Original Article

Vitamin D Deficiency in Pediatric Patients with Cystic Fibrosis: Associated Risk Factors in the Northern United States

Authors: Amy Hughes Lansing, MS, Catherine McDonald, PhD, RD, Raza A. Patel, MD, MPH, Suzanne Meihls, RN, Kody Crowell, MD, Barbara Chatfield, MD, John F. Pohl, MD


Objectives: Cystic fibrosis (CF) is associated with vitamin D deficiency, which can lead to adverse effects including recurrent pulmonary infections and osteoporosis. We longitudinally investigated calcifediol or 25-hydroxyvitamin D (25(OH)D) levels for our pediatric patients with CF based on the time of year as well as vitamin D supplementation dosing ranges for these patients at our CF center.

Methods: We retrospectively evaluated vitamin D deficiency in our pediatric CF center for 2 years (baseline and annually) while evaluating 25(OH)D serum changes based on vitamin D supplementation, seasonality, patient age, and other factors associated with CF.

Results: Vitamin D supplementation was noted to be higher than current Cystic Fibrosis Foundation dosing recommendations, and no patient experienced vitamin D toxicity. Seasonality was a strong indicator of 25(OH)D levels, especially during summer or fall. Significantly fewer patients with initially low 25(OH)D levels maintained low levels at the conclusion of the study, suggesting benefit. Older patient age and higher supplemental dosing correlated with significantly lower 25(OH)D levels.

Conclusions: This study suggests that targeted intervention among pediatric patients with CF living in northern latitudes of the United States, especially older children, is needed to prevent vitamin D deficiency.

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1. Cutting GR. Phenotype-genotype relationships. In: Hodson M, Geddes D, eds. Cystic Fibrosis. 2nd ed. New York: Arnold Press; 2000.
2. Javier RM, Jacquot J. Bone disease in cystic fibrosis: what’s new? Joint Bone Spine 2011;78:445-450.
3. Rovner AJ, Stallings VA, Schall JI, et al. Vitamin D insufficiency in children, adolescents, and young adults with cystic fibrosis despite routine oral supplementation. Am J Clin Nutr 2007;86:1694-1699.
4. Aris RM, Merkel PA, Bachrach LK, et al. Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab 2005;90:1888-1896.
5. Robberecht E, Vandewalle S, Wehlou C, et al. Sunlight is an important determinant of vitamin D serum concentrations in cystic fibrosis. Eur J Clin Nutr 2011;65:574-579.
6. Huotari A, Herzig KH. Vitamin D and living in northern latitudesVan endemic risk area for vitamin D deficiency. Int J Circumpolar Health 2008;67:164-178.
7. Gilbert CR, Arum SM, Smith CM. Vitamin D deficiency and chronic lung disease. Can Respir J 2009;16:75-80.
8. McCauley LA, Thomas W, Laguna TA, et al. Vitamin D deficiency is associated with pulmonary exacerbations in children with cystic fibrosis. Ann Am Thorac Soc 2014;11:198-204.
9. McDonald CM, Zobell J, MacKay M. Vitamin D status in children with CF. Pediatr Pulmonol 2008;S31:656.
10. Tangpricha V, Kelly A, Stephenson A, et al. An update on the screening, diagnosis, management and treatment of vitamin D deficiency in individuals with cystic fibrosis: evidence-based recommendations from the Cystic Fibrosis Foundation. J Clin Endocrinol Metab 2012;97:1082-1093.
11. Lagman R, Walsh D. Dangerous nutrition? Calcium, vitamin D, and shark cartilage nutritional supplements and cancer-related hypercalcemia. Support Care Cancer 2003;11:232-235.
12. Koul PA, Ahmad SH, Ahmad F, et al. Vitamin D toxicity in adults: a case series from an area with endemic hypovitaminosis D. Oman Med J 2011;26:201-204.
13. Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner Res 2007;22(Suppl 2):V64-V68.
14. Farrar MD, Webb AR, Kift R, et al. Efficacy of a dose range of simulated sunlight exposures in raising vitamin D status in South Asian adults: implications for targeted guidance on sun exposure. Am J Clin Nutr 2013;97:1210-1216.
15. Rhodes LE, Webb AR, Fraser HI, et al. Recommended summer sunlight exposure levels can produce sufficient (> or =20 ng ml(-1)) but not the proposed optimal (> or =32 ng ml(-1)) 25(OH)D levels at UK latitudes. J Invest Dermatol 2010;130:1411-1418.
16. Earth’s seasons: equinoxes, solstices, perihelion, and aphelion, 2000-2020. http://aa.usno.navy.mil/data/docs/EarthSeasons.php. Accessed July 20, 2014.
17. Simoneau T, Bazzaz O, Sawicki GS, et al. Vitamin D status in children with cystic fibrosis. Associations with inflammation and bacterial colonization. Ann Am Thorac Soc 2014;11:205-210.
18. Sheikh S, Gemma S, Patel A. Factors associated with low bone mineral density in patients with cystic fibrosis. J Bone Miner Metab 2014 Mar 16. [Epub ahead of print]
19. Smith BA, Cogswell A, Garcia G. Vitamin D and depressive symptoms in children with cystic fibrosis. Psychosomatics 2014;55:76-81.
20. Brodlie M, Orchard WA, Reeks GA, et al. Vitamin D in children with cystic fibrosis. Arch Dis Child 2012;97:982-984.
21. Ferguson JH, Chang AB. Vitamin D supplementation for cystic fibrosis. Cochrane Database Syst Rev 2009;4:CD007298.
22. Kasahara AK, Singh RJ, Noymer A. Vitamin D (25OHD) serum seasonality in the United States. PLoS One 2013;8:e65785.
23. Chavasse RJ, Francis J, Balfour-Lynn I, et al. Serum vitamin D levels in children with cystic fibrosis. Pediatr Pulmonol 2004;38:119-122.
24. Hirschler V, Maccallini G, Molinari C, et al. Low vitamin D concentrations among indigenous Argentinean children living at high altitudes. Pediatr Diabetes 2013;14:203-210.
25. Chao YS, Brunel L, Faris P, et al. Vitamin D status of Canadians employed in northern latitudes. Occup Med (Lond) 2013;63:485-493.
26. Lagunova Z, Porojnicu AC, Aksnes L, et al. Effect of vitamin D supplementation and ultraviolet B exposure on serum 25-hydroxyvitamin D concentrations in healthy volunteers: a randomized, crossover clinical trial. Br J Dermatol 2013;169:434-440.
27. Binkley N, Novotny R, Krueger D, et al. Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab 2007;9:2130-2135.
28. Hayes CE, Cantorna MT, DeLuca HF. Vitamin D and multiple sclerosis. Proc Soc Exp Biol Med 1997;216:21-27.
29. Bregnballe V, Schiøtz PO, Boisen KA, et al. Barriers to adherence in adolescents and young adults with cystic fibrosis: a questionnaire study in young patients and their parents. Patient Prefer Adherence 2011;5:507-515.
30. Robinson C, Chiang M, Thompson SN, et al. Occurrence of vitamin D deficiency in pediatric patients at high risk in West Virginia. South Med J 2012;105:504-507.
31. Samson CM, Morgan P, Williams E, et al. Improved outcomes with quality improvement interventions in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2012;55:679-688.