Pediatr Nephrol (2015) 30:327332
DOI 10.1007/s00467-014-2927-z
ORIGINAL ARTICLE
Can vitamin D status be assessed by serum 25OHD in children?
Mara Agustina Alonso & Zamir Francisco Pallavicini &
Julin Rodrguez & Noelia Avello & Pablo Martnez-Camblor &
Fernando Santos
Received: 9 June 2014 / Revised: 21 July 2014 / Accepted: 22 July 2014 / Published online: 20 August 2014
# IPNA 2014
Abstract
Background To examine the relationship of serum 25-
hydroxyvitamin D (25OHD) concentrations with serum para-
thyroid hormone (PTH) levels, body mass index (BMI), and
environmental factors in a population of Caucasian children
living at latitude 43N.
Methods Cross-sectional study on 288 children aged 1 month
to 13 years who presented to a pediatric emergency unit
during a 21-month period.
Results Mean (SD) serum 25OHD concentrations were 40.6
(17.6), 30.9 (12.0), and 26.4 (9.9) ng/ml (1 ng/ml=2.5 nmol/
l), in children aged 01, 25, and6 years, respectively.
Serum PTH levels were 26.6 (13.6), 24.3 (11.9), and 32.7
(12.1) pg/ml in the same groups. Infants had 25OHD concen-
trations significantly higher. PTH levels were significantly
M. A. Alonso (*) : J. Rodrguez
Department of Pediatrics, Hospital Universitario Central de Asturias,
Oviedo 33011, Spain
e-mail: maruchialonso@gmail.com
Z. F. Pallavicini
Primary Health Center, Oviedo, Spain
N. Avello
Laboratory of Medicine, Hospital Universitario Central de Asturias,
Oviedo 33011, Spain
P. Martnez-Camblor
Oficina de Investigacin Biosanitaria (OIB) de Asturias and
Universidad Autonoma de Chile, Oviedo 33011, Spain
F. Santos
Department of Pediatrics, Hospital Universitario Central de Asturias,
Medical School, University of Oviedo, Oviedo 33011, Spain
M. A. Alonso : Z. F. Pallavicini : J. Rodrguez : N. Avello :
P. Martnez-Camblor : F. Santos
Health Service of the Principality of Asturias (SESPA),
Oviedo 33011, Spain
higher in children aged6 years. There was no significant
correlation between serum 25OHD and PTH concentrations.
Totals of 15.6 % and 2.1 % of children had 25OHD values less
than 20 and 10 ng/ml, respectively, but none had elevated
serum PTH or clinical manifestations related with vitamin D
deficiency. Age (inverse correlation) and season (higher
values in summer), but not BMI, sex, and time spent outdoors,
influenced serum 25OHD concentrations.
Conclusions Our results raise doubt on the assumption of
only a serum 25OHD threshold as indicative of vitamin D
deficiency in children.
Keywords 25OHD . PTH . Deficiency . Correlation .
Threshold . Children
Introduction
Vitamin D is essential for health. Its major physiologic func-
tion is related to the homeostasis of mineral metabolism by
maintaining serum calcium and phosphorus levels within the
normal physiologic range to ensure bone mineralization.
However, nowadays the vast majority of publications on
vitamin D are not focused on rickets or its prevention. A
recent PubMed search yielded only 1,118 references on this
topic out of a total of 25,928 on vitamin D published over the
last 10 years. Thus, current priority lines of interest on vitamin
D focus on its physiological extraskeletal effects are not well
known yet [1]. The potential link between adequate vitamin D
status and decreased risk for a variety of diseases [2, 3] has
given rise to a growing demand for measurement of serum 25-
hydroxyvitamin D (25OHD) concentrations [4] as a reliable
biomarker of an individuals vitamin D status useful to define
vitamin D deficiency. However, the basis for determining
what represents an adequate vitamin D status in the pediatric
population is not clear [1, 5]. Intestinal calcium absorption,
328
bone mineral density and rates of bone loss, falls, and fractures
have all been proposed as physiological criteria to define
vitamin D sufficiency but there are no studies that support
the validity of these clinical indicators in children. Studies on
the relationship between serum 25OHD and parathyroid hor-
mone (PTH) concentrations in adults have suggested that the
optimal serum 25OHD concentration could be defined as the
level at which PTH declines to a minimum [6, 7]. On this basis,
a serum 25OHD concentration of 20 ng/ml is usually consid-
ered in adults as the threshold of vitamin D deficiency [8]. The
American Academy of Pediatrics revised its policy on vitamin
D supplementation in 2008 and proposed new recommenda-
tions on the daily intake of vitamin D with the aim of main-
taining serum 25OHD concentrations greater than 20 ng/ml.
