Introduction
Vitamin D comprises a group
of fat-soluble micronutrients, responsible for intestinal absorption of calcium (Ca) and phosphate
(P). It
is mainly two types - Cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2).[1]
Synthesis
& Metabolism
Vitamin D has two main forms: D2 (ergocalciferol) and D3
(cholecalciferol). Vitamin D3 is synthesized in skin by exposure to sunlight
(ultraviolet radiation) and obtained in the diet chiefly in fish liver oils and
egg yolks. In some developed countries, milk and other foods are fortified with
vitamin D. Human breast milk is low in vitamin D, containing an average of only
10% of the amount in fortified cow's milk. Requirements for vitamin D increase
with aging. Vitamin D is a prohormone with several active metabolites that act
as hormones. Vitamin D3 is metabolized by the liver to 25(OH)D, which is then
converted by the kidneys to 1,25(OH)2D (1,25-dihydroxycholecalciferol,
calcitriol, or active vitamin D hormone). 25(OH)D, the major
circulating form, has some metabolic activity, but 1,25(OH)2D is the most
metabolically active. Inadequate exposure to sunlight may
cause vitamin D deficiency. Deficiency impairs bone mineralization, causing
rickets in children and osteomalacia in adults and may contribute to osteoporosis.[2]
Biological
activity
The active vitamin D metabolite calcitriol mediates its biological
effects by binding to the vitamin D receptor(VDR), which is principally located in the nuclei of target
cells. The binding of calcitriol to the VDR allows the VDR to act as a transcription
factor that modulates the gene expression of
transport proteins (such as TRPV6 and calbindin),
which are involved in calcium absorption in the intestine. The vitamin D
receptor belongs to the nuclear receptor superfamily
of steroid/thyroid hormone receptors, and VDRs
are expressed by cells in mostorgans,
including the brain, heart, skin, gonads, prostate,
and breast. VDR
activation in the intestine, bone, kidney, and parathyroid gland cells leads to
the maintenance of calcium and phosphorus levels in
the blood (with the assistance of parathyroid hormone and calcitonin) and to the maintenance of bone content.
The VDR is known to be involved in cell proliferation and differentiation. Vitamin D also
affects the immune system, and VDRs are expressed in several white blood cells, including monocytes and activated T and B cells.
Vitamin D increases expression of the tyrosine
hydroxylase gene in adrenal medullary cells. It also is involved in the biosynthesis
of neurotrophic factors, synthesis of nitric oxide synthase, and increased
glutathione levels.
·
Low vitamin D level causes osteomalacia (called rickets when it occurs in children), which is a
softening of the bones. This condition is characterized by bow legs, which can
be caused by calcium or phosphorus deficiency as well as a lack of vitamin D.
·
Vitamin D appears to have effects on immune function. It has been
postulated to play a role in influenza with lack of
vitamin D synthesis during the winter as one explanation for high rates of
influenza infection during the winter.
·
Low levels of vitamin D appear to be a risk factor for tuberculosis, and historically it was used as a treatment.
As of 2011, it is being investigated in controlled clinical trials. Vitamin D
may also play a role in HIV. Although there are tentative data linking low levels of vitamin
D to asthma, there is inconclusive evidence to support a beneficial effect
from supplementation. Accordingly, supplementation is not currently
recommended for treatment or prevention of asthma. Also, preliminary data
is inconclusive for supplemental vitamin D in promotion of human hair growth. [3]
Recommended
Dietary Allowances for Vitamin- D
|
Age
|
Male
|
Female
|
Pregnancy
|
0–12 months*
|
400
IU
(10 mcg)
|
400
IU
(10 mcg)
|
|
1–13 years
|
600
IU
(15 mcg)
|
600
IU
(15 mcg)
|
|
14–18 years
|
600
IU
(15 mcg)
|
600
IU
(15 mcg)
|
600
IU
(15 mcg)
|
19–50 years
|
600
IU
(15 mcg)
|
600
IU
(15 mcg)
|
600
IU
(15 mcg)
|
|
|
|
|
Sources of Vitamin D
The amount of
sunlight needed to synthesize adequate amounts of vitamin D. Vitamin D is made
in the skin under the influence of sunlight & vitamin D is found in cod
liver oil, some fish oils etc.
Vitamin D and Pain
Vitamin D in Chronic Musculoskeletal Pain-
From the perspective
of vitamin D involvement in musculoskeletal pain, the process is presumed to
begin with a lack of circulating calcium (hypocalcemia) due to inadequate
vitamin D, and this sets in motion a cascade of bio-chemical reactions
negatively affecting bone metabolism and health. Even mild hypocalcemia results
in an elevation of parathyroid hormone (PTH) that can diminish bone density
(osteopenia) and/or more severely affect bone architecture (osteoporosis).[4]
The effect relating more closely to
musculoskeletal aches and pains is that increased PTH levels also impair proper
bone mineralization causing a spongy matrix to form under periosteal membranes
covering the skeleton. This gelatin-like matrix can absorb fluid, expand, and
cause outward pressure on periosteal tissues, which generates pain since these
tissues are highly innervated with sensory pain fibers.[5]
This dysfunction of bone metabolism
(osteomalacia) is proposed in the literature as an explanation of why many
patients with vitamin D inadequacies may complain of dull, persistent,
generalized musculoskeletal aches, pains, and
weakness. Therefore, experts recommend that vitamin D deficiency and its
potential for associated osteomalacia should be considered in the differential
diagnosis of all patients with chronic musculoskeletal pain, muscle weakness or
fatigue, fibromyalgia, or chronic fatigue syndrome.[5]
Researchers also reported results of vitamin D
supplementation therapy in response to the symptoms putatively related to the
25(OH)D deficiencies that detected:
• In one large study of 360 female patients with
chronic back pain, vitamin D therapy produced symptomatic improvement in 96% of
all patients and in 100% of those with
the most severe 25(OH)D deficiencies.This study
was of interest because only cases of idiopathic pain probably associated with
osteomalacia were included; patients with pain diagnosed as due to anatomical,
neuropathic, or injury-related causes were excluded.
