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Comparison of response to vitamin D2 with vitamin D3 in children with nutritional rickets
S102
Abstracts / Bone 45 (2009) S59–S111
Design: In this prospective study we evaluated the clinical, biochemical and radiological responses of an IM injection of cholecalciferol (10,000 IU/kg) of cholecalciferol for 3 months. Results: At presentation, the most frequent manifestations were enlarged wrist joint, hypotonia, irritability, cranial bossing, wide anterior fontanel, bow legs, delayed teething and walking and Harrison's sulcus with chest rosaries. Short stature (length SDS < −2) was recorded in 30% of patients. Craniotabes and hypocalcemic tetany were the least common presentations. In VDD children the most frequent biochemical abnormality was high alkaline phosphatase (ALP) (100%), followed by low phosphate (PO4) (75%) and low calcium (Ca) (12.5%). One month after treatment, serum Ca, PO4 and 25 OH D concentrations were normal. Three months after the injection, serum level of ALP and parathormone (PTH) decreased to normal. The majority of patients (87.5%) had serum 25 OH D level = or > 20 ng/ml, but some (12.5%) had level < 20 ng/ml. Significant cure of all symptoms and signs related to vitamin D deficiency had been achieved in all children. Leg bowing showed significant improvement in all patients but was still evident in one-third of them. Complete healing of the radiological evidence of rickets was achieved in 95% of all children. Conclusion: An IM injection of a mega dose of cholecalciferol is a safe and effective therapy for treatment of hypovitaminosis D in infants and toddlers for 3 months with normalization of all the biochemical parameters and healing of radiological manifestations. Measurement of serum 25OH D level is highly recommended in the screening of all short children. doi:10.1016/j.bone.2009.04.166
PF-21 Is there any correlation between 1,25(OH)2D and 25OHD in infants with rickets? A. Haq, L.O. Abdel-Wareth, J. Rajah Departments of Laboratory Medicine and Pediatrics, Sheikh Khalifa Medical City, PO Box 51900, Abu Dhabi, United Arab Emirates Introduction: Some researchers suggest that 1,25(OH)2D vitamin D bears no relation to 25 (OH) vitamin D, and therefore, does not warrant measuring. The study aim was to demonstrate whether this assumption is true in rachitic infants. Method: We examined this relationship between 25 (OH)D and 1.25 (OH)D in children diagnosed with rickets, in the pre-treatment phase of their disease, at Sheikh Khalifa Medical City, Abu Dhabi, UAE. We also examined this relationship in different age groups of normal children acting as controls. Measurements were performed by using Waters-HPLC system for 25(OH)D, Biomnis-RIA for 1,25(OH)2D and enzyme immunoassay for PTH. Results: Correlation between 25 (OH)D and 1.25 (OH)D. Controls
Sample size
Pearson's r
P value
< 1 year 1–2 years 2–8 years > 8 years Children with rickets
14 21 64 40 28
− 0.03 0.53 0.30 0.005 0.72
0.90 0.01 0.01 0.97 < 0.0001
The median (IQR) age of rachitic infants was 8 months (5–13). Discussion: The positive correlation is strongest in the rachitic infants, making physiological sense and suggesting a biological relation between the 25OHD and 1,25(OH)2D. The striking differences in correlation in the different age groups (controls) suggest a putative role of PTH in changing the relationship. doi:10.1016/j.bone.2009.04.167
PF-22 Comparison of response to vitamin D2 with vitamin D3 in children with nutritional rickets T.D. Thachera, P.R. Fischera, M.O. Obadofinb, M.A. Levinec, R.J. Singha, J.M. Pettiford a Mayo Clinic, Rochester, Minnesota, USA b Jos University Teaching Hospital, Jos, Nigeria c Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania, USA d Chris Hani Baragwanath Hospital, Bertsham, South Africa Introduction: Nigerian children with rickets due to dietary calcium deficiency have evidence of an increased requirement for vitamin D to optimize mineral metabolism. We compared the metabolism of vitamin D2 with vitamin D3 in rachitic and control children. Methods: We administered a single bolus of vitamin D2 50,000 IU orally to 16 Nigerian rachitic and 11 control children and vitamin D3 50,000 IU to 12 rachitic and 10 control children. We measured serum levels of vitamin D metabolites at baseline, and 1, 3, 7, and 14 days after vitamin D by tandem mass spectrometry or radioimmunoassay. Results: Baseline serum 25OHD concentrations ranged from 7–24 ng/mL and 15–34 ng/mL in rachitic and control children, respectively (P < 0.001). Baseline 1,25(OH)2D values (mean ± SD) were 224 ± 72 pg/mL and 121 ± 34 pg/mL in rachitic and control children, respectively (P < 0.001). The peak change in 25OHD values was at day 3 and was similar with vitamin D2 and vitamin D3 in children with rickets (29 ± 17 and 25 ± 11 ng/mL, respectively) and in control children (33 ± 13 and 31 ± 16, respectively). 