However, pediatric studies have yielded no uniform results
about the threshold level [7, 913]. In addition, mathematical
models have disclosed a strong influence of age on the PTH-
25OHD relationship [14], which complicates the setting of a
safety threshold. These observations strengthen the need of
undertaking pediatric studies and prevent from adopting vita-
min D thresholds extrapolated from adult series [1, 5].
The present study was designed to determine the serum
25OHD concentrations of a pediatric population living in a
poorly sunlit geographical area located at a latitude of 43
North (N) to analyze the correlation between serum 25OHD
and PTH concentrations and to assess the influence on
25OHD levels of variables such as age, season of the year,
sun exposure, dietary calcium intake, and body mass index
(BMI) [9, 11, 1520].
Methods
Design and participants
A clinical, prospective, and cross-sectional study approved by
the Regional Ethics Committee of the Principality of Asturias
was conducted. Children (aged 1 month to 13 years) who
presented to the pediatric emergency unit of a tertiary hospital
sited in a community of northern Spain (Asturias, latitude, 43
N) during a 21-month period were enrolled in the study.
Inclusion criteria were the need of drawing a blood sample
for clinical reasons, the informed consent of parents to partic-
ipate in the study, the absence of severe disease, otherwise
healthy, and place of residence in Asturias. Those children
with conditions that might affect vitamin D or bone metabo-
lism were excluded. Serum 25OHD and PTH concentrations
were measured. After the visit to the emergency room, one of
the investigators (ZP) interviewed by phone one of the parents
to collect the following data included in a questionnaire:
ethnicity, urban or rural habitat, existence of chronic diseases,
treatments with drugs or vitamin supplements, daily intake of
milk and estimated time spent outdoors.
Pediatr Nephrol (2015) 30:327332
Laboratory measurements
Serum 25OHD and intact PTH concentrations were measured
in the hospital clinical laboratory by one of the investigators
(AN). Serum 25OHD was measured by using chemilumines-
cence (Roche Diagnostics, Mannheim, Germany and
DiaSorin, Saluggia, Italy). Interassay coefficients of variation
were less than 8.2 %. Intact PTH concentrations were mea-
sured by electrochemiluminescence (Roche). Interassay coef-
ficient of variation was less than 3 % for the intact PTH. The
reference ranges provided by the manufacturers of the assays
were 10 to 68 ng/ml for 25OHD and 15 to 65 pg/ml for PTH.
Definitions
Values of serum 25OHD less than 20 ng/ml [2124] and less
than 10 ng/ml [12, 2529] were taken as cut-off thresholds
indicative of vitamin D deficiency.
BMI was calculated as weight (kg)/height (m 2 ).
Overweight was defined as BMI80th percentile for age in
boys and85th percentile for age in girls. Obesity was defined
as BMI97th percentile for age and sex. BMI percentiles
were determined by using age- and gender-specific growth
charts for the Spanish population [30].
Statistical analysis
The usual descriptive statistics were used to represent the
general characteristics of participants (sex, age, residence,
ethnicity, exposure to the sun, BMI). Mean and standard
deviation (SD) were used for continuous variables and relative
and absolute frequencies for the categorical variables. The
differences between continuous variables in the different
groups (age, sex, deficiency of vitamin D) were contrasted
by the non-parametric test of MannWhitney (two groups)
and by the test of KruskalWallis (more than two groups). Chi-
square test was calculated for assessing differences in qualita-
tive variables. The relationship between the 25OHD and PTH
levels was studied with a dispersion graph, and the Pearson
correlation coefficient was calculated. Multivariate regression
analysis was performed to disclose the potential effects of
other variables on the serum concentrations of 25OHD.
Confidence intervals at 95 % were calculated. A p value<
0.05 was considered as indicative of significant difference.
Results
A total of 310 children were enrolled in the study, but the final
sample included 288 individuals. Twenty-one blood samples
were inadequate and one child was excluded because of living
outside Asturias. Characteristics of the participants are shown
in Table 1.
