Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1459-1465

Screening of vitamin D deficiency among preschool children in family health facilities


1 Department of Family Medicine, Faculty of Medicine, National Liver Institute, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, National Liver Institute, Menoufia University, Menoufia, Egypt
3 Department of Family Medicine, Ministry of Health, Menoufia, Egypt

Date of Submission21-May-2019
Date of Decision07-Jun-2019
Date of Acceptance17-Jun-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Safa H Alkalash
Shebeen El-Kom, Menoufia
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_188_19

Rights and Permissions
  Abstract 


Objective
To assess the prevalence and risk factors of vitamin D deficiency among preschool children in family health facilities in Birket El Sabaa district.
Background
Vitamin D deficiency in childhood may play an important function in pathophysiology not only of rickets but also of nonskeletal diseases that have an immune system-mediated pathogenesis.
Patients and methods
An analytical cross-sectional study was conducted on 96 preschool children who attended the selected family health facilities in Birket El Sabaa district during the period of data collection (3 months). This study started on the1st of April 2018 and lasted till March 2019. History, clinical examination, and serum vitamin D level measurement were conducted.
Results
The prevalence of vitamin D deficiency among preschool children was 63.5%, and 20.83% of them had mild deficiency, 31.25% moderate deficiency and, 11.46% had severe deficiency. Vitamin D deficiency was more among male children (54.10%) than female (45.90%). Fatigue, bone fracture, and delayed teething were significantly higher in vitamin D-deficient children than normal children. There was a statistically significant difference between vitamin D-deficient children and normal children regarding sex, education and work of mother, socioeconomic state, and sun exposure.
Conclusion
From the current study, we can conclude that vitamin D deficiency among preschool children was 63.5%. Risk factors for vitamin D deficiency were male children who had basically educated and working mothers and moderate socioeconomic status. Vitamin D deficiency was more among obese, exclusively breastfed children and who ate fish and egg and drank milk once daily and who did not have enough sun exposure. Fatigue and bone fracture were significantly higher in vitamin D-deficient children than normal children.

Keywords: family health facilities, preschool children, vitamin D deficiency


How to cite this article:
Shaheen HM, Diab KA, Salam NI, Alkalash SH. Screening of vitamin D deficiency among preschool children in family health facilities. Menoufia Med J 2019;32:1459-65

How to cite this URL:
Shaheen HM, Diab KA, Salam NI, Alkalash SH. Screening of vitamin D deficiency among preschool children in family health facilities. Menoufia Med J [serial online] 2019 [cited 2020 Jan 21];32:1459-65. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1459/274228




  Introduction Top


Vitamin D is a group of fat-soluble secosteroids; the two major physiologically relevant forms of which are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D3 is produced in the skin after exposure to ultraviolet B light from the sun or artificial sources and occurs naturally in a small range of foods [1]. Vitamin D is a prohormone that plays an essential role in the mineralization of bones. There are two ways for humans to meet requirement for vitamin D: the major amount produced in the skin after exposure to the sunlight and the rest is being fulfilled from dietary sources. There are few foods that are naturally rich with vitamin D, although there are some fortified products available for consumption [2]. It is essential for promoting calcium absorption from the gut and maintaining adequate serum calcium and phosphate concentrations to enable normal mineralization of bones. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts [3]. Vitamin D exists in two forms: vitamin D2 (ergocalciferol) is generated from ergosterol in plants and vitamin D3 (cholecalciferol) is produced in the skin of humans as well as by some animals from 7 dihydroxycholecalciferol, both reactions being prompted by exposure to sunlight [4]. The prevalence of vitamin D deficiency is greater in certain clinical subpopulations, and the presence of associated characteristics should raise the index of suspicion for the practicing clinicians regarding conditions associated with vitamin D deficiency, such as osteoporosis and osteomalacia. Further research investigating the pathophysiology of hypovitaminosis D and its clinical consequences can help better understand and prevent the development of associated comorbidities. There is emerging evidence that suggests vitamin D deficiency in childhood may play an important function in pathophysiology not only of rickets but also of nonskeletal diseases that have an immune system-mediated pathogenesis, for example, allergic diseases such as asthma and eczema [5].

Recent studies have suggested that vitamin D deficiency in children is widespread. However, the vitamin D status among Egyptian preschool children is seldom investigated, so the aim of this study was to assess the prevalence and risk factors of vitamin D deficiency among preschool children in family health facilities in Birket El Sabaa district to identify need for continuing vitamin D supplementation after 2 years of age.


