Sunshine is the main source of Vitamin D, but our long, dull winter months and 'slip, slap, slop' approach to sun protection in the summer means more and more children aren't enjoying the amount of sunshine needed to produce adequate levels of this essential vitamin. Diets lacking in Vitamin D are adding to the problem, resulting in a steady increase in the cases of Vitamin D deficiency. It's time for parents and early years practitioners to be more aware of the dangers, say the experts.
WHAT IS VITAMIN D?
Vitamin D is actually a steroid hormone which is made in the body via a series of reactions after skin is exposed to sunlight. The vitamin is also found in a few foods. Cod liver oil is a particularly rich source and was once given routinely to people in northern European countries during winter.
Vitamin D is essential for the growth and maintenance of strong and healthy teeth and bones because it helps calcium and phosphorus in our diet to be absorbed from the gut. The vitamin is also needed for the growth of cells and tissues as well as proper functioning of the body's immune system.
WHO IS AT RISK OF VITAMIN D DEFICIENCY?
Most people should get all the Vitamin D they need from a healthy balanced diet and from some summer sun, says NHS Choices, the online 'front door' to the NHS. A person does not need Vitamin D every day because it is a fat-soluble vitamin that the body will store. However, there are groups of the population at risk of not getting enough Vitamin D:
- babies and young children under the age of five, pregnant and breastfeeding women - especially teenagers and young women, because they need extra Vitamin D to promote growth
- older people aged 65 years and over who have thinner skin and so are unable to produce as much Vitamin D
- people who have low or no exposure to the sun, for example, those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods
- people who have darker skin, for example, those of African, African-Caribbean and South Asian origin because their bodies are not able to make as much Vitamin D.
WHAT ARE THE SYMPTOMS OF VITAMIN D DEFICIENCY?
Many people have negligible or vague symptoms such as tiredness or general aches, so the problem is often missed. Diagnosis is more easily reached in severe deficiencies where bones have softened because of a lack of calcium absorption.
The Department of Health says, 'In severe cases, deficiency can lead to bone problems such as rickets in children and in adults weakness, aches and pains due to osteomalacia (the adult form of rickets.)
In extreme cases in infants and children, rickets can cause children to suffer fractured bones, as in the case of four-month-old Jayden Wray whose parents were accused of abusing him, but it transpired that the fractures he sustained were caused by rickets.
The health advice website patient.co.uk says in severe cases:
- Babies can get muscle spasms (cramps), seizures and breathing difficulties. These problems are related to consequent low levels of calcium.
- Children may have soft skull or leg bones. Their legs may look curved (bow-legged) and they may suffer curvature of the spine. They may also complain of bone pains, often in the legs, and muscle pains or muscle weakness. This is the condition known as rickets.
- Children may have poor growth and be reluctant to start walking. Their height is usually affected more than their weight.
- Children 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 are more prone to infections. Respiratory symptoms can occur. In severe cases breathing can be affected because of weak chest muscles and a soft ribcage.
WHAT IS THE EXTENT OF VITAMIN D DEFICIENCY IN THE UK?
Up to a quarter of people in the UK have low levels of Vitamin D. The chief medical officers of England, Scotland, Wales and Northern Ireland wrote a joint letter earlier this year to all GPs, practice nurses, health visitors and community pharmacists to raise awareness of the risk of Vitamin D deficiency in certain groups: 'The National Diet and Nutrition Survey demonstrates that up to a quarter of people in the UK have low levels of Vitamin D in their blood, which means they are at risk of the clinical consequences of Vitamin D deficiency.'
While they said there is no 'clear data' on the uptake of the current advice of taking Vitamin D supplements by at-risk groups, it says information from the 2005 Infant Feeding Survey suggests that the majority of women do not take Vitamin D supplements during pregnancy.
IS VITAMIN D DEFICIENCY INCREASING IN THE UK POPULATION?
Yes, because we spend much less time outdoors than previous generations and, when we do, we are more careful about using sunblock. We do not routinely take supplements or cod liver oil.
WHAT ARE THE MAIN SOURCES OF VITAMIN D FOR YOUNG CHILDREN?
More than 90 per cent of our Vitamin D comes from ultraviolet B rays hitting the skin and converting a type of cholesterol into Vitamin D.
This is the aspect about Vitamin D that causes confusion and controversy especially in the early years sector. Practitioners worried about the risks of skin cancers do not allow young children to play outside without putting on sunblock, which prevents the synthesis of Vitamin D.
