COVID-19 Complications in Children and Vitamin D: A Need for Urgent Awareness-Hong Kong February 2022

Reading of the unfortunate and rapid deaths of the young children who had tested positive/preliminary positive for Covid-19 in Hong Kong over the past week reminded me of the Vitamin D situation which I came across when doing my research on Eczema in 2018. By 2022 it appears levels may have dropped even further.

Vitamin D is not only important for the bone and skin, it’s presence in the body at normal levels (30ng/ml or 75nmol/L) supports the healthy maturation of the immune system in babies and young children. Vitamin D enhances cellular immunity in young children, importantly the regulation of T cells.⁶ Healthy levels of Vitamin D are known to support protection from viral infection and bronchial inflammation.⁷

This article is a compilation of the most recent research and concerns about Vitamin D levels and response to COVID-19 in young children. I have written it to raise awareness about the need for healthy Vitamin D levels in children, a factor that can be easily modified with the correct guidance. If you know of people with young children make them aware of the facts below. Show it to the health professional looking after your child. Please remember Vitamin D in appropriate amounts is best, excessive dosing can cause problems. Over the counter Vitamin D supplements are affordable and easily available yet may not support severe deficiency quickly. Best approach would be to measure and then supplement under professional guidance as the need is urgent.

In Hong Kong recent data from 2021 shows that the Vitamin D levels have reduced even further in the child population since 2019.  Researchers at HKU found evidence of a progressive decline in Children’s serum 25(OH)D levels (Vitamin D3) since social distancing and home confinement first began during the COVID-19 pandemic. By Nov 2021 Vitamin D Levels were found to be declining at the rate of 6.32nmol/L per month and this is from an already lower baseline. Pregnant and breast feeding mothers would also have a lower Vitamin D levels due to reduced sun exposure unless supplemented.¹

Immuno-suppressant therapy and steroid medication taken orally is also known to reduce Vitamin D3 uptake. Children with tendency to Eczema are known to have lower Vitamin D3 levels.⁸

         In the UK population includes a high percentage of South-east Asian and Black ethnicities, known to have higher incidence of Vitamin D insufficiency and deficiency. Rickets (a bone disease in children due to Vitamin D deficiency) is still a reality in these populations therefore there is much more awareness in the NHS and society in general about Vitamin D supplementation during pregnancy, breast feeding and early childhood. I’m speculating that this might be similar in Singapore due to the local Singaporean population of Indian descent. There is much need for improvement in level of awareness in Hong Kong about healthy Vitamin D levels in young children and including this routinely in measurement during health check-ups and for supplementation.

      Unfortunately at present routine Vitamin D supplementation is not a part of the public paediatric healthcare system in Hong Kong.

Let me share the evidence that has fanned my concerns further:

           A cursory look over recently published studies from Israel, Turkey and Italy all confirm significant association of lower levels of Vitamin D with catching COVID-19 and complications from COVID-19 infections.

Studies in Turkey that looked at children who caught COVID-19 versus those that did not, found more cases of Vitamin D deficiency in the infected Children.^3-5

Vitamin D insufficiency was present in 93.1% of the patients with severe-critical COVID-19. ‘The Fever Symptoms’ were higher in patients with insufficient and deficient Vitamin D levels.⁵ Significantly lower Vitamin D levels were found in patients with severe-critical COVID-19 compared with moderate COVID-19.⁴

Research from Italy confirmed Vitamin D deficiency was associated with a 3-fold higher risk of lower arterial oxygen saturation (arterial pO2 <60 mmHg), breathlessness, increased CRP (a measure of inflammation), severe systemic inflammatory response (multi-organs swelling) and respiratory failure in COVID-19 patients.²

Their research shows that healthier Vitamin D levels in children can reduce the chances of getting COVID-19 and reduce how sick our child would get if infected. If we can rally together and create further awareness of improving the nutritional profile of our children especially the very young ones, it may make a required difference in their ability to respond to infections. Though it might be just one of the factors at least it is one that is easily modifiable.

Please note this article is meant to create awareness of the situation and should not be mistaken for medical advice.

Dr. Sonal Hattangdi-Haridas

MSc Nutritional Medicine University of Surrey (U.K)

B.H.M.S (Mum) H.M.D (Lon), ANutr (UK)