Pediatr Nephrol (2015) 30:327332 329

Table 1 Characteristics of the children Table 3 Serum concentrations [mean (SD)] of 25OHD and intact para-
thyroid hormone (PTH) in the three age groups
n (%) CI (95 %)
Age (years) 25OHD (ng/ml) PTH (pg/ml)
Sex
Boys 166 (57.6) [51.963.3] 01 40.6 (17.6) 26.6 (13.6)
Girls 122 (42.4) [37.648.1] 25 30.9 (12.0) 24.3 (11.9)
Age group 6 26.4 (9.9) 32.7 (12.1)
02 years 102 (35.4) [29.940.9] p<0.01 p<0.01
26 years 112 (38.9) [33.344.5]
> 6 years 74 (25.7) [20.630.7]
Habitat For the whole sample, there was a weak inverse correlation
Urban 212 (76.8) [71.881.8] between serum PTH and 25OHD levels (r= 0.099) (Fig. 1).
Rural 64 (23.2) [18.228.2] Correlations were 0.033, 0.017, and 0.079 for children
Ethnicity aged 01, 25, and6 years.
Caucasian 243 (88.1) [82.690.6] Serum 25OHD concentrations were higher (p<0.001) in
Asian 1 (0.3) [0.02.0] spring and summer (from April to September) than in autumn
Hispanic 20 (7.4) [4.411.0] and winter (from October to March) [38.2 (17.1) vs. 30.1
Gypsy 12 (4.2) [2.27.4] (12.5) ng/ml]. There were no significant differences in serum
Body mass index PTH levels between these two groups (p=0.250).
Obesity 27 (9.5) [6.2713.5] Multivariate regression analysis showed no effect of sex,
Overweight 39 (14.2) [10.118.3]
ethnicity, habitat, outdoor exposure, milk consumption, and
Normal weight 210 (76.3) [71.381.4]
BMI on serum concentrations of 25OHD.

n sample size; CI confidence interval

The questionnaire could not be completed in 12 children Discussion

Totals of 15.6 % and 2.1 % of children had serum 25OHD This study shows that 15.6 % of children living in an area
concentrations less than 20 ng/ml and 10 ng/ml, respectively located at 43N latitude, which may preclude the cutaneous
(Table 2). Their PTH levels were not significantly elevated in synthesis of vitamin D [9], were vitamin D deficient according
comparison with those children having serum 25OHD values
equal to or greater than 20 ng/ml. The greatest prevalence of
25OHD levels<20 ng/ml was found in the group of children 6
or more years of age (p=0.006). There was no significant
difference in the prevalence of 25OHD levels<20 ng/ml be-
tween girls and boys (16.4 vs. 15.1 %, p=0.499).
Serum concentrations of 25OHD and PTH are shown in
Table 3. Serum 25OHD concentrations were significantly
higher (p<0.010) in children younger than 2 years whereas
serum PTH concentrations were higher in children of 6 years
of age or older (p<0.010).

Table 2 Prevalence of serum 25OHD concentrations less than 20 and

10 ng/ml according to age

Age (years) 25OHD<20 ng/ml 25OHD<10 ng/ml

n (%) CI 95 % n (%) CI 95 %

01 7 (6.8) 2.813.6 1 (0.9) 0.00.5

26 18 (16.1) 9.222.9 3 (2.6) 0.57.6
>6 20 (27) 17.438.6 2 (2.7) 0.39.4
Total 45 (15.6) 11.419.8 6 (2.1) 0.74.4
Fig. 1 Relationship between serum 25OHD and parathyroid hormone
n sample size; CI confidence interval levels (r=0.099)
330
to an upper limit of serum 25OHD concentration to define
deficiency of 20 ng/ml. Only 2.1 % of children had 25OHD
levels less than 10 ng/ml. Importantly, this study shows that
children with serum 25OHD values considered to be insuf-
ficient did not have apparently related clinical manifestations
or elevated levels of serum PTH and that the correlation
between serum PTH and 25OHD concentrations was extreme-
ly weak. These findings indicate that the threshold for vitamin
D deficiency in the pediatric population still needs to be
established.
Other studies that assessed the prevalence of
hypovitaminosis D in a healthy population using different
thresholds of deficiency obtained similar data [31, 32]. In a
sample of US children from the 20012006 National Health
and Nutrition Examination Survey, Mansbach et al. found that
1 and 18 % had serum 25OHD concentrations lower than
11 ng/ml and 20 ng/ml, respectively [31, 33].
