Children's Doctor

Nutrition - Fall 2011

A Lot of Milk; No Vitamin D

Michael A. Levine, MD

Amish parents concerned over poor growth during the last 6 months bring 2 sons, 4 and 6 years old, to their pediatrician. Both boys were full-term babies and breast-fed for 10 months. Their diet is quite good and includes 3 to 4 glasses of fresh milk daily from the family dairy farm. They take no medications or vitamins. The brothers have bone pain but no history of fractures. Of their 5 older siblings, a brother and sister have a history of similar bone problems. Both boys appear well and are active.

You recommend the boys be admitted for treatment and further evaluation. Both are given oral calcium carbonate, 3 times per day, plus vitamin D 400 IU daily, but after a week there is little improvement.

Discussion: Both brothers have rickets, a childhood condition that results in undermineralized bones and poor growth. Bones that are undermineralized are weak and “soft,” and this defect can affect children and adults alike. Undermineralization is termed osteomalacia in adults. By contrast, when skeletal undermineralization occurs in children the bone defect is termed “rickets,” as the condition not only affects mature bone but also impairs endochondral ossification in the growth plate (ie, the physis), leading to bone deformities and poor growth. Bones that do not mineralize properly bend more easily. This is readily seen in young children with bowed legs or knock-knees, since the weightbearing bones are “soft.”

Rickets is among the most frequent childhood diseases and occurs in children throughout the world. Rickets is most often due to a deficiency of vitamin D, which is critically important for maintenance of bone and mineral metabolism. Vitamin D deficiency affects upwards of 1 billion people. The major source of vitamin D for most people is cutaneous production of cholecalciferol (vitamin D3) when the skin is exposed to ultraviolet B (UVB) radiation from direct sunlight. See online-only Figure 1. Foods and supplements can also provide vitamin D, either as cholecalciferol or ergocalciferol (vitamin D2).

Online-only Figure 1: Vitamin D Metabolism and Action

ricket-diagram-01
 

Serum 25(OH)D concentrations of Americans 19 and younger show that many have deficient (<50 nmol/L, 20 ng/ ml) or insufficient (<75 nmol/L, 30 ng/ml) vitamin D status. Vitamin D levels are low because of inadequate sunlight exposure, but rickets generally occurs in children who have poor intake of dietary vitamin D as well. Persons with darker skin pigmentation are at greater risk of vitamin D deficiency because the increased skin melanin absorbs UVB radiation and thereby prevents vitamin D synthesis. Similarly, cutaneous production of vitamin D is reduced by use of sunscreens and modest styles of dress that cover most skin. During winter months, the angle of the sun is too acute to permit UVB rays to reach earth, so no cutaneous vitamin D production occurs. When the cause of vitamin D deficiency is not clear, consider malabsorptive conditions such as celiac disease. In some children, rickets occurs due to rare genetic defects in activation or responsiveness to vitamin D. Defects in phosphorus metabolism or dietary calcium deficiency can also lead to similar clinical features.

Very few foods contain high amounts of vitamin D naturally, although fatty fish, sun-dried shitake mushrooms, and egg yolks are good choices. The prevalence of rickets declined sharply after the fortification of milk and infant formulas with vitamin D, but not all milk and dairy products sold in the United States are fortified. To meet AAP guidelines for vitamin D intake, all infants, whether breastfed or on formula, should receive vitamin D supplements.

The two brothers in the case above have vitamin D deficiency rickets: They have mild hypocalcemia and no calcium in their urine, consistent with reduced absorption of dietary calcium. The low serum phosphate levels suggest secondary hyperparathyroidism. See online-only Figure 2. The elevated alkaline phosphatase is an important marker of the growth plate defect. The important clinical risk factors include a conservative style of dress that limits sunlight exposure, intake of noncommercial cow’s milk that has not been fortified with vitamin D, and lack of vitamin D supplementation. Although the presence of similar features in their siblings might suggest a genetic disorder, it is equally likely the entire family is vitamin D deficient due to shared customs and diet. Hence, siblings of a child with vitamin D deficiency or rickets should be screened.

