Nutritional Hypovitaminosis D Presenting as Tetany in an Infant
 
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Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {w}, Mumbai 400056, India.


Clinical Problem :
A 12 months-old boy presented with vomiting, diarrhoea and carpopedal spasm. He was exclusively breast-fed till 6 months of age and was on full diet now. On examination, he had fronto-parietal bossing. There were no other signs of rickets. Other systems were normal. Investigations showed serum calcium 6.5 mg, dl {normal=8.5-11 mg, dl}, with ionic calcium of 0.65 mmol, L {normal =1.1- 1.3 mmol, L}, phosphorus of 4.9 mg, dl and alkaline phosphatase of 1067 IU, L. 25-OH vitamin D3 was 5.0 ng, ml. The patient was treated with IV and oral calcium and vitamin D, to which he responded.


Question :
How common is carpopedal spasm in vitamin D deficient infants_? How to treat it_?

Expert Opinion :
It has been estimated that 1 billion people worldwide have low serum levels of vitamin D. {1} Vitamin D deficiency causes hypocalcemia and rickets in children leading to hypocalcemic convulsions. Tetany is a rare presentation of hypocalcemic hypovitaminosis D in infants. {2,3} As breast milk is not a good source of vitamin D, exclusively breast fed infants are at a greater risk of developing hypovitaminosis D. {4} The presentations of hypovitaminosis D in infants depends on the stage of deficiency. In the early stages, the presentations are mainly a consequence of hypocalcemia, such as seizures, tetany. Skeletal deformities like craniotabes, rachitic rosary and frontal bossing of the skull are prominent in the later stages of vitamin D deficiency. {4}
Prevention of vitamin D deficiency is very important. Vitamin D supplementation of 400 IU, day coupled with adequate exposure to the sun has been recommended for exclusively breast-fed children upto 1 year of age. {1} According to the Indian Council of Medical Research, under situations of minimal exposure to light, the recommended dietary allowance of vitamin D is 400 IU {10 microgram}. However, it has been suggested that this is inadequate and intake should be increased to atleast 800 IU per day. {1} Treatment strategies for vitamin D deficiency have included 1000-2000 IU of vitamin D2 or vitamin D3 per day orally or 200,000 IU of vitamin D3 orally every 3 months. {1} Calcium supplementation should be given concurrently to avoid hypocalcemia from remineralization of bones.

References
1. Holick MF. Vitamin D Deficiency. N Engl J Med 2007` 357:266-81
2. Bakwin H, Backwin RM. Vitamin D deficiency: Tetany in infants without rickets. J Pediatr. 1933` 3: 880-882
3. Duplechin RY, Nadkarni M, Schwartz RP. Hypocalcemic tetany in a toddler with undiagnosed rickets. Ann Emerg Med. 1999` 34: 399-402
4. Balasubramanian S, Ganesh R. Vitamin D deficiency in exclusively breast-fed infants. Indian J Med Res. 2008` 127: 250-255.


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