It is controversial if these thresholds are adequate to define
vitamin D deficiency in the pediatric population [2, 4, 5, 7,
34]. Several measurable functional outcomes have been sug-
gested to define clinically relevant vitamin D deficiency in
children. The most studied has been the occurrence of rickets,
but a circulating concentration of 25OHD, above which rick-
ets does not occur, cannot be defined for a general population
[5, 7, 22, 35]. Anyway, no clinical signs or symptoms of
rickets were found in any child in our study. If maximal
suppression of serum PTH concentrations is taken as a sign
of good vitamin D status, it is of note that children theoreti-
cally deficient in our study did not have higher levels of PTH
than children with 25OHD levels greater than 20 ng/ml. The
correlation between the serum concentrations of 25OHD and
PTH, widely used in adults to assess the threshold of adequacy
of vitamin D, was weak and not significant in our study.
It could be argued that children with circulating 25OHD
levels less than 20 ng/ml might benefit of vitamin D supple-
mentation because of potential extraskeletal effects. Currently,
there is insufficient evidence from interventional studies to
support vitamin D supplementation on this basis [22, 29] and
the values of serum 25OHD concentrations required to obtain
these hypothetical beneficial effects on global health are un-
known [1, 2, 7, 3537]. In our study, only two children having
25OHD levels lower than 20 ng/ml underwent chronic illness
(bronchial asthma), this prevalence being even lower than
expected in the general child population in our community
(4 vs. 11.7 %) [38].
Regarding the influence of age on vitamin D status, we
found that children of 6 years or older had the highest prev-
alence of 25ODH levels below 20 ng/ml. This finding is
consistent with former pediatric studies showing lower levels
of 25OHD as the childs age increases [31, 39, 40]. It is also of
note that serum 25OHD concentrations were higher in the
group of infants younger than 24 months of age, likely as a
result of the supplementation with vitamin D (400 IU/day)
Pediatr Nephrol (2015) 30:327332
commonly recommended from birth to 18 months of age in
our community and the consumption of foods fortified with
vitamin D in infants (formula-fed, cereals), variables that
likely influence 25OHD levels [9, 41].
The mean serum PTH concentrations were normal at all
age groups although significantly higher in the group of older
children. Only four children had PTH levels above the normal
reference values, two of them were infants and two were in the
25 years group. These four children had 25OHD concentra-
tions greater than 20 ng/ml and did not present clinical or
biochemical data of secondary hyperparathyroidism [42].
As for the influence of the season of year on vitamin D
status, the serum 25OHD concentrations were significantly
higher in spring and summer, from April to September, the
period of greater solar irradiation in our region [43].
Nevertheless, serum PTH levels did not vary. As more than
90 % of vitamin D comes from photo conversion of 7-
dehydrocholesterol to cholecalciferol by solar ultraviolet B
radiation in the skin, the latitude is considered a factor that
affects cutaneous vitamin D synthesis and therefore a risk
factor for vitamin D deficiency [44]. This agrees with the
mean serum 25OHD concentrations below 20 ng/ml found
in February and March in our study.
An apparently paradoxical finding of our study was that the
group of older children spent more time outdoors according to
the questionnaire and, however, its serum 25OHD concentra-
tions were lower. By contrast, the group of infants younger
than 2 years had high circulating levels of 25OHD but spent
less time outside. Besides the potential limitation of the infor-
mation obtained by a telephonic questionnaire, the vitamin D
supplementation received by infants must be taken into ac-
count for the interpretation of these results, as stated above.
There is controversy about the relationship between body
fat and vitamin D status. Some studies have associated vita-
min D deficiency with excessive body weight [45, 46], per-
haps as a result of the sequestration of vitamin D by the fat, but
others found opposite results [47]. Few data are available in
children [18]. We did not find any significant relationship
between BMI and serum 25OHD levels as well as we did
not demonstrate any influence of sex, habitat residence, milk
intake, or time outdoors on serum concentrations of 25OHD.
This study shows that 15.6 % of children aged 013 years
had serum 25OHD concentrations below 20 ng/ml, but not
associated to elevated levels of serum PTH or clinical mani-
festations. Recent publications [48, 49] indicate that the con-
cept of vitamin D deficiency needs to be redefined to consider
not only total but also bioavailable 25OHD levels. In the
circulation, 25OHD is bound to vitamin D binding protein
(DBP) and albumin. Only a small fraction is unbound.
