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Am Fam Physician. 2003 Jun 1;67(11):2417-2420.

AAP Guidelines on Rickets and Vitamin D Supplementation

All healthy infants within the first two months of life, children, and adolescents should receive vitamin D supplementation to prevent rickets and vitamin D deficiency, according to a new clinical report from the American Academy of Pediatrics (AAP). “Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake”appears in the April 2003 issue of Pediatrics and is available online at www.aap.org.

A supplement of 200 IU per day of vitamin D is suggested for the following:

  • All breastfed infants unless they are weaned to at least 500 mL per day of vitamin D-fortified formula or milk. Vitamin D supplementation should begin within the first two months of life.

  • All nonbreastfed infants who are ingesting less than 500 mL per day of vitamin D-fortified formula or milk.

  • Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.

The AAP report affirms guidelines from the National Academy of Sciences. Public health officials are becoming increasingly concerned about continued reports of infants who have been diagnosed with rickets, the bone-softening disease caused by insufficient exposure to sunlight and inadequate vitamin D intake. Unfortunately, an infant may be vitamin D-deficient long before being diagnosed with rickets because the symptoms are not obvious.

Sunlight is a major source of vitamin D, but sunlight exposure is difficult to measure. Factors such as skin exposure and the amount of pigment in an infant's skin affect how much vitamin D the body produces from sunlight. Children should wear sun-screen when they are in the sun. Sunscreen, however, prevents the skin from making vitamin D.

Exclusively breastfed infants are at increased risk of vitamin D deficiency and rickets. This is because the amount of vitamin D contained in human milk is not sufficient to prevent rickets.

Most bottle-fed infants should be able to get their daily requirements of vitamin D from formula, because all infant formulas sold in the United States contain a sufficient amount of vitamin D.

AHRQ Report on Neonatal Jaundice

More research is needed to determine whether the use of standardized data charts used to plot results from bilirubin measurements based on hours since birth can help physicians do a better job of predicting potentially serious cases of jaundice in newborns, according to a new evidence report released by the Agency for Healthcare Research and Quality (AHRQ). “Management of Neonatal Hyperbilirubinemia” is available online at www.ahrq.gov/clinic/tp/neonataltp.htm or by calling the AHRQ at 800-358-9295.

Although the report did not directly address the appropriateness of universal screening for hyperbilirubin-emia, it did examine strategies for identifying the condition. High bilirubin levels are a major cause for readmission of newborns to the hospital in the first two weeks of life.

Jaundice affects more than one half of the infants born in the United States each year but generally resolves without any clinical intervention. However, in rare instances, some infants with a bilirubin level greater than 20 mg per dL (342 μmol per L) could develop kernicterus. The current practice for diagnosing and treating significant hyperbiliru-binemia begins with a visual assessment of the infant for jaundice. If significant hyperbilirubinemia is suspected, a blood test is performed to determine the level of bilirubin. Phototherapy (light therapy) is then given to infants with high bilirubin levels. Six to 10 healthy, term or near-term infants with a bilirubin greater than 15 mg per dL (256.5 μmol per L) have to be treated with photother-apy to prevent one infant's bilirubin level from rising above 20 mg per dL.

Researchers reviewed the literature to determine whether measurements by noninvasive instruments are reliable in identifying infants who need blood tests to confirm high bilirubin levels. They found that measurements by several noninvasive devices traditionally used to examine the pigment of an infant's skin correlated well with bilirubin levels directly measured from blood. They concluded that these devices could serve as reliable screening tools to determine which infants should have blood tests performed and, if necessary, be treated with phototherapy. This could lead to earlier detection of potentially serious cases of hyperbilirubinemia and may decrease the need for invasive blood tests in infants found to be at lower risk. Additional research is needed to validate newer noninvasive measurement devices and to address issues of cost-effectiveness and reproducibility in clinical practice.

AAP Statement on Radiation Disasters and Children

The American Academy of Pediatrics (AAP) has released recommendations to help prevent and minimize damage from harmful levels of radiation. “Radiation Disasters and Children” is available online at www.aap.org/policy/radiation.html.

Households within 10 miles of a nuclear power plant should keep potassium iodide (KI) on hand to protect the thyroid in the event of an accidental or intentional release of radioactive iodines (“radioiodines”) into the environment. Schools and child-care facilities within the same radius should have immediate access to KI. It may be prudent to consider stockpiling KI within a larger radius because of more distant windborne fallout. Available KI products include Thyro-Block (MedPointe Inc., Somerset, N.J.) and IOSAT (Anbex Inc., Palm Harbor, Fla.).

Children are more vulnerable to the harmful effects of radiation disasters than the general population because their bodies absorb and metabolize substances differently and because they are more likely to develop certain cancers from such exposure. They also are closer to the ground, where radioactive fallout settles. In addition to physical harm, children may suffer from loss of parents, separation from their homes, and post-traumatic stress.

Appropriate response to any radiation emergency would depend on the source of the radiation, the level of exposure, the population density of the affected area, and other factors.