1,25(OH)2D increases at day 3 in children with rickets were 166 ± 80 and 209 ± 83 pg/mL after vitamin D2 and vitamin D3 respectively, which were significantly increased over baseline values (P < 0.001) but not different from each other (P = 0.18). By contrast, control children had no significant increase in 1,25(OH)2D (19 ± 28 and 16 ± 38 pg/mL after vitamin D2 and vitamin D3, respectively). The rates of decline of 25OHD and 1,25 (OH)2D values after day 3 were similar with vitamin D2 and vitamin D3. Conclusion: In the short term, vitamin D2 and vitamin D3 appear to be bioequivalent in increasing 25OHD in rachitic and healthy children. A marked increase in 1,25(OH)2D concentration in response to vitamin D distinguishes children with putative dietary calcium deficiency rickets from healthy children and is consistent with increased vitamin D requirements in children with calcium deficiency rickets. doi:10.1016/j.bone.2009.04.168
PF-23 Children, milk, bone and osteoporosis in menopause A. Bazarra-Fernandeza a La Coruna University Hospital Trust, La Coruña, Spain Objective: To determine if milk is always good for preventing osteoporosis in children. Material and method: Worldwide bibliography review on the problem and our experience. Results: Studies performed in children and adolescents relate to the subject of the long-term relative effects on bone health of the protein content of the diet compared with that of the diet's net load of acid in the body. Long-term acid loading in humans causes an increase in renal acid excretion. People taking high doses of PPIs are more likely to break a hip. Consumption of animal protein, grain, and high amounts of milk increases the acidity of the body. Metabolic acidosis in humans results in a significant decrease in serum IGF-1 concentration without a demonstrable effect on IGF binding protein 3. Scant evidence supports nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting child and adolescent bone mineralization. Sodium chloride elevates urinary calcium excretion. Higher long-term protein intakes are
Abstracts / Bone 45 (2009) S59–S111
Design: In this prospective study we evaluated the clinical, biochemical and radiological responses of an IM injection of cholecalciferol (10,000 IU/kg) of cholecalciferol for 3 months. Results: At presentation, the most frequent manifestations were enlarged wrist joint, hypotonia, irritability, cranial bossing, wide anterior fontanel, bow legs, delayed teething and walking and Harrison's sulcus with chest rosaries. Short stature (length SDS < −2) was recorded in 30% of patients. Craniotabes and hypocalcemic tetany were the least common presentations. In VDD children the most frequent biochemical abnormality was high alkaline phosphatase (ALP) (100%), followed by low phosphate (PO4) (75%) and low calcium (Ca) (12.5%). One month after treatment, serum Ca, PO4 and 25 OH D concentrations were normal. Three months after the injection, serum level of ALP and parathormone (PTH) decreased to normal. The majority of patients (87.5%) had serum 25 OH D level = or > 20 ng/ml, but some (12.5%) had level < 20 ng/ml. Significant cure of all symptoms and signs related to vitamin D deficiency had been achieved in all children. Leg bowing showed significant improvement in all patients but was still evident in one-third of them. Complete healing of the radiological evidence of rickets was achieved in 95% of all children. Conclusion: An IM injection of a mega dose of cholecalciferol is a safe and effective therapy for treatment of hypovitaminosis D in infants and toddlers for 3 months with normalization of all the biochemical parameters and healing of radiological manifestations. Measurement of serum 25OH D level is highly recommended in the screening of all short children. doi:10.1016/j.bone.2009.04.166
PF-21 Is there any correlation between 1,25(OH)2D and 25OHD in infants with rickets? A. Haq, L.O. Abdel-Wareth, J. Rajah Departments of Laboratory Medicine and Pediatrics, Sheikh Khalifa Medical City, PO Box 51900, Abu Dhabi, United Arab Emirates Introduction: Some researchers suggest that 1,25(OH)2D vitamin D bears no relation to 25 (OH) vitamin D, and therefore, does not warrant measuring. The study aim was to demonstrate whether this assumption is true in rachitic infants. Method: We examined this relationship between 25 (OH)D and 1.25 (OH)D in children diagnosed with rickets, in the pre-treatment phase of their disease, at Sheikh Khalifa Medical City, Abu Dhabi, UAE. We also examined this relationship in different age groups of normal children acting as controls. Measurements were performed by using Waters-HPLC system for 25(OH)D, Biomnis-RIA for 1,25(OH)2D and enzyme immunoassay for PTH. Results: Correlation between 25 (OH)D and 1.25 (OH)D. Controls
