Childhood cancers – give Vitamin D loading dose if low – Oct 2021

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Can screening for low vitamin D levels prevent bone health complications in paediatric oncology patients?

Cancer Rep (Hoboken) . 2021 Oct 26;e1534. doi: 10.1002/cnr2.1534
Leonie Naeije 1, Mandy Pohlui de Silva 1, Paul Hofman 2

Background: No international standards include vitamin D levels at diagnosis or during treatment. It is included in the Children's Oncology Group long-term follow-up guidelines. However, bone health complications (like osteopenia and atraumatic fractures) can occur at diagnosis or during treatment as well.

Cases: In this small case series, we illustrate the complexity of bone health complications among our broad paediatric oncology population. If the vitamin D level is low we supplement the patient with one standard oral dose (150 000 units for 1-2 year olds, 300 000 units for 2-5 year olds and 600 000 units for >5 year olds). We do not adjust depending on diagnosis.

Conclusion: Because of the potentially negative outcomes on short, medium and long term, we recommend checking vitamin D levels on diagnosis for all newly diagnosed patients. It is a simple, low cost test and one dose of oral supplementation can easily treat the deficiency.
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REFERENCES

• Ward LM, Ma J, Lang B, et al. Bone morbidity and recovery in children with acute lymphoblastic leukemia: results of a six-year prospective cohort study. J Bone Miner Res. 2018;33(8):1435-1443.
• Halton JM, Atkinson SA, Fraher L, et al. Altered mineral metabolism and bone mass in children during treatment for acute lymphoblastic leukemia. J Bone Miner Res. 2009;11(11):1774-1783.
• Mabey T, Singhatanadgige W, Yingsakmongkol W, Limthongkul W, Honsawek S. Vitamin D and spine surgery. World J Orthop. 2016;7(11):726-730.
• Frisk P, Arvidson J, Ljunggren Ö, Gustafsson J. Decreased bone mineral density in young adults treated with SCT in childhood: the role of 25-hydroxyvitamin D. Bone Marrow Transplant. 2012;47(5):657-662.
• Marcucci G, Beltrami G, Tamburini A, et al. Bone health in childhood cancer: review of the literature and recommendations for the management of bone health in childhood cancer survivors. Ann Oncol. 2019;30(6):908-920.
• Wallace G, Jodele S, Myers KC, et al. Single ultra-high-dose cholecalciferol to prevent vitamin D deficiency in pediatric hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2018;24(9):1856-1860.
• Revuelta Iniesta R, Rush R, Paciarotti I, et al. Systematic review and meta-analysis: prevalence and possible causes of vitamin D deficiency and insufficiency in pediatric cancer patients. Clin Nutr. 2016;35(1):95-108.
• Wallace G, Jodele S, Howell J, et al. Vitamin D deficiency and survival in children after hematopoietic stem cell transplant. Biol Blood Marrow Transplant. 2015;21(9):1627-1631.
• Orgel E, Mueske NM, Sposto R, et al. A randomized controlled trial testing an adherence-optimized Vitamin D regimen to mitigate bone change in adolescents being treated for acute lymphoblastic leukemia. Leuk Lymphoma. 2018;58(10):2370-2378.
• Halton J, Gaboury I, Grant R, et al. Advanced vertebral fracture among newly diagnosed children with acute lymphoblastic leukemia: results of the Canadian STeroid-associated osteoporosis in the pediatric population ( STOPP ) research program. J Bone Miner Res. 2009;24(7):1326-1334. https://doi.org/10.1359/jbmr.090202
• Cummings EA, Ma J, Fernandez CV, et al. Incident vertebral fractures in children with leukemia during the four years following diagnosis. J Clin Endocrinol Metab. 2015;100(9):3408-3417.
• COG. Long term follow up resourceguide. www.childrenoncologygroup.org

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15+ VitaminDWiki Infant-Child pages containing CANCER in the title

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VitaminDWiki - Infant-Child category has 851 items and starts with__

• No consensus on MINIMUM International Units (IU) for healthy infant of normal weight
• 400 IU Vitamin D is no longer enough
  Was OK in the past century, but D levels have been dropping for a great many reasons.
  FDA doubles the amount of vitamin D permitted in milk – July 2016
• No consensus: range is 600 to 1600 IU – based on many randomized controlled trials
• Review of 400 IU to 2000 IU daily and higher if non-daily
• Fewer pre-infants were vitamin D deficient when they got 800 IU – RCT Feb 2014
• 1600 IU was the conclusion of three JAMA studies
     1000 IU recommended in France and Finland – 2013 - appears to be a good level
• 5X less mite allergy after add vitamin D
• Child bone fractures with low vitamin D were 55X more likely to need surgery
• 75 % of SIDS had low vitamin D
• Children stayed in ICU 3.5 days longer if low vitamin D – Dec 2015
• 5 out of 6 children who died in pediatric critical care unit had low vitamin D – May 2014
• Infants have gotten free 400 IU of vitamin D in Turkey since 2005, More for longer would be even better – Feb 2022
• Preemies should have vitamin D supplements – reaching an agreement – April 2021
• Vitamin D loading dose was as effective as daily dosing (rickets in this case) – RCT July 2021

Having a good level of vitamin D cuts in half the amount of:

• Asthma, Chronic illness, Doctor visits, Allergies, infection
  Respiratory Tract Infection, Growing pains, Bed wetting

Need even more IUs of vitamin D to get a good level if;

• Have little vitamin D: premie, twin, mother did not get much sun access
• Get little vitamin D: dark skin, little access to sun
• Vitamin D is consumed faster than normal due to sickness
• Older (need at least 100 IU/kilogram, far more if obese)
• Not get any vitamin D from formula (breast fed) or (fortified) milk
  Note – formula does not even provide 400 IU of vitamin D daily

Infants-Children need Vitamin D

• Sun is great – well known for 1,000’s of years.
  US govt (1934) even said infants should be out in the sun
• One country recommended 2,000 IU daily for decades – with no known problems
• As with adults, infants and children can have loading doses and rarely need tests
• Daily dose appears to be best, but monthly seems OK
• Vitamin D is typically given to infants in the form of drops
     big difference in taste between brands
     can also use water-soluable form of vitamin D in milk, food, juice,
• Infants have evolved to get a big boost of vitamin D immediately after birth
  Colostrum has 3X more vitamin D than breast milk - provided the mother has any vitamin D to spare
• 100 IU per kg of infant July 2011, Poland etc.
  
  More than 100 IU/kg is probably better