Trending Topics pieces (Article Analyses, Evidence Clips and Other Topics) are published in timely response to recent media and journal articles, position statements, clinical guidelines, etc. Since they are based on the most recent evidence/publications, they may not be consistent with PEN evidence in other PEN content areas. As soon as possible, when this occurs, the PEN content will be reviewed and updated as needed.
Vitamin D Update: Supplementation and Pregnancy and Perinatal Outcomes and 25-hyroxy-vitamin D as a Marker for Nutrient Deficiency and Sufficiency
Vitamin D has been a very active area of research in recent decades. Not only have there been numerous research studies published, there have also been numerous systematic reviews published summarizing these studies. Recently, researchers in Alberta, Canada undertook a systematic review of the systematic reviews that investigated the importance of vitamin D in pregnancy for important perinatal and infant outcomes (1).
This systematic review of systematic reviews found 42 systematic reviews of 204 primary studies that evaluated either vitamin D supplementation in pregnant women and/or examined the association between serum vitamin D levels for at least one predefined perinatal outcome (1). The researchers evaluated the systematic reviews for research quality using the AMSTAR tool and only analyzed data from the 13 systematic reviews with high AMSTAR scores.
The systematic reviews of randomized controlled trials (RCTs) with the highest quality of evidence showed no benefits from vitamin D supplementation regarding preterm birth, preeclampsia, gestational diabetes, stillbirth, low birth weight or caesarean section (1). A significant difference was found for small-for-gestational age; however, this evidence was low quality for two reasons: 1) the high risks of bias in the included studies without an accompanying sensitivity analysis to examine the low risk of bias studies separately, and 2) imprecision due to the small numbers of small-for-gestational age births in the included studies. Systematic reviews of observational studies showed that women with low 25-hyroxy-vitamin D levels had higher rates of preterm birth, preeclampsia, gestational diabetes and small-for-gestational age.
The findings of this systematic review (1) reinforce the findings of a 2017 systematic review (2) that found that the superior health of people with higher vitamin D serum levels suggested by the frequent associations observed in observational studies are not seen in randomized trials of vitamin D supplementation. Additionally, there is increasing evidence that serum 25-hyroxy-vitamin D, the vitamin D status marker, is a negative acute phase reactant, which decreases in response to other variables (2-9). Specifically, researchers have observed that 25-hyroxy-vitamin D decreases in response to inflammation (3), acute illness (4), ill health (2), critical illness (5), surgery (6,7) and when C-reactive protein increases (3,7-9). If a marker changes in response to other variables, then it has limited use as a nutritional adequacy marker.
- Bialy L, Fenton T, Shulhan-Kilroy J, Johnson DW, McNeil DA, Hartling L. Vitamin D supplementation to improve pregnancy and perinatal outcomes: an overview of 42 systematic reviews. BMJ Open. 2020 Jan 20;10(1):e032626. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/31964667
- Autier P, Mullie P, Macacu A, Dragomir M, Boniol M, Coppens K, et al. Effect of vitamin D supplementation on non-skeletal disorders: a systematic review of meta-analyses and randomised trials. Lancet Diabetes Endocrinol. 2017 Dec;5(12):986-1004. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29102433
- McMillan DC, Maguire D, Talwar D. Relationship between nutritional status and the systemic inflammatory response: micronutrients. Proc Nutr Soc. 2019 Feb;78(1):56-67. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30220267
- Kostoglou-Athanassiou I, Pantazi E, Kontogiannis S, Kousouris D, Mavropoulos I, Athanassiou P. Vitamin D in acutely ill patients. J Int Med Res. 2018 Oct;46(10):4246-57. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30157690
- Czarnik T, Czarnik A, Gawda R, Gawor M, Piwoda M, Marszalski M, et al. Vitamin D kinetics in the acute phase of critical illness: a prospective observational study. J Crit Care. 2018 Feb;43:294-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/28968524
- Binkley N, Coursin D, Krueger D, Iglar P, Heiner J, Illgen R, et al. Surgery alters parameters of vitamin D status and other laboratory results. Osteoporos Int. 2017 Mar;28(3):1013-20. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27826645
- Waldron JL, Ashby HL, Cornes MP, Bechervaise J, Razavi C, Thomas OL, et al. Vitamin D: a negative acute phase reactant. J Clin Pathol. 2013 Jul;66(7):620-2. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=23454726
- Kruit A, Zanen P. The association between vitamin D and C-reactive protein levels in patients with inflammatory and non-inflammatory diseases. Clin Biochem. 2016 May;49(7-8):534-7. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=26778547
- Silva MC, Furlanetto TW. Does serum 25-hydroxyvitamin D decrease during acute-phase response? A systematic review. Nutr Res. 2015 Feb;35(2):91-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=25631715
Arsenic in Rice Products for Children
A recent CBC Marketplace program reported on the testing of the levels of arsenic in rice cereals and snacks for infants and children. For an in-depth examination and analysis of the evidence on the topic of arsenic in the diets of infants and children, see the 2018 PEN Trending Topic: Do New Parents or Parent-to-be Need to be Concerned About Dietary Arsenic Exposure?. For further information on rice and arsenic, see: PEN's Food Safety - Arsenic in Rice Background.
