Last reviewed 11 October 2012

By Elizabeth Walker

Introduction

Fresh concerns over the dangers of vitamin deficiencies in the early years have highlighted a need for greater awareness of supplement recommendations in the under-fives. A report on vitamin supplementation for young children by the Feeding for Life Foundation has revealed a worrying gap between best practice and what is happening in Britain today. Figures suggest that up to a quarter of the population has low levels of vitamin D in their blood and the majority of pregnant women do not take vitamin D supplements during pregnancy. This can increase the risk of poor bone health, including rickets in young children.

Government advice

Currently, all UK Health Departments recommend the following for at-risk groups.

  • All pregnant and breastfeeding women should take a daily supplement containing 10μg of vitamin D, to ensure the mother’s requirements for vitamin D are met and to build adequate fetal stores for early infancy.

  • All infants and young children aged six months to five years old should take a daily supplement containing vitamins A, C and D in the form of vitamin drops, to help them meet the requirement set for this age group of 7–8.5 micrograms of vitamin D per day. However, those infants who are fed infant formula will not need vitamin drops until they are receiving less than 500ml of infant formula a day, as these products are fortified with vitamin D. Breastfed infants may need to receive drops containing vitamin D from one month of age if their mother has not taken vitamin D supplements throughout pregnancy.

  • People aged 65 years and over, and people who are not exposed to much sun should also take a daily supplement containing 10 micrograms of vitamin D.

Growing children, especially those who do not eat a varied diet, sometimes do not get enough of vitamins A and C and it is difficult to get enough vitamin D through food alone. Health professionals can give advice on vitamin drops and where to find them and people on lower incomes can obtain free vitamin supplements through the Healthy Start Scheme (www.healthy start.nhs.uk).

The role of vitamins

Vitamins play an important role in children’s developing bodies and regulate many essential biochemical functions. Vitamin D is crucial for bone formation, vitamin A plays an important role in the immune function and vitamin C promotes healthy muscles, connective tissue and skin.

In all, there are 13 vitamins of which 4 (A, D, E and K) are fat soluble and can be stored in the body. Fat-soluble vitamins should be treated with caution as intakes above the recommended levels may result in an unhealthy accumulation within the body. Parents need to seek advice from health professionals or pharmacists on which vitamin supplements are suitable for their young children.

Nine vitamins, including vitamin C and the B-group, are water soluble and cannot be stored. Therefore a consistent daily intake of water soluble vitamins is required.

Experts agree that a healthy balanced diet should provide all the nutrients young children require. Ideally, children should get their vitamins from a healthy diet that includes:

  • milk and dairy products

  • plenty of fresh fruits and leafy, green vegetables

  • protein such as chicken, fish, meat, and eggs

  • whole grains such as cereal, oatmeal and brown rice.

However, vitamins D and K are the exception as additional processes are required to manufacture these nutrients within the body and it is hard to get the required amount from food alone. Vitamin K is now given routinely to newborn babies but there is still a worrying shortfall in vitamin D intake. Figures from the latest National Diet and Nutrition Survey (NDNS) highlight the need for greater focus on the public health threat of vitamin D deficiency and the interim statistics suggest there is no longer need for under-fives to receive additional vitamin A or C.

Sources of Vitamin D

Vitamin D only occurs naturally in a few foods, such as oily fish and egg yolks. Statutory fortification in the UK requires all margarines and infant formulas to be fortified with vitamin D and some manufacturers have also fortified foods by adding vitamin D to cereals, milks, spreads, yoghurts and processed cheeses.

Ninety per cent of our vitamin D intake comes from exposure of the skin to sunlight, which is needed to convert vitamin D to its active form. The amount of UVB radiation needed to make sufficient vitamin D may also depend on skin colour. People with fair complexions only need approximately one tenth of that required by those with a darker skin.

It is, however, necessary to be careful in the sun and we are all encouraged to cover up and protect young children's skin from damage in hot weather. Sunscreens reduce exposure and the body's ability to produce vitamin D. In addition, the angle of the sun means that in winter it may be impossible for under-fives living in certain areas of the UK to make sufficient vitamin D. This means many young children must draw on reserves or rely on vitamin supplements to achieve the requirement set for this age group of 7–8.5 micrograms of vitamin D per day.