1. Wong, R.S.; Tung, K.T.S.; So, H.-K.; Wong, W.H.S.; Wong, S.Y.; Tsang, H.W.; Tung, J.Y.L.; Chua, G.T.; Ho, M.H.K.; Wong, I.C.K.; Ip, P. Impact of COVID-19 Pandemic on Serum Vitamin D Level among Infants and Toddlers: An Interrupted Time Series Analysis and before-and-after Comparison. Nutrients 2021, 13, 1270. https://doi.org/10.3390/nu13041270
2. Adami G, Giollo A, Fassio A, Benini C, Bertoldo E, Bertoldo F, Orsolini G, Idolazzi L, Viapiana O, Giannini S, Passeri G, Tacconelli E, Micheletto C, Gatti D, Rossini M. Vitamin D and disease severity in coronavirus disease 19 (COVID-19). Reumatismo. 2021 Jan 18;72(4):189-196. doi: 10.4081/reumatismo.2020.1333. PMID: 33677945.
3. Alpcan A, Tursun S, Kandur Y. Vitamin D levels in children with COVID-19: a report from Turkey. Epidemiol Infect. 2021 Aug 10;149:e180. doi: 10.1017/S0950268821001825. PMID: 34375576; PMCID: PMC8365038.
4. Karahan S, Katkat F. Impact of Serum 25(OH) Vitamin D Level on Mortality in Patients with COVID-19 in Turkey. J Nutr Health Aging. 2021;25(2):189-196. doi: 10.1007/s12603-020-1479-0. PMID: 33491033; PMCID: PMC7533663.
5. Yılmaz K, Şen V. Is vitamin D deficiency a risk factor for COVID-19 in children? Pediatr Pulmonol. 2020 Dec;55(12):3595-3601. doi: 10.1002/ppul.25106. Epub 2020 Oct 13. PMID: 33017102; PMCID: PMC7675606.
6. Looman KIM, Jansen MAE, Voortman T, van den Heuvel D, Jaddoe VWV, Franco OH, van Zelm MC, Moll HA. The role of vitamin D on circulating memory T cells in children: The Generation R study. Pediatr Allergy Immunol. 2017 Sep;28(6):579-587. doi: 10.1111/pai.12754. Epub 2017 Aug 7. PMID: 28686349.
7. Mailhot G, White JH. Vitamin D and Immunity in Infants and Children. Nutrients. 2020 Apr 27;12(5):1233. doi: 10.3390/nu12051233. PMID: 32349265; PMCID: PMC7282029.
8. Hattangdi-Haridas SR, Lanham-New SA, Wong WHS, Ho MHK, Darling AL. Vitamin D Deficiency and Effects of Vitamin D Supplementation on Disease Severity in Patients with Atopic Dermatitis: A Systematic Review and Meta-Analysis in Adults and Children. Nutrients. 2019 Aug 9;11(8):1854. doi: 10.3390/nu11081854. PMID: 31405041; PMCID: PMC6722944.

維生素D和兒童的COVID-19並發症：迫切需要提高對維生素D重要性的認識 

香港 2022 年 2 月

過去一周在香港檢測出 Covid-19 呈陽性/初步呈陽性的幼兒不幸和迅速死亡的情況，讓我想起了我在 2018 年研究濕疹時遇到有關維生素D的情況。 到 2022 年，似乎維生素D水平可能會進一步下降。

維生素 D 不僅對骨骼和皮膚很重要，它以正常水平（30ng/ml 或 75nmol/L）存在於體內，支持嬰兒和幼兒免疫系統的健康成熟。 維生素 D 可增強幼兒的細胞免疫，尤其是 T 細胞的調節。6 已知健康水平的維生素 D 有助於防止病毒感染和支氣管炎症。 7

 本文彙編了有關幼兒維生素 D 水平和對 COVID-19 反應的最新研究和關注。 我寫這篇文章是為了提高人們對兒童健康維生素 D 水平需求的認識。 請家長們了解以下情況。 告訴您孩子的醫生。 請記住適量的維生素 D 是最好的，過量服用會導致問題。 非處方維生素 D 補充劑價格實惠且容易獲得，但可能無法快速支持嚴重缺乏症。最好的方法是測量，然後在專業指導下根據需要進行補充。

 在香港，2021 年的最新數據顯示，自 2019 年以來，兒童人群的維生素 D 水平進一步下降。香港大學的研究人員發現，由於社交距離和社交距離的增加，兒童血清 25(OH)D 水平（維生素 D3）逐漸下降。 居家隔離最早是在 COVID-19 大流行期間開始的。 到 2021 年 11 月，發現維生素 D 水平以每月 6.32nmol/L 的速度下降，這是從已經較低的基線開始的。 除非補充，否則孕婦和哺乳期母親的維生素 D 水平也會由於減少日曬而降低。 1

已知口服免疫抑製劑治療和類固醇藥物可減少維生素 D3 的攝取，所以有濕疹傾向的兒童維生素 D3 水平會較低。 8

在英國，東南亞和黑人的比例很高，眾所周知他們的維生素 D 不足和缺乏症的發病率較高。 佝僂病（一種由於維生素 D 缺乏而導致的兒童骨病）在這些人群中仍然存在。因此，英國NHS 和整個社會對在懷孕、母乳喂養和兒童早期補充維生素 D 有更多的認識。新加坡當地的印度裔人口比例和英國相似，所以新加坡可能有類似情況。 對於香港，大衆必須盡快提高對幼兒健康維生素 D 水平的認識，並將維生素D包括在健康常規檢查。

不幸的是，目前常規的維生素 D 補充劑並不是香港公共兒科醫療系統的一部分。

讓我進一步分享激起我擔憂的研究報告：

我對以色列、土耳其和意大利最近發表的研究進行粗略觀察，都證實了較低水平的維生素 D 與感染 COVID-19 和 COVID-19 感染並發症之間存在顯著關聯。

土耳其的研究對感染 COVID-19 的兒童與未感染 COVID-19 的兒童進行了研究，發現感染兒童中的維生素 D 缺乏症病例更多。3-5

百分之93.1的COVID-19 重症患者存著維生素 D 不足的情況。他們都有更多發燒症狀。5 

與中度 COVID-19患者相比， COVID-19 重症患者的維生素 D 水平顯著降低。4

意大利的研究證實，維生素 D 缺乏與動脈血氧飽和度降低（動脈血氧飽和度 <60 mmHg）、呼吸困難、CRP（炎症指標）升高、嚴重全身炎症反應（多器官腫脹）和呼吸衰竭的風險增加有關。

他們的研究表明，兒童健康的維生素 D 水平可以減少COVID-19 的感染機會，並減少他們被感染後的病情。 

如果我們能夠團結起來，進一步提高兒童尤其是幼兒營養狀況的意識，這會對他們應對感染的能力產生重要的影響。 雖然它可能只是眾多因素之一，但它是影響兒童健康的一個很重要的因素。

請注意，本文旨在提高對情況的認識，不應將其誤認為是醫療建議。