Different specialist groups and campaigners offer conflicting advice and currently the National Institute for Clinical Excellence (NICE) is conducting reviews for the Department of Health on implementing Vitamin D guidance and sunlight exposure: benefits and safety.
The guidance here is based on advice from NHS Scotland, Cancer Research UK and the Cancer Council of Australia.
The amount of time you need in the sun to make enough Vitamin D varies from person to person depending on their skin type, the season of the year, time of day and the ferocity of the sun.
Cancer Research UK offers advice about Vitamin D through its Sun Smart Campaign, which points out that in the UK the UVB rays from winter sun (from October to March) are not strong enough for the production of Vitamin D.
The concerns are around summer sun - April to September. Even then, says Sun Smart, 'the amount of time in the sun that you need to make enough Vitamin D is typically short and less than the amount that makes skin redden or burn.
'It should be enough to regularly go outside for a matter of minutes around the middle of the day without sunscreen. When it comes to sun exposure, little and often is best, and the more skin that is exposed, the greater the chance of making enough Vitamin D before burning.'
A key factor is the UV level of the sun. The advice from the Australian Cancer Council Sun Smart campaign is that most people need sun protection when the UV index is 3 or higher. Weather forecasts now routinely give the UV index.
For people living in Scotland an advice leaflet, 'Vitamin D and You', published by NHS Scotland, advises: 'In Scotland, we only get enough sunlight of the right wavelength (UVB) for our bodies to make Vitamin D roughly half the year (April to September), mostly between 11am and 3pm. Ten to 15 minutes of unprotected Scottish sun exposure is safe.'
However, it says this still might not be long enough for people with darker skin to make adequate levels of Vitamin D but they should not stay out longer unprotected in the sun because of the risk of skin cancer. Nor should they resort to sunbeds.
For these people the advice is to take Vitamin D supplements as the leaflet says, 'It is difficult to get enough Vitamin D from food alone.'
Vitamin D is found naturally in small amounts in:
- oily fish - both fresh and tinned - such as salmon, mackerel, trout, kippers and sardines
- eggs and meat.
Some foods have Vitamin D added to them, including:
- all margarines with a fat content above a certain level (manufacturers in the UK are required by law to add it to these)
- some breakfast cereals, soya and dairy products, powdered milks and low-fat spreads (amounts vary and are often quite small).
WHAT VITAMIN D SUPPLEMENTS SHOULD YOUNG CHILDREN TAKE?
The UK's chief medical officers advise that:
- All pregnant and breast-feeding women should take a daily supplement containing 10 micrograms of Vitamin D to ensure the mother's requirements for Vitamin D are met and to build adequate foetal stores for early infancy.
- All infants and young children aged six months to five years should take a daily supplement containing Vitamin D in the form of drops to help them meet the requirement set for this age group of 7-8.5 micrograms per day.
- Babies on infant formula will not need vitamin drops until they are on less than 500ml of formula milk a day because formula milk products are fortified with Vitamin D.
- Breast-fed babies may need vitamin drops from four weeks old if their mother has not been taking Vitamin D supplement throughout the pregnancy.
Women and children from families who are eligible for the Government's Healthy Start Scheme can get free vitamin supplements including Vitamin D, in the form of tablets for women and drops for children.
The Chief Medical Officers say, 'Uptake of the Healthy Start vitamins among families qualifying for the scheme is currently low.'
CAN TAKING EXCESSIVE AMOUNTS OF VITAMIN D CAUSE PROBLEMS?
Yes. Great Ormond Street Hospital advises, 'Taking high doses for long periods of time can cause side-effects such as bone weakness, chronic thirst and depression.'
WHAT CAN EARLY YEARS SETTINGS DO TO ENSURE CHILDREN ARE GETTING THE REQUIRED LEVELS?
- Advise parents about the importance of their child having adequate levels of Vitamin D.
- Encourage pregnant and breast feeding mothers to take Vitamin D supplements and to apply for Healthy Start, if they qualify - see criteria below.
- Discuss with parents their routines with their children outside nursery to see if it is feasible for the child to have a few minutes outside in the sun at weekends without sunblock.
- Discuss with parents allowing children outdoors for a few minutes without sunblock. For example, take the children outdoors to sit in the shade for story or circle time letting them catch some sun on their way to and from the shaded area.
- Discuss with staff the practicalities of changing the routine for applying sunblock. For example, instead of applying it at the garden entrance, designate the shaded area as the place where sunblock is applied so the children are in the sun for a few minutes en route.
- Discuss with staff the practicalities of starting the nursery day outdoors in the summer so the children can have some time in the sun before it becomes too fierce.
- Monitor sun exposure very carefully. Do not allow children's skin to become red or burn.