Sample size
Pearson's r
P value
< 1 year 1–2 years 2–8 years > 8 years Children with rickets
14 21 64 40 28
− 0.03 0.53 0.30 0.005 0.72
0.90 0.01 0.01 0.97 < 0.0001
The median (IQR) age of rachitic infants was 8 months (5–13). Discussion: The positive correlation is strongest in the rachitic infants, making physiological sense and suggesting a biological relation between the 25OHD and 1,25(OH)2D. The striking differences in correlation in the different age groups (controls) suggest a putative role of PTH in changing the relationship. doi:10.1016/j.bone.2009.04.167
PF-22 Comparison of response to vitamin D2 with vitamin D3 in children with nutritional rickets T.D. Thachera, P.R. Fischera, M.O. Obadofinb, M.A. Levinec, R.J. Singha, J.M. Pettiford a Mayo Clinic, Rochester, Minnesota, USA b Jos University Teaching Hospital, Jos, Nigeria c Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania, USA d Chris Hani Baragwanath Hospital, Bertsham, South Africa Introduction: Nigerian children with rickets due to dietary calcium deficiency have evidence of an increased requirement for vitamin D to optimize mineral metabolism. We compared the metabolism of vitamin D2 with vitamin D3 in rachitic and control children. Methods: We administered a single bolus of vitamin D2 50,000 IU orally to 16 Nigerian rachitic and 11 control children and vitamin D3 50,000 IU to 12 rachitic and 10 control children. We measured serum levels of vitamin D metabolites at baseline, and 1, 3, 7, and 14 days after vitamin D by tandem mass spectrometry or radioimmunoassay. Results: Baseline serum 25OHD concentrations ranged from 7–24 ng/mL and 15–34 ng/mL in rachitic and control children, respectively (P < 0.001). Baseline 1,25(OH)2D values (mean ± SD) were 224 ± 72 pg/mL and 121 ± 34 pg/mL in rachitic and control children, respectively (P < 0.001). The peak change in 25OHD values was at day 3 and was similar with vitamin D2 and vitamin D3 in children with rickets (29 ± 17 and 25 ± 11 ng/mL, respectively) and in control children (33 ± 13 and 31 ± 16, respectively). 1,25(OH)2D increases at day 3 in children with rickets were 166 ± 80 and 209 ± 83 pg/mL after vitamin D2 and vitamin D3 respectively, which were significantly increased over baseline values (P < 0.001) but not different from each other (P = 0.18). By contrast, control children had no significant increase in 1,25(OH)2D (19 ± 28 and 16 ± 38 pg/mL after vitamin D2 and vitamin D3, respectively). The rates of decline of 25OHD and 1,25 (OH)2D values after day 3 were similar with vitamin D2 and vitamin D3. Conclusion: In the short term, vitamin D2 and vitamin D3 appear to be bioequivalent in increasing 25OHD in rachitic and healthy children. A marked increase in 1,25(OH)2D concentration in response to vitamin D distinguishes children with putative dietary calcium deficiency rickets from healthy children and is consistent with increased vitamin D requirements in children with calcium deficiency rickets. doi:10.1016/j.bone.2009.04.168
PF-23 Children, milk, bone and osteoporosis in menopause A. Bazarra-Fernandeza a La Coruna University Hospital Trust, La Coruña, Spain Objective: To determine if milk is always good for preventing osteoporosis in children. Material and method: Worldwide bibliography review on the problem and our experience. Results: Studies performed in children and adolescents relate to the subject of the long-term relative effects on bone health of the protein content of the diet compared with that of the diet's net load of acid in the body. Long-term acid loading in humans causes an increase in renal acid excretion. People taking high doses of PPIs are more likely to break a hip. Consumption of animal protein, grain, and high amounts of milk increases the acidity of the body. Metabolic acidosis in humans results in a significant decrease in serum IGF-1 concentration without a demonstrable effect on IGF binding protein 3. Scant evidence supports nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting child and adolescent bone mineralization. Sodium chloride elevates urinary calcium excretion. Higher long-term protein intakes are