In situations involving release of radioiodines into the environment, KI is an effective, preventive treatment. KI works to block the thyroid's absorption of harmful radiation, preventing thyroid cancer, which is one of the most common harmful effects of radiation disasters. Explosion of nuclear weapons and accidents or sabotage at nuclear power plants are the most likely situations in which radioiodines would be released into the environment.

If administered shortly before exposure to radioiodines, KI can be 100 percent effective in preventing radiation-induced thyroid effects, including thyroid cancer. The need to administer KI just before or immediately after a radioiodine release is the reason that it should be kept in homes, schools, and day care centers. The efficacy of KI diminishes if administered later, from 100 percent at the time of the radiation exposure to 80 percent at two hours, 40 percent at eight hours, and 7 percent at 24 hours afterward. KI is not effective in preventing other long-term radiation effects, such as leukemia and breast cancer. KI will not prevent acute radiation effects such as nausea, vomiting, diarrhea, bleeding, and hair loss.

The AAP policy statement includes information on where to purchase KI and advice on administering it to children. There are special considerations for giving KI to newborns, pregnant and breastfeeding mothers, and older adults. The AAP calls on the U.S. Food and Drug Administration to facilitate development of a pediatric preparation of KI. Parents should know the risks and benefits of this medication and should not use it before consulting with health authorities.

Radioiodines are secreted in breast milk and pose particular risks to infants. Breastfeeding mothers should be cautioned to temporarily suspend breastfeeding after exposure to radiation, unless no other alternative exists. This is a short-term measure until public health authorities declare that it is safe to go back to breastfeeding.

Certain radiation disasters, such as explosion of “dirty bombs” containing radioactive materials, or an accident in transporting such materials, could spread radioactive fallout over several blocks and would dissipate quickly. In these instances, radio-iodines are not as likely to be involved, and so there would be no role for KI.

Evacuation to escape contamination would be the best response in many situations, time permitting. Sheltering in a home or other building is an important alternative to evacuation. Masonry structures provide more protection than wood, and basements are preferable to upper floors.

Other recommendations include:

  • Physicians should become familiar with local preparedness and evacuation protocols and work with public health agencies on their development.

  • Physicians should assist local schools and child-care facilities in developing protocols to reunite children with their parents in the event of a disaster.

  • Physicians and government planners should recognize and prioritize the need to respond to the psychosocial consequences of disasters on children, because past radiation disasters have resulted in significantly higher-than-normal rates of psychiatric and behavior problems, particularly in children and mothers of young children.

AHRQ Report on Health Insurance Coverage

During the first half of 2000, more than 60 percent of working Ameri-cans under age 65 had health insurance that they obtained through their primary place of employment, according to a report from the Agency for Healthcare Research and Quality (AHRQ). “Differentials in Employment-Related Health Insurance Coverage—2000” is available at www.meps.ahrq.gov.

Among the findings in the report are the following characteristics of workers and health insurance:

  • Managers and administrators were most likely to be insured (73.3 percent). Farm laborers were least likely to have insurance through their workplace (28.4 percent).

  • Higher hourly earnings were associated with a greater likelihood of workers having health insurance coverage through their primary place of employment. While only one third of workers making less than minimum wage ($5.15 per hour) had insurance coverage from their primary employer, 83.2 percent of workers making more than $21 per hour had insurance.

  • Employees who belonged to a labor union were much more likely to be covered by health insurance through their main job than non-union workers (88 percent of union workers versus 57.6 percent of nonunion workers).

  • Government employees had higher rates of health insurance coverage through their own workplace in 2000 than employees in private industry.

The report does not focus on other sources of insurance coverage obtained through a family member's employment, an individually purchased private policy, public insurance, or another job.

Another recent statistical report on workers, “The Health Insurance Status of U.S. Workers, 2001,” compared job characteristics of uninsured workers between 1996 and 2001. It found that, overall, the relationship between job characteristics and health insurance status of workers has not changed. In general, workers in 2001 were as likely to be uninsured as they were in 1996. That report is available at the same Web site.

FDA Advisory

  • Vinarol. The U.S. Food and Drug Administration (FDA) has issued a MedWatch alert warning consumers not to purchase or consume Vinarol tablets. This product, which is being marketed as a dietary supplement, contains the unlabeled prescription drug ingredient sildenafil, which may pose serious health risks to some users. Vinarol is marketed in tablet form in blister packages of two and seven tablets and is labeled as distributed by Ultra Health Laboratories, Inc. or Bionate International, Inc. The product is being promoted for increasing desire, confidence, and sexual performance and is sold over the counter, as well as via the Internet.

The interaction between nitrates and sildenafil can result in profound and life-threatening lowering of blood pressure. The use of nitrates in any form is an absolute contraindica-tion in sildenafil users. The potential for this product to be taken by unknowing nitrate users is real, because erectile dysfunction is often a concurrent condition in patients with diabetes, hypertension, and hyperlipi-demia, and in smokers and patients with ischemic heart disease.

Consumers who have used this product and have medical concerns are being advised to consult with their physician. Any adverse reactions experienced with the use of this product should be reported to the FDA MedWatch program by calling 800-FDA-1088.



Copyright © 2003 by the American Academy of Family Physicians.
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