Online-only Figure 2: An Algorithm for Rickets

rickets-diagram-02
 

Table 1: Dietary Reference Intakes for Calcium
Life Stage Group Estimated Average Requirement (mg/day) Recommended Dietary Allowance (mg/day) Upper Level Intake (mg/day)

Infants 0 to 6 months

* * 1,000

Infants 6 to 12 months

* * 1,500

1 to 3 years old

500 700 2,500

4 to 8 years old

800 1,000 2,500
9 to 13 years old 1,100 1,300 3,000
14 to 18 years old 1,100 1,300 3,000
* For infants, adequate calcium intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to 12 months of age.

Table 1: Dietary Reference Intakes for Vitamin D
Life Stage Group Estimated Average Requirement (IU/day) Recommended Dietary Allowance (IU/day) Upper Level Intake (IU/day)

Infants 0 to 6 months

** ** 1,000

Infants 6 to 12 months

** ** 1,500

1 to 3 years old

400 600 2,500

4 to 8 years old

400 600 3,500
9 to 13 years old 400 600 4,000
14 to 18 years old 400 600 4,000
** For infants 0 to 12 months of age, adequate Vitamin D intake is 400 IU/day.

Supplementation with calcium and vitamin D will eliminate most symptoms of rickets within weeks and will cure biochemical and radiological manifestations of rickets within a few months. In most cases, bone deformities resolve with proper treatment, but severe skeletal deformities will sometimes require orthopedic surgery. To heal rickets and will replenish vitamin D stores, we give oral cholecalciferol for 3 months at doses of 1000-2000 IU per day to infants under 1 year old and 2000-5000 IU per day to older children. Obese children will require more. Ergocalciferol is slightly less effective. A loading dose of 50000 IU of vitamin D appears safe and can accelerate the healing process. After therapy, children should maintain a daily vitamin D intake consistent with the new Institute of Medicine recommendations. (See Table 1).

References and Suggested Readings
Godar DE, Pope SJ, Grant WB, Holick MF 2011. Solar UV doses of young Americans and vitamin D3 production. Environ Health Perspect. 2011 Aug 18. [Epub ahead of print]

Ruppe MD, Brosnan PG, Au KS, Tran PX, Dominguez BW, Northrup H. Mutational analysis of PHEX, FGF23 and DMP1 in a cohort of patients with hypophosphatemic rickets. Clin Endocrinol (Oxf ). 2011;74(3):312-318.

DeLucia MC, Mitnick ME, Carpenter TO. Nutritional rickets with normal circulating 25-hydroxyvitamin D: a call for reexamining the role of dietary calcium intake in North American infants. J Clin Endocrinol Metab. 2003;88:3539-3545. 

Online-only Additional References
Holick MF, ChenTC. Vitamin D deficiency: a worldwide problem with health consequences. Am. J Clin Nutr. 2008;87:1080S-1086S. 

Wagner CL, Greer FR, Section on Breastfeeding and Committee on Nutrition 2008. Prevention of rickets and vitamin d deficiency in infants, children, and adolescents. Pediatrics. 2008; 122(5):1142-1152.

Perrine CG, Sharma AJ, Jefferds ME, Serdula MK, Scanlon KS. 2010. Adherence to vitamin D recommendations among US infants. Pediatrics. 2010;125(4):627-632.

Institute of Medicine 2011. Dietary reference intakes for calcium and vitamin D. The National Academies Press. Washington, DC. 2011. PMID: 21796828.

Ross AC, Manson JE, Abrams SA, et la. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011; 96(1):53-58.
 

Toddler’s Feeding Problems

Sherri Shubin Cohen, MD, MPH, FAAP

R.K. first presented to the Pediatric Feeding and Swallowing Center at 16 months old with the complaints of limited and inconsistent oral intake and inadequate weight gain. He had been a poor feeder since birth.

