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• Hypocalcaemic seizures and maternal Vitamin D deficiency
  Robert J Moy
  Published on: 9 January 2022
• Reply to Ladhani et al: Presentation of vitamin D deficiency
  N F Ismail
  Published on: 9 January 2022
• Is no vitamin D for danger if breast feeding?
  Simon Fountain-Polley
  Published on: 9 January 2022

• Published on: 9 January 2022

  Hypocalcaemic seizures and maternal Vitamin D deficiency

  • Robert J Moy, Senior Lecturer in Child Health
  • Other Contributors:
    • Nick Shaw, Ian Mather, Melanie Kershaw, Nicola Trevelyan

  Dear Editor,

  We note with interest the article by Ladhani et al [1] on the modes of presentation of vitamin D deficiency in a retrospective survey of 65 children aged between birth and 13 years admitted over a 5 year period to 3 London hospitals. A similar resurgence of vitamin D deficiency disease (hypocalcaemic seizures and rickets) has been reported from the West Midlands [2] primarily among Asian and...

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  Dear Editor,

  We note with interest the article by Ladhani et al [1] on the modes of presentation of vitamin D deficiency in a retrospective survey of 65 children aged between birth and 13 years admitted over a 5 year period to 3 London hospitals. A similar resurgence of vitamin D deficiency disease (hypocalcaemic seizures and rickets) has been reported from the West Midlands [2] primarily among Asian and black children. We would like to emphasise the importance of vitamin D supplementation during pregnancy as a means of preventing the early presentation of this deficiency as hypocalcaemic seizures in infants of vitamin D deficient mothers.

  Case notes were obtained of all 65 children who had attended 3 inner city Birmingham hospitals that serve a multi-ethnic community over a 2 year period (June 2001- June 2003) who had vitamin D deficiency disease as indicated by laboratory records of vitamin D levels of less than 10 ng/ml. Additional cases with low vitamin D levels due to extreme prematurity, hepatic or renal disease were excluded. 48 children had rickets presenting as bony or joint deformity or gross motor delay. A further 17 children had presented with hypocalcaemic seizures (serum calcium 0.64 – 1.92 mmol/l). The age of presentation with seizures ranged from 3 days to 18 months (median age 12 weeks with 6 of the 17 presenting in the first week of life). 3 children aged 7, 12 and 18 months were found to have physical and radiological signs of rickets as well. 14 children were of Asian origin, 2 Moslem Black Africans and 1 Afro-Caribbean. Vitamin D levels ranged from less than 3 to 8.0 ng/ml and parathormone levels 56 to 423 pmol/l (normal range 1.1-6.8 pmol/l).

  Vitamin D levels were obtained from 12 of the mothers of these 17 cases. All were low and within the range 5.1 to 8.2 ng/ml. No mothers had recorded evidence of receiving vitamin D supplements during pregnancy despite one mother having had a previous infant with hypocalcaemic seizures. Furthermore there was no recorded evidence that the infants had received vitamin D supplements. Importantly over half of the cases were receiving formula milk which is fortified with vitamin D. The remainder were breastfed and some were receiving a weaning diet.

  Our cases were all admitted as emergencies with seizures and subsequently spent between 2 and 9 days as inpatients often with an unclear initial diagnosis and so were subsequently subjected to a range of invasive investigations (mean number of tests 15) including EEG and brain imaging in some. Each case required up to 7 out patient follow up appointments

  Our data would therefore strongly support the recommendations of the Committee on Medical Aspects of Food (COMA) that “all pregnant and lactating women should have an intake of 10 mg of vitamin D daily, and as their average dietary intake is 3 mg, so all pregnant and breast feeding mothers should take a supplement as they have higher requirements than other adults “ [3].

  However we have already noted [4] that the recent clinical guideline from the National Institute for Clinical Excellence (NICE) on antenatal care [5] has stated that there is apparently insufficient evidence to recommend routine supplementation of all pregnant women. This contention is based on a limited systematic review [6] that included only two small- scale randomised controlled trials of vitamin D supplementation done more than 20 years ago. The outcomes of these trials were mainly concerned maternal weight gain and birth weight, and gave contradictory results. However one study [7] did find an elimination of symptomatic hypocalcaemia within the first 48 hours of life in babies whose mothers has been supplemented with vitamin D during the last trimester of pregnancy.

  A local telephone survey of a sample of 75 health professionals caring for pregnant women found that although they were aware of those women at high risk of vitamin D deficiency, few actually assessed the level of risk in their patients and no obstetrician or midwife recommended vitamin D supplementation. We would therefore support the 1991 COMA recommendation on vitamin D supplementation of all pregnant women.

  References

  (1). Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Arch Dis Child 2004;89:781-784.

  (2). Callaghan A, Booth IW, Moy RJD, Shaw NJ, Debelle G. Rickets returns. Arch Dis Child 2002:86 (suppl 1):A35.