  Patients and Methods Top


An analytical cross-sectional study was conducted on 96 preschool children who attended the selected family health facilities in Birket El Sabaa district during the period of data collection (3 months). This study was conducted in the context of time frame of 12 months (starting on the1st of April 2018 till March 2019).

Ethical consideration

The study was approved by the ethical committee of Menoufia Faculty of Medicine. An informed consent obtained from all participants' guardians before the study was commenced.

Selection criteria of participants

All apparently healthy preschool children and their mothers who attended the selected family health facilities in Birket El Sabaa district were included in the study.

Exclusion criteria

Chronic illnesses, for example, renal and hepatic; malabsorption syndromes, for example, celiac disease and cystic fibrosis; refusal to participate; and intake of vitamin D supplement were the exclusion criteria.

The sample size was 96 preschool children (all preschool children who fulfilled the eligibility criteria and attended the selected health facilities during the period of data collection; 3 months). The selected health facilities were Birket El Sabaa family health center (urban), which is the only family health center in Birket El Sabaa district, and Shentina Al Hager family health unit (rural), which was selected by simple random sampling technique out of seven family health units in Birket El Sabaa district.

Interview process

The purpose of research was explained to the participants, and an informed written consent was obtained from each participant after explanation of the purpose of research. Then, a detailed history about children was obtained from the mothers through using self-designed questionnaire followed by complete examination of the children.


  Tools of Data Collection Top


The questionnaire

A structured interviewing questionnaire for children and their parents was constructed to cover the following items:

The first part included data regarding the sociodemographic and socioeconomic characteristics of the preschool children and their families such as age, sex, residence, parent education and occupation, socioeconomic state (low, medium, or high), crowding index (number of chambers in house/children number), and presence of waste and garbage. The socioeconomic level of the family was determined based on the scoring system of Fahmy et al. [6] (Social Class Classification Scale).

The second part included nutritional history of the children, which was composed of four questions such as normal breast feeding, added nutrition elements with breastfeeding, milk taking every day, and fish consumption.

The third part included four questions to identify sources of vitamin D among children such as sun exposure, taken food containing vitamin D, other vitamins or mineral supplement, and vitamins or mineral supplementation during lactation.

The fourth part included 19 questions to detect signs and symptoms of vitamin D deficiency among preschool children such as bone fracture, pain of bones or joints, fatigue, depressed mode, delayed teething, bowing of lower limb, delayed walking, delayed closure of fontanel, brooding of skull, rachitic rosary, and kyphosis.

Assessment of children's weight, height, and BMI was done.

Laboratory investigation

Assessment of serum level of vitamin D was done by 25-OH vitamin D enzyme-linked immunosorbent assay (ELISA) kit. This ELISA kit is designed, developed, and produced for the quantitative measurement of total 25-OH vitamin D2/3 in serum utilizing the competitive immunoassay technique. This assay utilizes a monoclonal antibody that binds to both 25-OH vitamin D2 and 25-OH vitamin D3 equally.

Assay calibrators, controls, and test samples are added directly to the wells of a microliter plate that is coated with specific anti-25-OH vitamin D2, D3 antibody. A buffer designed to release vitamin D from binding proteins is then added to the wells. After the first incubation period, unbound material is washed away, and biotinylated vitamin D analog is added to the wells and binds to remaining antibody sites. After the second incubation period, unbound biotin-D is washed away, and horseradish peroxidase conjugated streptavidin is added to each well. During the third incubation step, an immune complex of well-coated 'vitamin D antibody – vitamin D, biotin-D, and horseradish peroxidase conjugated streptavidin' is formed. The unbound matrix is removed in the subsequent washing steps. For the detection of this immunocomplex, the well is then incubated with a substrate solution in a timed reaction, which is terminated with an acidic reagent (ELISA stop solution). The absorbance is then measured in a spectrophotometric microplate reader.

Statistical analysis

Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS version 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using descriptive, for example, percentage, mean, and SD, and analytical, which includes χ2 and Mann–Whitney test. A value of P less than 0.05 was considered statistically significant.


  Results Top


Results showed that 36.46% (n = 35) of the studied children had normal level of vitamin D. On the contrary, 63.54% (n = 61) had vitamin D deficiency. Of the deficient children, 20.83% had mild deficiency, 31.25% (n = 30) had moderate deficiency and, 11.46% (n = 11) had severe deficiency [Figure 1].
Figure 1: Vitamin D status in relation to 25 (OH) D level among 1–6-year-old children in Birket El Sabaa (N = 96).