The Bottom Line
Limit or avoid giving infants and young children cereals made from brown rice flour and products with brown rice syrup, since they have more arsenic. Some rice is okay for young children, but it is best to give infants and children a variety of grains and use infant rice cereals and rice-based products, such as wafers and crackers, in moderation.
Malnutrition in Infants Fed Plant-based Beverages
Cases (n=34) of protein-energy malnutrition have been described in France among infants who were fed plant-based beverages/drinks (age at diagnosis 8.8 + 3.8 months) (1). These cases were discovered when pediatricians were asked to see these children because of fatigue or a growth deficit. One of these infants died, one-third had malnutrition, 29% (10/34) had a seizure, one suffered from respiratory distress and one had a bone fracture. Among the children who had blood work done, 60% (12/20) had anemia, 55% (11/20) had hypoalbuminemia, and 40% (8/20) had hyponatremia. The children were all fed plant-based drinks, mostly almond, chestnut and rice drinks. Previous reports involved smaller numbers of children (2).
The infants’ health improved after resuming a normal infant diet (which was not described), although one-third of the parents were not happy about the change in diet (1). The parents stated that their main influencers to give the plant-based drinks to their infants were the media (44%) and “alternative medical professionals” (38%). The researchers attributed the malnutrition to the low protein and energy contents of these drinks.
Although it is not possible to state with certainty that the malnutrition was caused by the plant-based drinks, the fact that 30 children (who were assessed) overcame their illnesses when placed on a normal infant diet suggests that this was the case. These cases may represent the health halo, a belief that these drinks are healthier than other choices.
For information on the recommendations for the use of plant-based beverages in infants, see PEN® Practice Question: What are the recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants?
- Lemale J, Salaun JF, Assathiany R, Garcette K, Peretti N, Tounian P. Replacing breastmilk or infant formula with a nondairy drink in infants exposes them to severe nutritional complications. Acta Paediatr. 2018 Jun 20. doi: 10.1111/apa.14437. [Epub ahead of print]. Citation available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=29923219.
- Dietitians of Canada. Trending Topics: Plant-based Beverages – Are They Really Healthier for Young Children? In: Practice Based Evidence in PEN® [PEN]. 2017 Aug 29. Available from: http://www.pennutrition.com/resourcestools.aspx?trcatid=496&trid=26285&sr=plant-based#. Access only by subscription.
Introduction of Allergenic Food to Infants, Especially Peanuts: Interim Guidelines for Canadian Dietitians
This interim DC communication provides DC members with information on the scientific evidence regarding the introduction of peanuts to infants and how the current dietetic practice recommendations agree and differ from NIAID recommendations published in January 2017. In brief, the key differences between these new NIAID guidelines and current Canadian Nutrition for Healthy Term Infant (NHTI) recommendations are in the different definitions of “at risk” infants, the strength of wording for introducing peanut containing food early, and the recommendation to undergo physician supervised testing/feeding before introduction for a small subset of very high-risk infants . Refer to the full document for more information. See also the PEN Evidence Clip : Food Allergy Prevention in Infants.