Vitamin D Supplementation in Healthy Children and Adolescents

1. Vitamin D Supplementation in Healthy Children and Adolescents SCH Journal Club Rachel Harrison 20th September 2012

2. Background Vit D plays an essential role in maintaining good health: calcium and phosphate regulation may regulate cell growth, neuromuscular and immune function, and reduction of inflammation. Sunshine! Vitamin D supplementation agenda since 1990’s An independent advisory committee is reviewing current recommendations on vit D (expected 2014)

4. Background Vitamin D deficiency serum 25(OH)D level ≤25nmol/l Insufficiency serum 25(OH)D level between 26 and 50nmol/l

5. DOH DOH says the following people may be at risk of vit D deficiency: all pregnant and breastfeeding women all children aged under five years old all people aged 65 or over people who are not exposed to much sun people who have darker skin (because their bodies are less able to produce as much vit D)

6. Current Guidelines http://www.sheffield.nhs.uk/professionals/resources/Vitamin_D_guidelines_children_Final_March%202012[1].pdf Advice – obtain Vit D from safe sun exposure and diet. Improving availability and uptake of Vit D supplements for children in multiethnic populations is essential to the strategy of rickets prevention. During treatment of deficiency consider referral to secondary care at any stage if new symptoms cause parental or professional concern.

7. Trust Policy

8. Available multivitamin preparations

9. The Clinical Question

10. Effects of Vitamin D supplementation on bone density in healthy children: a systematic review Winzenberg,T. Powell, S. Shaw, K A. Jones, G. BMJ. 2011;342:c7254.

11. Objectives To determine effectiveness of Vitamin D supplementation for improving BMD in children and adolescents To determine if effects of supplementation vary with factors such as vitamin D dose and status

12. Methods Systematic review and meta-analysis RCT’s of vitamin D supplementation including a placebo control Children and adolescents aged 1 month to <20 years Identification of papers Databases Conference abstracts Cited references

13. Methods Extracted data by 2 reviewers Percent change in baseline of bone outcomes Standardised mean difference Hetrogeneity Fixed effects model

14. Outcomes BMD – spine, radius, hip BMC – total body Subgroup analysis Age Gender Pubertal stage Vitamin D dose Vitamin D status

15. Results – Papers Reviewed 1599 excluded 54 disagreements 6 German papers 1653 papers identified 4 not RCTs 3 children not 1/12 to <20 yr 2 not bone outcomes 1 not Vit D intervention 1 not placebo controlled 23 full text review 1 no variance measured reported 12 papers for 7 studies 6 studies included in meta analysis

16. Results – Baseline Characteristics Event Title If Required (Change Text in Footer)

17. Results – Main Effects Event Title If Required (Change Text in Footer)

18. Results – Forrest Plot Event Title If Required (Change Text in Footer)

19. Results – Vit D Status

20. Are the results of the review valid? Did the review address a clearly focused question? Yes – Clear population, intervention, and outcome Did the authors look for the appropriate sort of papers? Yes – RCT’s placebo controlled

21. Is it worth continuing? Do you think the important, relevant studies were included? Yes – appropriate databases searched, no language restrictions, reference lists of cited studies searched, conference abstracts Did the review’s authors do enough to assess the quality of the included studies? Yes – independently assessed by 2 reviewers If the results of the review have been combined, was it reasonable to do so? Yes – Similar studies, similar outcomes

22. What are the results? What are the overall results of the reviews? LS BMD 0.15 (-0.01 to 0.31; p=0.07) standardised mean difference Supplementation not beneficial in children and adolescents with normal Vit D levels In deficient children may be useful, but needs confirmation How precise are the results? Not sure – Confidence intervals reported, standardised mean difference

23. Will the results help locally? Can the results be applied to the local population? Yes - children 8-17 yrs Were all important outcomes considered? Not sure – main outcome covered Are the benefits worth the harms and costs? No

24. Summary and Conclusions Overall a good paper Publication of negative results Clear bottom line reported For clinicians and other health professionals: No action to be take. What this space.