Click here to view


The current study showed that there was no significant difference between vitamin D-deficient children and normal children regarding their age, education, and work of father, with P value more than 0.05. On the contrary, there were statistically significant differences between vitamin D-deficient children and normal children regarding sex, education and work of mother, socioeconomic state, and presence of waste and garbage, with P value less than 0.05 [Table 1].
Table 1: Statistical comparison between vitamin D.deficiency children and normal children regarding sociodemographic data (n=96)

Click here to view


Approximately two-thirds (65.57%) of vitamin D-deficient children had been breastfeed. Approximately one-third (32.79%) of vitamin D-deficient children did not eat fish versus more than a third (34.30%) of normal children ate fish more than once per week. In addition, more than one-third (37.70%) of vitamin D-deficient children did not drink milk, whereas more than two-thirds (68.60%) of normal children drank milk more than once per week. Furthermore, 31.15 and 49.18% of vitamin D-deficient children did not eat egg and cheese versus 45.70 and 71.43% of normal children who ate fish and cheese more than once per week, respectively. In addition, there was a highly significant difference (P < 0.001) between vitamin D-deficient children and normal children regarding sun exposure and BMI [Table 2].
Table 2: Comparison between studied participants regarding possible risk factor: dietary habits, sun exposure, and BMI

Click here to view


The current study showed that there were no significant differences between vitamin D-deficient and normal children regarding presence of symptoms and signs of vitamin D deficiency except for fatigue, bone fracture, and delayed teething, which were significantly higher in vitamin D-deficient children than normal children [Table 3].
Table 3: Statistical comparison between vitamin D.deficiency children and normal children regarding symptoms and signs of vitamin D deficiency (n=96)

Click here to view



  Discussion Top


The current study showed that approximately two-thirds of the studied children had vitamin D deficiency (63.54%), and they were classified into: 20.83% had mild deficiency, 31.25% had moderate deficiency, and 11.46% had severe deficiency. This result agrees with Dooki et al. [7] who found that subnormal vitamin D levels were found in 68.9% of preschool children. This result is in agreement with a cross-sectional study by Sharawat and Dawman [8], which included 96 apparently healthy school going children (50 male and 46 female) from age 5–10 years. They found that one-third of the children had vitamin D levels (33.33%) less than 25 nmol/l and a third of them had between 25 and 50 nmol/l (33.33%). Moreover, 20.83% had levels between 50 and 75 nmol/l and 12.50% had more than 75 nmol/l. In contrast, Goswami et al. [9] found that most of the children had levels of 25(OH) D3 less than 50 nmol/l (91.1%). Moreover, Puri et al. [10] reported that most of children between 1 and 5 years of age had a 25(OH) D3 level less than 50 nmol/l (91.1%).

The present study showed that there was no relation between vitamin D status of children and their age. On the contrary, there was a statistically significant relation between vitamin D level among children and their sex. Vitamin D deficiency was more deficient among male children (54.10%) than female (45.90%). These results come in agreement with Khalessi et al. [11] who found that age was not significantly different in children who had higher vitamin D levels as compared with those who had vitamin D deficiency. In addition, Choi et al. [12] reported that age was not significantly different among the studied groups of children as stratified by vitamin D status. Our results disagree with Sahu et al. [13] who did not find a significant difference between vitamin D levels in boys and in girls.

The present study revealed that vitamin D deficiency was more among obese children (42.62%) than overweight (18.03%). These results are in agreement with Khalessi et al. [11] who found a significant difference in BMI of studied children as those who had higher BMI had vitamin D deficiency compared with others. In addition, Vandevijvere et al. [14] reported that the risk of vitamin D deficiency increased significantly with BMI of children. Moreover, Grineva et al. [15] confirmed a high prevalence of obesity among children who had vitamin D deficiency. Our results disagree with Gupta et al. [16] who concluded that there was no significant difference between vitamin D deficiency infants and normal children regarding birth weight. However, the follow-up assessments by Maghbooli et al. [17] showed that there was no significant effect of maternal vitamin D deficiency on weight of children. This difference may be owing to larger number of cases and different conditions.