According to the free-hormone hypothesis, the free form
is primarily responsible for biological activity. Variation in
DBP levels and binding properties related with genetic differ-
ences may affect the amount of free 25OHD. New research
Pediatr Nephrol (2015) 30:327332
indicates that the free form of 25OHD and DBP levels may be
a more informative measure of vitamin D status; however,
there are doubts about the correlation between calculated and
directly measured circulating free 25OHD concentrations, and
there are still no studies in children to evaluate this. Recent
findings suggest that current algorithms to calculate free
25OHD may not be accurate, and direct measurement of free
25OHD concentrations is now in development in the clinical
setting [50].
Currently, no evidence is available on the benefits of
treating asymptomatic children with serum 25OHD levels
below the threshold of deficiency with pharmacological doses
of vitamin D. These children should be given lifestyle rec-
ommendations [1] including safe sunlight exposure and ade-
quate diet.
Acknowledgments The authors are grateful to the infants and their
families for their participation in the study and the pediatricians of the
Hospital Universitario Central of Asturias who recruited children for the
study. This work was partly presented at the 47th ESPN Annual Scientific
Meeting of the European Society for Pediatric Nephrology.
Funding/support Partly supported by grant FIS ECO8/00238 from the
Instituto de Salud Carlos III and by the Fundacin Nutricin y
Crecimiento.
Author contributions Dra. Alonso had full access to all of the data in
the study and took responsibility for the integrity of the data and the
accuracy of the data analysis. Study concept and design: Alonso,
Rodrguez, Santos. Obtainment of data: Pallavicini, Avello. Analysis
and interpretation of data: Alonso, Santos, Pallavicini. Drafting of the
manuscript: Alonso, Santos. Critical revision of the manuscript: Santos.
Statistical analysis: Martnez-Camblor.
References
1. Shaw NJ, Mughal MZ (2013) Vitamin D and child health: part 2
(extraskeletal and other aspects). Arch Dis Child 98:368372
2. Glade MJ (2013) Vitamin D: health panacea or false prophet?
Nutrition 29:3741
3. Rey C, Snchez-Arango D, Lpez-Herce J, Martnez-Camblor P,
Garca-Hernndez I, Prieto B, Pallavicini Z (2014) Vitamin D deficien-
cy at pediatric intensive care admission. J Pediatr (Rio J) 90:135142
4. Sattar N, Welsh P, Panarelli M, Forouhi NG (2012) Increasing
requests for vitamin D measurement: costly confusing, and without
credibility. Lancet 379:9596
5. Greer FR (2009) Defining vitamin D deficiency in children: beyond
25-OH vitamin D serum concentrations. Pediatrics 124:14711473
6. Hollis BW (2005) Circulating 25-hydroxyvitamin D levels indicative
of vitamin D sufficiency implications for establishing a new effective
dietary intake recommendation for vitamin D. J Nutr 135:317322
7. Cranney A, Horsley T, ODonnell S, Weiler H, Puil L, Ooi D,
Atkinson S, Ward L, Moher D, Hanley D, Fang M, Yazdi F,
Garritty C, Sampson M, Barrowman N, Tsertsvadze A, Mamaladze
V (2007) Effectiveness and safety of vitamin D in relation to bone
health. Evid Rep Technol Assess (Full Rep) 158:1235
8. Ginde AA, Wolfe P, Camargo CA Jr, Schwartz RS (2012) Defining
vitamin D status by secondary hyperparathyroidism in the U.S.