He ate only if distracted with toys and attention, and meals lasted up to 90 minutes. He accepted tastes of a variety of foods, but generally held food in his cheeks and spit it out. Past medical history was significant for gastroesophageal reflux, constipation, mildly abnormal tone, and mild developmental delay. He was followed by Gastroenterology and Neurology. Diagnostic evaluation was essentially normal including upper GI, endoscopy and brain MRI. He demonstrated no weight gain in the 3 months preceding his initial visit to the Feeding Center. He was moderately wasted at 75% of his ideal body weight and mildly stunted at 93% of his standard height for age. He was admitted from his initial visit for inpatient initiation of supplemental NG-tube feeds due to the severity of his failure to thrive and inability to consume adequate nutrition orally.

He was then followed as an outpatient by the feeding team, Neurology, Gastroenterology, Allergy, and ENT until he was admitted to the intensive behavioral feeding program (Day Hospital Feeding Program) at 25 months old. His medical course prior to admission was significant for G-tube placement, diagnosis of egg and tree nut allergies and adenotonsillectomy for obstructive sleep apnea. He had no measurable oral intake but gained weight well on supplemental G-tube feeds. He was 98% of his ideal body weight at the time of admission. He was admitted for almost 4 weeks. Upon discharge he had increased his dietary variety by 10 new foods and was eating 3.5 ounces of food and drinking 1 ounce of Pediasure 3 times per day. He decreased his reliance on tube feeds from 100% to 51% of his total daily intake.

Discussion: Feeding disorders are common, complex, and multifactorial. Feeding is influenced by interactions between the feeder and child, mealtime structure and routine, gastrointestinal and medical health, appetite, early learning, sensory processing, oral-motor functioning, gross and fine motor skill development, and temperament. The multidisciplinary team of the Pediatric Feeding and Swallowing Center at CHOP is designed to assess difficulties and strengths in each of these areas. During the initial evaluation, patients are evaluated by a physician, nurse practitioner, dietitian, speech pathologist, occupational therapist, and psychologist. The physician assesses underlying medical issues that can impact feeding such as gastroesophageal reflux or constipation. The dietitian evaluates the child’s nutritional status, growth parameters, and the need for micro- and macro-nutrient supplementation. The speech pathologist does not focus on language but rather on oral-motor skills and safety of the swallowing function. The occupational therapist assesses self-feeding skills, positioning, and sensory processing. The psychologist evaluates mealtime structure, food refusal behaviors, behavioral difficulties outside of mealtimes, and parent-child interactions. A social worker is also available to provide support for the family.

The etiology of R.K.’s feeding disorder was most likely a learned avoidance from gastrointestinal discomfort. Oral-motor dysfunction and developmental issues impacting feeding were ruled out by the speech pathologist and occupational therapist at his initial visit. The severity of his feeding disorder, as evidenced by complete oral refusal and reliance on tube feeds, warranted intensive behavioral feeding therapy.

The Day Hospital Feeding Program is an intensive feeding program that utilizes the principles of applied behavior analysis (ABA) to improve eating in children. With this method, positive reinforcement is used to motivate children to alter their eating habits and improve acceptance at mealtimes while maladaptive mealtime behaviors are minimized. Children are initially fed 3 structured meals per day by trained feeding specialists while their caregivers observe through a one-way mirror. Later in the admission, caregivers are taught to feed their child using a structured mealtime program. Typical goals for admission include increasing variety, increasing volume, increasing consistency of acceptance, decreasing reliance on nutritional supplementation, and caregiver teaching. Patients must be medically and nutritionally stable (at least 85% of their ideal body weight) before they are candidates for admission. Children are not usually admitted before they reach a developmental age of 15 months because they must have an understanding of cause-and-effect as well as be able to separate easily from their caregivers.