Dangers of vitamin D deficiency

Vitamin D deficiency impairs the absorption of dietary calcium and phosphorus which can give rise to bone problems, such as rickets in children and bone pain and tenderness as a result of osteomalacia in adults. Symptoms of vitamin D deficiency are often very non-specific or vague and therefore the problem is often missed. The diagnosis is more easily reached in children with severe deficiencies. Symptoms of vitamin D deficiency in babies and young children can include the following.

  • Babies with severe vitamin D deficiency can get muscle spasms (cramps), seizures and breathing difficulties. These problems are related to consequent low levels of calcium.

  • Children with severe deficiency may have soft skull or leg bones. Their legs may look curved (bow-legged). They may also complain of bone pains, often in the legs, and muscle pains or muscle weakness. This condition is known as rickets.

  • Poor growth. Height is usually affected more than weight. Affected children might be reluctant to start walking.

  • Tooth delay. Children with vitamin D deficiency may be late teething as the development of the milk teeth has been affected.

  • Irritability in children can be due to vitamin D deficiency.

  • Children with vitamin D deficiency are more prone to infections. Respiratory (breathing) symptoms can occur in severe cases. Breathing can be affected because of weak chest muscles and a soft ribcage.

  • Rarely, an extremely low vitamin D level can cause weakness of the heart muscle (cardiomyopathy).

Vitamin D deficiency can be diagnosed by a simple blood test. Blood tests for calcium and phosphate levels and liver function may also show changes linked to a low level of vitamin D. Sometimes, a wrist X-ray is done for a child. This can assess how severe the problem is by looking for changes in the wrist bones.

Vitamin D deficiency is treated by taking supplements in the form of injections or liquid/tablet medicine. The dosage depends on age and the severity of the deficiency. Both the vitamin levels and the symptoms generally respond well to treatment. However, it can take months for bones to recover and symptoms to improve. In severe cases, where the deficiency has led to rickets, permanent bone deformities can occur if the condition is untreated or treatment is delayed.

Education and awareness

Last year, research by the Feeding for Life Foundation found that the majority of healthcare professionals (52%) and parents are unsure or unaware of vitamin supplement recommendations for the under-fives. The uptake of the Healthy Start vitamins among families qualifying for the scheme is also currently low. Education and awareness of the Government’s recommendations are therefore critical factors in encouraging the uptake of vitamin supplementation.

The UK's four Chief Medical Officers have recently written to health professionals to remind them of these recommendations following fresh concerns about vitamin D deficiency. Health professionals are being encouraged to use their routine contact with at-risk groups, including the under-fives, to raise awareness of the advice of taking vitamin D supplements and to remind them to be alert to the signs and symptoms of vitamin D deficiency.

Funding for early years providers

A new grant is now available to early years providers where they can apply for up to £5000 to fund projects that promote vitamin D and encourage children under the age of five to take supplements. Nurseries can apply for a share (from £100 up to £5000) of the Feeding for Life Foundation’s Promoting Best Practice grant to fund a new or existing project. The grant is also open to health visitors, practice and community nurses, dieticians and nutritionists and other specialists working in the areas of child nutrition.

Examples of suitable projects include educating parents about the importance of supplementation in children under five by holding meetings or providing factsheets about vitamin D, and the development of educational tools to promote best practice.

Conclusion

Despite government advice on vitamin supplements in the early years, there is still a large percentage of young children not achieving the recommended intake of vitamin D which is crucial to their healthy development. Therefore it is vital that there is a continued effort to increase awareness of this public health issue and ensure that at-risk groups, such as the under-fives, can access these important daily supplements.

Further information

  • Feeding for Life Foundation (www.feedingforlifefoundation.co.uk) is a new education initiative committed to raising awareness of the importance of early nutrition.

  • National Diet and Nutrition Survey (www.dh.gov.uk).

  • Healthy Start (www.healthystart.nhs.uk) is a scheme which provides free food vouchers and vitamin supplements to low income and disadvantaged families.

  • NHS (www.nhs.uk) offers advice on vitamin supplements in the early years.