- During the autumn and winter incorporate foods containing Vitamin D such as oily fish into the menu regularly, for example, by serving salmon fishcakes.
WHO IS ELIGIBLE FOR VITAMIN D SUPPLEMENTS?
Women qualify for Healthy Start from the tenth week of pregnancy or if they have a child under four years old, and if she or her family receive:
- Income Support, or
- Income-based Jobseeker's Allowance, or
- Income-related Employment and Support Allowance, or
- Child Tax Credit (but not Working Tax Credit unless the family is receiving Working Tax Credit run-on only) and has an annual family income of £16,190 or less.
Women under 18 and pregnant also qualify, even if they do not get any of the above benefits or tax credits.
CASE STUDY: WILLOW COTTAGE NURSERIES
As a food scientist and former home economics teacher Valerie Grady, founding director of Willow Cottage Nurseries in Oxfordshire, is acutely aware of the dangers of Vitamin D deficiency and uses a three-pronged strategy to ensure that children attending absorb enough of this essential vitamin: high-quality food, lots of outdoor 'sunshine' play, and parent and staff education.
Some 130 children attend Willow Cottage Nurseries in Oxfordshire and their well-being is a top priority. 'For me, the health and well-being of children is as important as their learning,' says Mrs Grady.
From the outset, she has strived to provide top-quality food in her nurseries.
A Nursery World food awards finalist three years running, Willow Cottage last year received the prestigious national Leading Aspect Award, entitled 'Nursery Food Matters - An Embedded Educational Philosophy'.
Oily fish, eggs, milky puddings and high-quality fats feature regularly on the nurseries' menus to help ensure that children receive their daily requirements of Vitamin D.
'I think much of the problem based around our current Vitamin D deficiency is the nation's obsession with low-fat diets,' says Mrs Grady. 'Vitamin D is one of the fat-soluble vitamins which means it is present in fats and we need some fat or Vitamin D supplement in our diet just to compensate for the lack of sunshine in the UK!
'Vitamin D is also important as it helps regulate the amount of calcium and phosphate in the body; calcium and phosphate are needed to help keep bones and teeth healthy.
At Willow Cottage we don't scrimp on the use of good-quality fats in their diet.
We obviously consider portion size and use our own low sugar recipes at all times.'
Outdoors
With sunshine being the major source of Vitamin D, children at Willow Cottage Nurseries are also given every opportunity to play outdoors, and sometimes the babies even have their naps in the garden.
On warmer spring and autumn days, staff ensure that the children aren't overly wrapped up so that they can benefit from any sunshine available. In high season, though, the nursery continues to ensure that the children wear hats and high-factor sun cream provided by their parents for their child's particular skin type.
'As part of our staff and parent education, we encourage parents not to smother their children in high-factor barrier cream all the time. We are all so worried about skin cancer and slap on factor 50 sun cream and put on hats as soon as the sun comes out,' says Mrs Grady.
The messages about the importance of sunshine and warnings about always wearing sun cream and hats are part of a wider programme of health and nutrition awareness that Willow Cottage Nurseries pass on to to their parents and followers via their newsletters and news articles on their website. To make learning about food fun, they have created a healthy food hero called Mr Willow, a teddy bear chef.
'I'm very aware of the importance of staff and parent education and put on our website articles that I think will benefit the children and their families,' says Mrs Grady. And messages are getting through. 'The news article on rickets was the most visited page on our website in 2012.'
FURTHER INFORMATION
- Letter from the UK Chief Medical Officers raising awareness of the risks of Vitamin D deficiency www.dh.gov.uk/health/2012/02/Vitamin-d/
- Information about eligibility for free vitamin supplements, www.healthystart.nhs.uk
- Great Ormond Street Hospital advice sheet www.gosh.nhs.uk/medical-conditions/ search-for-medical-conditions/Vitamin-d-deficiency/
- Vitamin D and You' and 'Vitamin D ... An Essential Nutrient' leaflets for general public and healthcare professionals respectively, from NHS Scotland, www.scotland.gov.uk/Topics/Health/Healthy-Living/ Food-Health/VitaminD
- Information from patient.co.uk, www.patient.co.uk/health/ Vitamin-d-deficiency-including-osteomalacia-and-rickets
- Cancer Research UK Sun Smart campaign including UV chart and advice on skin types, www.sunsmart.org.uk/advice-and-prevention/uv-index/uv-index
- Cancer Council Australia advice on sun exposure and Vitamin D www.cancer.org.au/cancer-control-policy/position-statements/ sun-smart/.