The Day Hospital Program is a significant commitment that is not a good fit for every family, nor is it appropriate for every child. Families must bring their child to CHOP 5 days per week for about 4 weeks, and then continue to feed 2 to 4 meals per day after discharge using the structured program for a year or longer. The appropriateness of an intensive program for each child and family is assessed at initial and follow-up appointments with staff of the Feeding Center. When R.K. was seen for follow-up, his parents were proficient in using the structured mealtime program and he was consuming 5.5-6 ounces of food and 1.5 ounces of Pediasure three times per day.

References and Suggested Readings
A video made for families about the Day Hospital Feeding Program 

Treating Youth Obesity

Liberty Foley, CRNP, and Shirley Huang, MD

M.G. is an 11-year-old boy referred to the Healthy Weight Clinic at Children’s Hospital for his weight, an elevated LDL of 130 mg/dL, and a low HDL of 35 mg/dL. He also had a normal fasting glucose, ALT, and AST (see Table 3). His weight gain started about 3 to 4 years ago when the family moved into the city from the suburbs. Limited fruits and vegetables, limited physical activity, and excess sweetened beverages may contribute to his weight.

Table 3: Recommended screening labs according to age and BMI category
Age BMI Category Recommended screening labs

2 to 9 years

Overweight/Obese/Severe obesity Fasting lipid profile only
10+ years Overweight
Obese/Severe obesity
Fasting lipid profile, Fasting glucose if 2 or more risk factors*
Fasting lipid panel, Fasting glucose, ALT and AST

* American Diabetes Association risk factors: family history of type 2 diabetes, race/ethnicity other than Caucasian, signs of insulin resistance (acanthosis, hypertension, polycystic ovary syndrome [PCOS])


M.G. was born at full-term without any failure to thrive, poor feeding during infancy, or developmental delay. M.G.’s past medical history includes asthma. He has had no hospitalizations or surgeries. His only medication is albuterol as needed.

Family history includes father with hypercholesterolemia, maternal grandfather with hypertension and heart disease at 55 years of age, and maternal grandmother with diabetes.

On social history, M.G. lives at home with his mother, father and 2 siblings. He is in the sixth grade and does well in school. He has no academic or behavioral issues.

On review of systems, M.G. has no symptoms of reflux, constipation, headaches, hip/knee/shin pain, or polyuria. His asthma is generally in good control, although he may wheeze or become short of breath after playing basketball. His mother reports that M.G. snores near nightly, is often tired, and has difficulty paying attention in class recently. M.G. describes himself as “always thirsty.” His blood pressure has been high at the primary care office previously. All other systems reviewed were negative.

On physical exam, M.G.’s weight is 77.9 kg (171.38 lbs) and his height is 152.7 cm (60.1 in). His body mass index (BMI) is 33.41 kg/m2 (>99th percentile for age and gender). His BP at today’s visit is normal at 118/66 (<90th percentile/<90th percentile, taken manually with a large adult cuff). He appeared obese without acute distress. He had moderate acanthosis behind his neck and under his axillae but no skin findings for candida, xanthomas, striae, or acne. On HEENT exam, there were 2+ tonsils and no thyromegaly. His cardiac, pulmonary, and abdominal exams were normal. He had no leg-length discrepancy, bowing of knees, or pain with hip abduction or internal rotation, and had a grossly normal neurologic exam and gait.

Discussion: M.G.’s BMI is >99th percentile, which places him in the severe obesity category. See online-only Table 1. He has dyslipidemia, which is particularly concerning given his family history of early heart disease. His signs of insulin resistance and family history of diabetes place him at high risk for diabetes. His weight and symptoms of snoring, tiredness and poor attention span also place him at risk for obstructive sleep apnea. In this setting, it is important to first find out how the family feels about M.G.’s weight and his health risks. Not all families are ready to make lifestyle changes, and assessing their readiness to change is a key step before formulating a management plan with the family. If the family is ready to move forward with making some lifestyle changes, it may be helpful to set goals that are specific, measureable, attainable, realistic, and timely (“SMART” goals). The goals should tie in with his current or at-risk co-morbidities. In addition, the goals should be small and expanded upon over time to build confidence and increase the likelihood of long-term adherence.