population. J Endocrinol Invest 35:4248
331
9. Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ (2004)
Prevalence of vitamin D deficiency among healthy adolescents. Arch
Pediatr Adolesc Med 158:531537
10. Marwaha RK, Tandon N, Reddy DR, Aggarwal R, Singh R,
Sawhney RC, Saluja B, Ganie MA, Singh S (2005) Vitamin D and
bone mineral density status of healthy schoolchildren in northern
India. Am J Clin Nutr 82:477482
11. Gordon CM, Feldman HA, Sinclair L, Williams AL, Kleinman PK,
Perez-Rossello J, Cox JE (2008) Prevalence of vitamin D deficiency
among healthy infants and toddlers. Arch Pediatr Adolesc Med 162:
505512
12. Ziegler EE, Hollis BW, Nelson SE, Jeter JM (2006) Vitamin D
deficiency in breastfed infants in Iowa. Pediatrics 118:603610
13. Greer FR, Marshall S (1989) Bone mineral content, serum vitamin D
metabolite concentrations, and ultraviolet B light exposure in infants
fed human milk with and without vitamin D2 supplements. J Pediatr
114:204212
14. Valcour A, Blocki F, Hawkins DM, Rao SD (2012) Effects of age and
serum 25-OH-vitamin D on serum parathyroid hormone levels. J Clin
Endocrinol Metab 97:39893995
15. Carbone LD, Rosenberg EW, Tolley EA, Holick MF, Hughes TA,
Watsky MA, Barrow KD, Chen TC, Wilkin NK, Bhattacharya SK,
Dowdy JC, Sayre RM, Weber KT (2008) 25-Hydroxyvitamin D,
cholesterol, and ultraviolet irradiation. Metabolism 57:741748
16. Ashwell M, Stone EM, Stolte H, Cashman KD, Macdonald H,
Lanham-New S, Hiom S, Webb A, Fraser D (2010) UK Food
Standards Agency Workshop Report: an investigation of the relative
contributions of diet and sunlight to vitamin D status. Br J Nutr 4:19
17. Jamal-Allial A, Griffith JL, Tucker KL (2013) The longitudinal
association of vitamin D serum concentrations & adiposity pheno-
type. J Steroid Biochem Mol Biol. doi:10.1016/j.jsbmb.2013.12.004
18. Rodrguez-Rodrguez E, Navia-Lombn B, Lpez-Sobaler AM,
Ortega RM (2010) Associations between abdominal fat and body
mass index on vitamin D status in a group of Spanish schoolchildren.
Eur J Clin Nutr 64:461467
19. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley
DA, Heaney RP, Murad MH, Weaver CM, Endocrine Society (2011)
Evaluation, treatment, and prevention of vitamin D deficiency: an
Endocrine Society clinical practice guideline. J Clin Endocrinol
Metab 96:19111930
20. Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF (2000)
Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr
72:690693
21. Wagner CL, Greer FR, the Section on Breastfeeding and Committee
on Nutrition (2008) Prevention of rickets and vitamin D deficiency in
infants, children, and adolescents. Pediatrics 122:11421152
22. Braegger C, Campoy C, Colomb V, Decsi T, Domellof M, Fewtrell
M, Hojsak I, Mihatsch W, Molgaard C, Shamir R, Turck D, van
Goudoever J, ESPGHAN Committee on Nutrition (2013) Vitamin D
in the healthy paediatric population: a position paper by the
ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr
56:692701
23. National Research Council (2011) Dietary reference intakes for cal-
cium and vitamin D. The National Academies Press, Washington,
DC, Assessed at http://www.nap.edu/ca on January 2014
24. Willis CM, Laing EM, Hall DB, Hausman DB, Lewis RD (2007) A
prospective analysis of plasma 25-hydroxyvitamin D concentrations
in white and black prepubertal females in the southeastern United
States. Am J Clin Nutr 85:124130
25. Pearce SH, Cheetham TD (2010) Diagnosis and management of
vitamin D deficiency. BMJ 340:140147
26. Dawodu A, Agarwal M, Hossain M, Kochiyil J, Zayed R (2003)
Hypovitaminosis D and vitamin D deficiency in exclusively breast-
feeding infants and their mothers in summer: a justification for
vitamin D supplementation of breast-feeding infants. J Pediatr 142:
169173
332
27. Roth DE, Martz P, Yeo R, Prosser C, Bell M, Jones AB (2005) Are
national vitamin D guidelines sufficient to maintain adequate blood
levels in children? Can J Public Health 96:443449
28. Kim MJ, Na B, No SJ, Han HS, Jeong EH, Lee W, Han Y, Hyeun T
(2010) Nutritional status of vitamin D and the effect of vitamin D
supplementation in Korean breast-fed infants. J Korean Med Sci 25:
8389
29. Consensus Vitamin D position statement (2010) Assessed at http://
www.nos.org.uk on September 2013
30. Carrascosa A, Fernndez JM, Fernndez A, Lpez-Siguero JP, Lpez
D, Snchez E (2010) Estudios Espaoles de Crecimiento. Assessed
at: http://www.aeped.es/noticias/estudios-espanoles-crecimiento-
2010 on February 2014
31. Mansbach JM, Ginde AA, Camargo CA (2009) Serum 25-
hydroxyvitamin D levels among US children aged 1 to 11
years: do children need more vitamin D? Pediatrics 124:
14041410
32. Akman AO, Tumer L, Hasanoglu A, Ilhan M, Cayc B (2011)
Frequency of vitamin D insufficiency in healthy children between 1
and 16 years of age in Turkey. Pediatr Int 53:968973
33. Yetley EA (2008) Assessing the vitamin D status of the US popula-
tion. Am J Clin Nutr 88:S558S564
34. Pela I (2012) How much vitamin D for children? Clin Cases Miner
Bone Metab 9:112117
35. Medical Advisory Secretariat (2010) Clinical utility of vitamin D
testing: an evidence-based analysis. Ont Health Technol Assess
Ser 10:195, Assessed at:http://www.health.gov.on.ca/english/
providers/program/mas/tech/reviews/pdf/rev_vitamin d_201002.
