Free vitamin D supplementation for every infant in Turkey

We read with interest the article by Zipitis et al¹ concerning primary care trusts providing funds for vitamin D supplementation of Asian children for at least the first 2 years of life.

Nutritional rickets remains prevalent in developing regions of the world such as Africa, the Indian subcontinent, Asia and the Middle East, and ranks among the five most common diseases in children.²,³,⁴ The prevalence of nutritional rickets in developed countries also seems to be rising.⁵,⁶,⁷,⁸,⁹,¹⁰,¹¹

In Turkey, nutritional rickets has long been among the leading diseases in childhood. Although the prevalence is not known, a recent study indicates that 6% of children <3 years of age presenting to a general outpatient clinic were found to have nutritional rickets.¹² Maternal vitamin D deficiency is also endemic. Severe vitamin D deficiency was identified in 46–80% of pregnant women and nursing mothers in different regions of Turkey.¹³,¹⁴ Similarly, almost half of the Turkish adolescent girls have varying degrees of vitamin D deficiency.¹⁵

Several lifestyle and environmental factors are probably responsible for the high prevalence of vitamin D deficiency in developing countries, as well as its resurgence in the developed world. Inadequate exposure to sunlight is becoming more common as individuals spend more time indoors with access to television and computers, or actively avoid the outdoors because of concerns about pollution or the long‐term effects of sun exposure on skin cancer. Cultural practices including traditional clothing (covered dress) for women and limited access to open space for pregnant and nursing women also limit adequate sunlight exposure.¹⁶ In addition, there are increasing numbers of women breast feeding and a decrease in the number of doctors routinely prescribing vitamin D supplementation for breastfed infants.¹⁷,¹⁸ In the face of increasing reports of rickets, the American Academy of Pediatrics, the Department of Health's committee on Medical Aspects of Food Policy in the UK and the European Society of Pediatric Endocrinology developed vitamin D intake guidelines for healthy infants, children and adolescents to prevent vitamin D deficiency and rickets. Daily supplementation of 200–400 IU of vitamin D is recommended to all infants, particularly to those who are exclusively breastfed. However, there are potential problems with the initiation and maintenance of vitamin D supplementation. These include limited public awareness, the cost of supplementation and limited access to healthcare. In 2003, the Bone Health Committee of the Turkish Association of Pediatric Endocrinology issued a consensus document on vitamin D deficiency and its prevention in Turkey. The Turkish Medical Association facilitated its dissemination to all primary care providers. The consensus document defined two specific goals: (1) attain adequate vitamin D status for the whole population, particularly high‐risk groups such as infants, children, adolescents, pregnant and nursing women; and (2) ensure early diagnosis and adequate treatment of nutritional rickets and osteomalacia. Proposed public health strategies to achieve these goals were: (1) develop a public awareness campaign to establish adequate sunlight exposure; (2) provide all infants with 400 IU/day of vitamin D supplementation starting at birth; (3) educate primary care providers in the diagnosis and treatment of nutritional rickets and osteomalacia; (4) provide vitamin D supplementation to adolescent girls and women at risk, particularly those using traditional clothing (covered dress); (5) advocate for regulation mandating vitamin D enrichment of all dairy products. In 2004, the committee appealed to the Ministry of Health of Turkey to assume a leadership role in realising these strategies. In May 2005, the Ministry of Health initiated a 5‐year project coordinated by the General Directorate of Maternal Child Heath and Family Planning. This project will implement all the proposed strategies. A nationwide campaign has been launched to encourage the entire population, particularly pregnant and nursing women and infants, to have adequate sunlight exposure. A curriculum has been developed to train healthcare workers. The most significant step, however, is that the Ministry of Health will distribute vitamin D supplements to every newborn throughout infancy at no financial cost to families through its network of primary care units and maternal–child health centres. This should undoubtedly improve access to vitamin D supplementation and compliance with its use. We believe this initiative is a major step towards eliminating nutritional rickets in Turkey. It also is a unique opportunity to establish a model for populations in which vitamin D deficiency is a significant child health problem.