Online-only Table 1: Weight status and BMI percentile: definition and identification
Category Children (ages 2-18) Adults (ages > 18)
Healthy weight BMI > fifth and < 85th
percentile for age and gender
BMI from 18.5 to 24.9
Overweight BMI > 85th and < 95th
percentile for age and gender
BMI from 25 to 29.9
Obese BMI > 95th and < 99th
percentile for age and gender
Class I: BMI 30-34.9
Severe obesity BMI > 99th percentile
for age and gender
Class II: BMI 35-39.9
Class III: BMI 40-49.9
Class IV: BMI 50-59.9
Class V: BMI ≥50

Treatment plan for M.G.:

1. Obesity. We discussed that a safe rate of weight loss for M.G. would be no more than 1 to 2 lbs per week as he continues to grow taller. See online-only Table 2. After further discussion, we set the following initial goals with M.G.: having a piece of fruit with breakfast every morning, limiting juice/soda to 1 cup per day, and playing basketball for at least 30 minutes 3 days per week. We also reviewed 5-2-1-0 obesity prevention messaging as the ultimate daily goal: “5” fruits and vegetables, no more than “2” hours of screen time, “1” hour of moderate physical activity and “0” sweetened beverages per day.

Online-only Table 2: Weight status and BMI percentile: definition and identification
Category Children (ages 2-18) Adults (ages > 18)
Healthy weight BMI > fifth and < 85th
percentile for age and gender
BMI from 18.5 to 24.9
Overweight BMI > 85th and < 95th
percentile for age and gender
BMI from 25 to 29.9
Obese BMI > 95th and < 99th
percentile for age and gender
Class I: BMI 30-34.9
Severe obesity BMI > 99th percentile
for age and gender
Class II: BMI 35-39.9
Class III: BMI 40-49.9
Class IV: BMI 50-59.9
Class V: BMI ≥50



2. Dyslipidemia and family history of early heart disease. We discussed that M.G.’s LDL or “bad” cholesterol is high at 130 mg/ dL (optimal <110 mg/dL). We encouraged M.G. to limit foods high in cholesterol, saturated fat, and trans fats. We discussed adding more fiber into his diet with fresh fruits and vegetables and that high-fiber foods will help to lower his LDL cholesterol. In addition, we reviewed that M.G.’s HDL or “good” cholesterol is low at 35 mg/dL (optimal >40 mg/dL). Increasing physical activity can improve his HDL levels. We will repeat a lipid panel in 2 to 3 months.

3. Acanthosis, possible polydipsia, family history of diabetes, and increased risk for diabetes. We discussed that increasing physical activity, limiting simple sugars, and increasing fiber will help to improve M.G.’s darkened skinfolds, risk for diabetes and his weight. We will send a fasting insulin and hemoglobin A1C to complete his diabetes screening given his risk for the disease.

4. Possible sleep apnea. We ordered a sleep study for M.G., and if the sleep study is abnormal, then he will be referred to ENT given his enlarged tonsils.

5. Asthma. M.G. may try using his albuterol 15 minutes prior to physical activity to reduce symptoms which could impede his ability to exercise.

6. Follow up in 6 weeks.

References and Suggested Readings
Barlow SE and the Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120;suppl 4:S164-S192.

Referral information  
To refer a child with suspected vitamin D deficiency, contact the Center for Bone Health at 1-877-972-BONE or www.chop.edu/bonehealth.
For questions on feeding problems in toddlers, call 267-426-0073. Families should call 215-590-7500 to schedule an appointment in the feeding disorders clinic.
For sport nutrition questions, call 215-590-6919.
For questions or requests for information or appointments to the Healthy Weight Program, call 267-426-2782 or go to www.chop.edu/healthyweight.
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