pdf, on March 2013
36. Ross C (2011) The 2011 dietary reference intakes for calcium and
vitamin D: what dietetics practitioners need to know. J Am Diet
Assoc 111:524527
37. Brannon PM (2012) Key questions in vitamin D research. Scand J
Clin Lab Invest 72:154162
38. Margolles M, Donate I, Alonso P (2009) Ministry of health and
health services. Survey of childrens health in Asturias. Assessed at:
www.astursalud.es on Janury 2014
39. Absoud M, Cummins C, Lim MJ, Wassmer E, Shaw N (2011)
Prevalence and predictors of vitamin D insufficiency in children: a
Great Britain population-based study. PLoS One 6:e22179
Pediatr Nephrol (2015) 30:327332
40. Lapatsanis D, Moulas A, Cholevas V, Soukakos P, Papadopoulou ZL,
Challa A (2005) Vitamin D: a necessity for children and adolescents
in Greece. Calcif Tissue Int 77:348355
41. Alonso A, Rodrguez J, Carvajal I, Prieto ML, Rodrguez RM, Prez
AM, Cepeda A, Nuo F, Santos F, Collaborative Group on
Prophylaxis with Vitamin D in Asturias (2011) Prophylactic vitamin
D in healthy infants: assessing the need. Metabolism 60:17191725
42. Hashemipour S, Larijani B, Adibi H, Sedaghat M, Pajouhi M,
Bastan-Hagh MH, Soltani A, Javadi E, Shafaei AR, Baradar-Jalili
R, Hossein-Nezhad A (2006) The status of biochemical parameters in
varying degrees of vitamin D deficiency. J Bone Miner Metab 24:
213218
43. Sancho AJM, Riesco MJ, Jimnez AC, Snchez de Cos EM,
Montero CJ, Lpez BM (2012) Atlas of solar radiation in Spain.
EUMETSAT. Assessed at: http://www.aemet.es/documentos/es/
serviciosclimaticos/datosclimatologicos/atlas_radiacion_solar/atlas_
de_radiacion_24042012.pdf on May 2014
44. Shaw NJ, Mughal MZ (2013) Vitamin D and child health Part 1
(skeletal aspects). Arch Dis Child 98:363367
45. Bischof MG, Heinze G, Vierhapper H (2006) Vitamin D status and its
relation to age and body mass index. Horm Res 66:211215
46. Reinehr T, De Sousa G, Alexy U, Kersting M, Andler W (2007)
Vitamin D status and parathyroid hormone in obese children before
and after weight loss. Eur J Endocrinol 157:225232
47. Nesby-ODell S, Scanlon KS, Cogswell ME, Gillespie C, Hollis BW,
Looker AC, Allen C, Doughertly C, Gunter EW, Bowman BA (2002)
Hypovitaminosis D prevalence and determinants among African
American and white women of reproductive age: third National
Health and Nutrition Examination Survey 198894. Am J Clin
Nutr 76:187192
48. Holick MF (2013) Bioavailability of vitamin D and its metabolites in
black and white adults. N Engl J Med 369:20472048
49. Powe CE, Evans MK, Wenger J, Zonderman AB, Berg AH, Nalls M,
Tamez H, Zhang D, Bhan I, Karumanchi SA, Powe NR, Thadhani R
(2013) Vitamin Dbinding protein and vitamin D status of black
Americans and white Americans. N Engl J Med 369:19912000
50. Schwartz JB, Lai J, Lizaola B, Kane L, Markova S, Weyland P,
Terrault NA, Stotland N, Bikle D (2014) A comparison of measured
and calculated free 25(OH) vitamin D levels in clinical populations. J
Clin Endocrinol Metab 99:16311637
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