Got Vitamin D?

Vitamin D is the new vitamin du jour. This week, the American Academy of Pediatrics Committee on Nutrition doubled its recommended intake of vitamin D from 200 to 400 IUs (international units)/day.

Why the change? I wrote about this 2 years ago (Vitamin D, Infants and Teenagers) and, as far as I can tell, it's not because there have been any new important studies.

Rather, it has just gotten clearer that vitamin D is good stuff; that when taken in infancy and childhood it promotes strong bones lasting into adulthood; that it may play a role in preventing such nasty adult diseases as diabetes and cancer; that it may bolster the immune system; and that it can lower the rate of hip fractures in the elderly (yes, Lord willing, some day your little one will be an old coot). Not bad for a long ignored vitamin!

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At the same time, low vitamin D levels have been documented in about 40% of infants, children, and teenagers. Why?

• It's well established that breast milk often doesn't contain enough vitamin D to meet these requirements. This can be especially problematic in the dark winter months and with dark skinned infants (whose skin pigment repels the sunlight needed to make vitamin D in the body).


• To ingest the new recommended amount of vitamin D, a child would have to drink about a quart of vitamin D-enriched milk a day (or, to reprise an old childhood nightmare, a teaspoon of cod liver oil). Lots of luck!


• Most teenagers aren't getting nearly enough vitamin D and there is reasonable evidence that adult bone hardness is related to vitamin D and calcium intake during the growth spurt of puberty.


• People with darker skin or those who take their doctor's advice and avoid direct sun exposure, also can't make enough vitamin D (it's estimated you need 10-15 minutes of direct exposure without sunscreen a few days per week to do so - much more if your skin is dark).

In fact, many argue that 400 IUs is still too low a dose for older kids. I think they are right: it really doesn't make sense that the recommendation is 400 IUs / day for everybody, whether you are a 6 pound baby or a 160 pound teenager. My guess is that in a few years they will bump up the recommendations for bigger kids, so stay tuned.

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FAQs: What to make of these new guidelines?

Should I give my child vitamin D supplements?
Consult your pediatric provider about this, but I vote yes to 400 IUs /day, unless it's clear your child is getting enough through his/her diet and/or sun exposure (or unless s/he needs more due to a chronic disease or medication).

What if my infant is breast fed?
Then it's all the more important to add a daily supplement of vitamin D to avoid the problems associated with inadequate intake and poor sunlight exposure.

What if my baby is formula fed?
In that case there is no need to supplement since all formulas sold in the United States contain extra vitamin D.

How will I know if my baby might have rickets?
Rickets - due to inadequate vitamin D over a long time - causes soft bones. Mostly it is seen in dark-skinned, breast-fed babies with little direct sun exposure who are not taking supplemental vitamins. Rickets is diagnosed by an X-ray, at which time there may be excessive bowing of the legs and/or swelling of the wrists and ankles.

Should I give more than the recommended 400 IUs?
Vitamin D is great stuff, but there is an important catch: Too much can be harmful. Unlike vitamin C which is just peed out if taken in excess, vitamin D is stored in our fat tissues. Too much can lead to an overdose and serious medical problems, so it's important to strike the right balance. 400 IUs may still be too little in older kids and teenagers but, until we know more, I'd err on the side of too little, rather than too much.

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Dr. P's Bottom Line
I think vitamin D supplementation is a good idea for infants, children, and teenagers. 400 IUs extra/day appears safe and may have important short-term and long-term benefits for your child. I say, go for it!

Related Topics:

• Vitamin D May Cut Risk of Type 1 Diabetes
• WebMD Video: Pregnancy and Vitamin D

A "Minute Clinic" Visit for Your Kids?

Is there a 'minute clinic' in your area? One just opened in mine.

Housed in a CVS pharmacy or Target or Wal-Mart or Albertsons, these are health care dispensaries staffed by nurse practitioners and physician's assistants intended to care for minor, self-limited medical issues (like ear infections, strep throat, skin rashes and vaccinations).

Hmm... Let's see, I'll get some school supplies, milk and, while we are at it, have that pesky rash looked at. "You're sick. We're quick!" is their motto. Apparently there's gold in them thar hills. Consider:

• 25 states already have such clinics.


• No less than Wal-Mart has gotten into the act. They currently have about 75 clinics in 12 states and plan to open thousands more in-store medical clinics in the next 5 years.

Is this good idea? Have you or will you take your kids to a minute clinic?

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Here, as I see it, are the pros and cons. On the positive side:

• Patients can be seen promptly, without an appointment. No muss, no fuss.


• The charge is generally only about $50, much less than an emergency room or primary care doctor's visit.


• Most use electronic medical records so there can be access to previous visits at any site.


• Most parents are capable of distinguishing a minor illness from a potentially more serious one, as are the health professionals who are seeing them.

On the worrisome side:

• The providers don't really know your child. What if there are some complicating medical concerns they should, but don't, know about?


• Sometimes parents underestimate the nature and severity of the symptoms. Will the minute clinic, for example, be able to pick up early and subtle signs of meningitis?


• There is no physician oversight on-site. What happens if the child is too sick to be seen or there is some mysterious complication?


• Care is fragmented. Will your primary care provider ever even know about the multiple diagnosed ear infections?

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Alas, I can't find any good studies assessing the quality and appropriateness of the care delivered at such places. Of course, most of the time, things will go well. Most illnesses are self-limited and kids get better no matter what we do or don't do. It's our dirty little pediatric secret.

The real question is this: how often will the rare, but much more serious illness be missed? And what will be the effect of this further fragmentation of care on the general well-being of our kids?

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You may be surprised to hear I'm not necessarily opposed to minute clinics, as long as there are quality safeguards and oversights in place.

I think parents should have choices when it comes to their child's health care. Lord knows emergencies rooms are often an expensive, endless nightmare. I can see why you might want your child checked out quickly and inexpensively, instead of waiting in my office for an hour, only to be told "it's probably just a virus. Nothing to do." I can see why uninsured families might make use of this service, in lieu of more expensive health care services.

Also. it will be interesting to see how insurance companies deal with minute clinics. Sure, the price is right, but if your child was not sick enough to see a doctor, perhaps she was not sick enough to warrant reimbursable medical care and perhaps these clinics will make it too easy to seek care for trivial complaints and, they may reason, perhaps we shouldn't pay at all. Stay tuned for Blue Cross vs.Wal-Mart battle of the titans on pay per view.

I'm sure some of you are making or will make use of this convenient form of acute health care. On the other hand, some of you may want the comfort of seeing someone who knows your child, someone whom you trust, and someone who is more likely to pick up the unexpected, unusual cause of the symptoms. In such cases, the wait and expense of seeing someone like me will be worth it. It will be (and should be) your call.

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Have any of you used a minute clinic? What was your experience? If not, would you use one for your children? Inquiring minds want to know.

Related Topics:

• WebMD Video: Walk-In Clinics Revealed
• Retail Clinics Catch On in U.S.
• Parents Like Retail Clinics for Kids