children aged 118 yr who are vitamin D deficient, we suggest treatment with
2000 IU/d of vitamin D3 for at least 6 wk or with 50,000 IU of once a week for at
least 6 wk to achieve a blood level of 25(OH)D above 30 ng/ml, followed by
maintenance therapy of 6001000 IU/d
All adults who are vitamin D deficient be treated with 50,000 IU of vitamin D3
once a week for 8 wk or its equivalent of 6000 IU of or vitamin D3 daily to achieve
a blood level of 25(OH)D above 30 ng/ml, followed by maintenance therapy of
15002000 IU/d

Proper sunlight exposure may contribute to prevent vitamin D deficiency




Thank You !!!