In this study, there was a statistically significant relationship between vitamin D status of the children and sun exposure. This comes in agreement with El Rifai et al. [18] who showed a significant correlation between vitamin D level and skin exposure. Moreover, a cross-sectional study including 50 Pakistani children stated that vitamin D levels were significantly affected by sunlight exposure [19].

The current study indicated that there was a significant relation between vitamin D levels among children, as approximately a third of vitamin D-deficient children did not eat fish (32.79%). More than a third of vitamin D-deficient children did not drink milk (37.70%). Furthermore, approximately a third and approximately half of vitamin D-deficient children did not eat egg (31.15%) and cheese (49.18%), respectively. More than 50% of vitamin D-deficient children were consuming fish infrequently. In addition, Vandevijvere et al. [14] reported that there are very few dietary sources of vitamin D, for example, oily fish such as sardines and other useful sources being eggs, fortified margarines, and some fortified yogurts and breakfast cereals [20]. However, a retrospective review by Turner et al. [21] indicated that vitamin D status could be affected in the children by compliance with the gluten-free diet, poor absorption, and decreased intake.

The present study revealed that less than half of the studied children had bone pain (39.51%), more than one-quarter experienced delayed walking (27.78%), and less than a tenth had depressed mood (7.41%). In addition, approximately one-third of them had fatigue (30.86%), and approximately a tenth of children had bone fracture (9.26%). Moreover, less than a quarter of children experienced delayed teething (13.58%) and had bowing of lower limb (12.35%). Less than a quarter of them had boxing of their heads (15.43%) and delayed closure of fontanels (18.52%). In addition, 9.26% of children exhibited rachitic rosary and 3.09% of the studied children had kyphosis. The findings of the current study are consistent with Hazzazi et al. [22], at the King Abdul-Aziz Medical City in Riyadh, as bone pain was found in 38% of cases. A study by Ahmed et al. [23] in Glasgow found that 1% of cases had fatigue and 2% experienced developmental delays. In addition, Ward et al. [24] found that rickets and delayed developmental milestones were seen in 7% of cases in a Canadian study. A previous study done by Puri et al. [10] reported widening of the wrist in 24% of cases, lower limb deformities in 37% of cases, and bowing of the legs in 2.6% of cases. In addition, a study at King Khalid University Hospital in Riyadh by Al-Jurayyan et al. [25] found that bone fractures were seen in 7.1% of cases, which is approximate to the results of our study (a history of bone fractures seen in 9.26%).


  Conclusion Top


From the current study, we can conclude that vitamin D deficiency among preschool children was 63.5%. Risk factors for vitamin D deficiency were male children who had basically educated and working mothers and moderate socioeconomic status. Vitamin D deficiency was more among obese, exclusively breastfed children, and who ate fish and egg and drank milk once daily, and who did not have enough sun exposure. Fatigue and bone fracture were significantly higher in vitamin D-deficient children than normal children.

Owing to high prevalence of subnormal vitamin D levels among preschool children in the current study, it is recommended that vitamin D deficiency prevention programs are continued in this age group. Moreover, proper maternal education should be conducted regarding calcium-rich foods, adequate number of servings/day, and adequate sun exposure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abbas MA. Physiological functions of Vitamin D in adipose tissue. J Steroid Biochem Mol Biol 2017; 165:369–381.  Back to cited text no. 1
    
2.
Abrams SA. Committee on Nutrition. Calcium and vitamin d requirements of enterally fed preterm infants. Pediatrics 2013; 131:1676–1683.  Back to cited text no. 2
    
3.
Cranney A, Horsley T, O'Donnell S. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess 2007; 158: 229–235.  Back to cited text no. 3
    
4.
Rutstein R, Downes A, Zemel B, Schall J, Stallings V. Vitamin D status in children and young adults with perinatally acquired HIV infection. Clin Nutr 2011; 30:624–628.  Back to cited text no. 4
    
5.
Fawzi MM, Mahmoud SB, Ahmed SF, Shaker OG. Assessment of vitamin D receptors in alopecia areata and androgenetic alopecia. J Cosmet Dermatol 2016; 15:318–323.  Back to cited text no. 5
    
6.
Fahmy S, Nofal L, Shehata SH, Elkady H, Ibrahim H. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90:1–7.  Back to cited text no. 6
    
7.
Dooki E, Moslemi L, Moghadamnia A, Aghamaleki A, Bijani A, Pornasrollah M, et al. Vitamin D status in preschool children: should vitamin D supplementation, preventing vitamin D deficiency be continued in children over 2 years?. Journal of Public Health (Oxf) 2019;41:575–582.  Back to cited text no. 7
    