  (3). Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects 41: dietary reference values for food energy and nutrients for the United Kingdom. London: the Stationery Office, 1991: 123-127.

  (4). Moy R, Shaw N, Mather I. Vitamin D supplementation in pregnancy. Lancet 2004;363:574.

  (5). National Collaborating Centre for Women’s and Children’s Health. Antenatal care: routine care for healthy pregnant woman. London RCOG Press, 2003.

  (6). Mahomed K, Gulmezoglu AM. Vitamin D supplementation in pregnancy (Cochrane Review). In: The Cochrane Library, Issue 4, Oxford: Update Software, 2003.

  (7). Brooke OG, brown IRF, Bone CDM, et al. Vitamin D supplements in pregnant Asian women: effects on calcium status and fetal growth. BMJ 1980;280:751-754.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Reply to Ladhani et al: Presentation of vitamin D deficiency

  • N F Ismail, Senior house officer

  Dear Editor,

  I have read with great interest the article titled “Presentation of vitamin D deficiency” by Ladhani et al in the in the August 2004 issue of Archives of Disease in Childhood. [1] The article was excellent, however, I would like to point out a mistake in the legend of Figure 1 which states:

  "Figure 1 (A) Radiograph of patient aged 1 year with severe rickets. (B) Radiograph of pati...

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  Dear Editor,

  I have read with great interest the article titled “Presentation of vitamin D deficiency” by Ladhani et al in the in the August 2004 issue of Archives of Disease in Childhood. [1] The article was excellent, however, I would like to point out a mistake in the legend of Figure 1 which states:

  "Figure 1 (A) Radiograph of patient aged 1 year with severe rickets. (B) Radiograph of patient aged 11 years presenting with hypocalcaemic symptoms and no radiological evidence of rickets"

  The radiograph in (A) is clearly a normal radiograph of some one who is definitely not a 1 year old. I think the description in radiograph (A) fits to radiograph (B) and vice versa. With kind regards

  Reference

  (1). Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Arch Dis Child. 2004;89:781-784.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Is no vitamin D for danger if breast feeding?

  • Simon Fountain-Polley, SpR Paediatrics

  Dear Editor,

  The paper by Ladhani et al on vitamin D deficiency reminds us of our wider duty of care to children in considering background nutrition [1].

  Prolonged breast feeding has been recognised as a risk factor for vitamin D deficiency [2]; it will be interesting to observe whether its incidence will increase with the international drive to promote exclusive breast feeding for the first six m...

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  Dear Editor,

  The paper by Ladhani et al on vitamin D deficiency reminds us of our wider duty of care to children in considering background nutrition [1].

  Prolonged breast feeding has been recognised as a risk factor for vitamin D deficiency [2]; it will be interesting to observe whether its incidence will increase with the international drive to promote exclusive breast feeding for the first six months, and its continuation for two years [3]. The recent United Kingdom Infant Feeding Survey reported an increase in the initiation of breast feeding, and the length of time providing breast milk [4]. Whether this trend will continue remains to be seen, but if so, then vitamin D deficiency may rise.

  The use of supplements may prevent this, and has been previously recommended for at risk children [5,6]. Although not specifically mentioning vitamin D, the World Health Organisation has suggested that nutrient supplementation may ensure adequate micronutrients [3] and this seems increasingly important if their feeding recommendations are to be embraced. On a local level, although premature infants receive vitamin supplementation, neither term babies or their breast feeding mothers are advised to supplement their intake of vitamin D. This is amongst a large, ethnically diverse, underpriviledged population within the West Midlands.

  As the accompanying editorial suggests [7], it may be time to highlight the preventable morbidity of vitamin D deficiency: whether this should involve the routine supplementation of vitamin D in breast feeding infants and their mothers needs further thought if a D for danger is to be avoided.

  References

  (1). S Ladhani, L Srinivasan, C Buchanan, and J Allgrove. Presentation of vitamin D deficiency Arch. Dis. Child. 2004; 89: 781-784

  (2). M Z Mughal, H Salama, T Greenaway, I Laing, and E B Mawer. Lesson of the week: Florid rickets associated with prolonged breast feeding without vitamin D supplementation BMJ 1999; 318: 39-40

  (3). World Health Organization. Infant and young child nutrition Global strategy on infant and young child feeding. Geneva: WHO, 2002

  (4). Hamlyn B, Brooker S, Oleinikova K, Wands S. Infant Feeding 2000. London: The Stationery Office, 2002

  (5). Department of Health. Dietary reference values for food energy and nutrients for the United Kingdom. London: HMSO , 1991(Report on health and social subjects 41.)

  (6). N J Shaw and B R Pal Vitamin D deficiency in UK Asian families: activating a new concern Arch. Dis. Child. 2002; 86: 147-149

  (7). J Allgrove Arch. Dis. Child. Is nutritional rickets returning? 2004 89: 699-701

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  Conflict of Interest:
  None declared.

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