Indian Academy of Pediatrics Revised (2021) Guidelines on Prevention and Treatment of Vitamin D Deficiency and Rickets.

JUSTIFICATION: The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India. OBJECTIVES: To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children. PROCESS: A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members. RECOMMENDATIONS: The group reiterates the serum 25-hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as <12 ng/mL, 12-20 ng/mL and >20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD >100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day, respectively) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of >20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Iron deficiency anemia in children presenting with lymphoreticular malignancies and the effect of induction therapy.

There is scant information regarding iron deficiency in children with malignant disorders. Serum iron status of children with lymphoreticular malignancies (LRMs) at onset and at the end of induction therapy, compared to the normal population, was evaluated. Prospective cohort study conducted between July 2002 and March 2004. Previously untreated children recently diagnosed with LRM were studied. Age-matched controls were enrolled from follow-up and growth monitoring clinics. Hematological (complete blood counts and red cell indices) parameters and markers of iron status (serum iron, serum ferritin, total iron binding capacity) were estimated at presentation and at the end of remission induction therapy, that is, 5 weeks after initial evaluation. Bone marrow iron store were only assessed in cases. Thirty-five children (31 with acute lymphoid leukemia, 2 with acute myeloid leukemia, and 2 with non-Hodgkin lymphoma; 27 boys and 8 girls; 2 to 12 years of age) were evaluated in the study cohort. Anemia was documented in 80% of children with LRM. Iron deficiency was an important etiological factor. In the majority of cases therapy resulted in significant improvement towards normalization of deranged hematological parameters. This phenomenon could be attributed to enhanced quantity and quality of erythropoietic activity and red cell transfusions. The observation suggests that therapeutic iron supplements are not indicated in the majority of children on therapy for malignant disorders. Various hematological and body iron status parameters should be assessed on a case-by-case basis.

Nutritional rickets presenting with myelofibrosis.

We describe the clinical course of a 10-month-old breastfed infant with rickets and associated myelofibrosis presenting with anemia and hepatosplenomegaly. Over the follow up, on therapeutic supplementation of vitamin D, child showed reduction in liver and spleen size along with improvement in rickets, anemia, growth and developmental parameters.