8.
Sharawat IK, Dawman L. Bone mineral density and its correlation with vitamin D status in healthy school-going children of Western India. Arch Osteoporos 2019; 14:13.  Back to cited text no. 8
    
9.
Goswami R, Gupta N, Goswami D. Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi. Am J Clin Nutr 2000; 72:472–475.  Back to cited text no. 9
    
10.
Puri S, Marwaha RK, Agarwal N. Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: relation to nutrition and lifestyle. Br J Nutr 2008; 99:876–882.  Back to cited text no. 10
    
11.
Khalessi N, Kalani M, Araghi M. The relationship between maternal vitamin D deficiency and low birth weight neonates. J Family Reprod Health 2015; 9:113–117.  Back to cited text no. 11
    
12.
Choi R, Kim S, Yoo H. High prevalence of vitamin D deficiency in pregnant Korean women: the first trimester and the winter season as risk factors for vitamin D deficiency. Nutrients 2015; 11.7:3427–3448.  Back to cited text no. 12
    
13.
Sahu M, Bhatia V, Aggarwal A. Vitamin D deficiency in rural girls and pregnant women despite abundant sunshine in northern India. Clin Endocrinol (Oxf) 2009; 70:680–684.  Back to cited text no. 13
    
14.
Vandevijvere S, Amsalkhir S, Van H. High prevalence of vitamin D deficiency in pregnant women: a national cross-sectional survey. Plos One 2012; 7:438–446.  Back to cited text no. 14
    
15.
Grineva EN, Karonova T, Micheeva E. Vitamin D deficiency is a risk factor for obesity and diabetes type 2 in women at late reproductive age. Aging (Albany NY) 2013; 5:575–581.  Back to cited text no. 15
    
16.
Gupta M, Debnath A, Jain S. Vitamin D status in pregnancy: fetomaternal outcome and correlation with cord blood vitamin D. Indian J Med Biochem 2017; 21:42–48.  Back to cited text no. 16
    
17.
Maghbooli Z, Hossein A, Shafaei A. Vitamin D status in mothers and their newborns in Iran. BMC Pregnancy Childbirth 2007; 7:1–6.  Back to cited text no. 17
    
18.
El Rifai NM, Abdel Moety GA, Gaafar HM. Vitamin D deficiency in Egyptian mothers and their neonates and possible related factors. J Matern Fetal Neonatal Med 2014; 27:1064–1068.  Back to cited text no. 18
    
19.
Karim SA, Nusrat U, Aziz S. Vitamin D deficiency in pregnant women and their newborns as seen at a tertiary-care center in Karachi, Pakistan. Int J Gynaecol Obstet 2011; 112:59–62.  Back to cited text no. 19
    
20.
Morse-Jones S, Bateman IJ, Kontoleon A. Stated preferences for tropical wildlife conservation amongst distant beneficiaries: charisma, endemism, scope and substitution effects. Ecol Econ 2012; 78:9–18.  Back to cited text no. 20
    
21.
Turner J, Cho Y, Dinh NN. Activities of LL-37, a cathelin-associated antimicrobial peptide of human neutrophils. Antimicrob Agents Chemother 2009; 42:2206–2214.  Back to cited text no. 21
    
22.
Hazzazi MA, Alzeer A, Tamimi W, Al Atawi M, Al Alwan I. Clinical presentation and etiology of osteomalacia/rickets in adolescents. Saudi J Kidney Dis Transpl 2013; 24:938–941.  Back to cited text no. 22
    
23.
Ahmed SF, Franey C, McDevitt H, Somerville L, Butler S. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children's hospital in Glasgow. Arch Dis Child 2011; 96:694–696.  Back to cited text no. 23
    
24.
Ward LM, Gaboury I, Ladhani M, Zlotkin S. Vitamin D-deficiency rickets among children in Canada. Can Med Assoc J 2007; 177:161–166.  Back to cited text no. 24
    
25.
Al-Jurayyan NA, El-Desouki ME, Al-Herbish AS, Al-Mazyad AS, Al-Qhtani MM. Nutritional rickets and osteomalacia in school children and adolescents. Saudi Med J 2002;23:182–5.  Back to cited text no. 25
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Tools of Data Co...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed40    
    Printed0    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]