• In a study of 33 patients with chronic back pain
and/or multiple somatic pain symptoms, researchers reported that vitamin D
therapy led to a resolution of all symptoms in two-thirds of the subjects.65
Partial pain relief was achieved in 18% of patients and 16% were not helped.
• A case-series report noted that aches, pains,
and extreme muscle weakness were resolved by vitamin D supplementation in five
patients who had been confined to wheelchairs. Four of the patients reportedly
became fully mobile upon normalization of their 25(OH)D concentrations.
• An earlier case report of five patients by Gloth
and colleagues noted that vitamin D supplementation produced significant and
rapid improvements of hyperesthesias (nonspecific oversensitivity to physical
stimuli) that had been unresponsive to analgesic therapy. [6]
Vitamin D and bone health
In general, there is no good evidence to support the commonly-held
belief that vitamin D can help prevent osteoporosis. Its general use for prevention of this disease in those without vitamin
D deficiency is thus likely not needed.
For older people with osteoporosis, taking vitamin D with calcium may
help prevent hip fractures, but it also slightly increases the risk of stomach
and kidney problems. Supplementation with higher doses of vitamin D, in those
older than 65 years, may decrease fracture risk. This
appears to apply more to people in institutions than those living
independently.
Vitamin D deficiency causes osteomalacia (called rickets when it occurs in children). Use of vitamin D in
children with normal vitamin D levels does not appear to improve bone density. Beyond that, low serum vitamin D levels have been associated with falls, and low bone mineral
density. Taking
extra vitamin D; however, does not appear to change the risk. [5]
Beyond Musculoskeletal Pain-
It is also found that the role of vitamin D
extends beyond bone and muscle involvement in chronic pain syndromes. For
example, vitamin D receptors have been identified in various brain structures,
the spinal cord, and sensory Ganglia. Accordingly, results of some studies
suggest non-musculoskeletal benefits of vitamin D supplementation. Like-
Inflammation-
Clinical research indicates that vitamin D
supplementation modulates or decreases pro-inflammatory cytokines (eg,
C-reactive protein, interleukin 6 and 12, and tumor necrosis factor-alpha)
while increasing anti-inflammatory cytokines (eg, interleukin-10).
Investigators have further suggested that vitamin
D may help to moderate painful chronic inflammatory autoimmune conditions that
are influenced by excessive cytokine activity, such as inflammatory bowel
disease.[7]
Analgesic effects
The diffuse musculoskeletal pains associated with vitamin
D inadequacy are often poorly responsive to opioid and NSAID analgesics,
sometimes resulting in patients taking large doses of these medications on a
daily basis. Several investigations are suggestive of a potential
analgesic-sparing effect achieved by more adequate vitamin D concentrations in
such patients, and this could have important implications for better pain
management.
The concept was first suggested in an animal model. Vitamin
D-deficient rats exhibited increased pain sensitivity and developed morphine
tolerance more rapidly than non- deficient animals. Both the pain sensitivity
and opioid tolerance were normalized by vitamin D3 administration.
In humans, studies at the Mayo Clinic found that more than half
(140/267) of the enrolled patients with chronic pain were taking opioid
analgesics.
However, almost twice the amount of morphine-equivalent opioid was
required by patients who had inadequate vitamin D. They also were taking
opioids significantly longer, reported poorer physical functioning, and had
poorer health perceptions than opioid-taking patients having adequate vitamin D
levels.
Another investigation reported analgesic consumption in 33 women with
chronic symptoms of osteomalacia and deficient 25(OH)D concentrations. Their
use of both opioids and NSAIDs decreased by 75% as a result of vitamin D
supplementation therapy.
In a case report, a 94-year-old woman experiencing severe lower leg
pain was taking oxycodone/ acetaminophen every 4 hours. Within 1 week of daily
therapy with 1600 IU D2, and only a small increase in her very deficient serum
25(OH)D level, she could discontinue the opioid medication, and analgesia
consisted mainly of once-daily acetaminophen.
The relative roles of vitamin D in achieving analgesic-sparing effects
by either reducing pain sensitivity, improving the activity of NSAIDs or
opioids, or resolving underlying pain-generating processes (eg, osteomalacia, myopathy) need further
exploration. Meanwhile, this could be an important benefit of vitamin D
supplementation, even if the pain itself is only partially resolved.
Vitamin D deficiency Symptoms and signs in
children
Infants
|
Seizures,
tetany and cardiomyopathy
|
Children
|
Aches
and pains; myopathy causing delayed walking; rickets with bowed legs, knock
knees, poor growth and muscle weakness
|
Adolescents
|
Aches
and pains, muscle weakness, bone changes of rickets or osteomalacia
|
|
Blood
tests
25hydroxyVitaminD is the standard
blood test, and is an excellent marker of body stores. People with risk factors
and symptoms of hypocalcaemia or D deficiency should have a check of their
blood level. The blood test requires about 2ml of serum and does not need to be
transported to the laboratory urgently. The cost of this test is approximately
Rs. 1000 to 1500. Basic bone biochemistry (calcium, phosphate and alkaline
phosphatase) is often normal despite significant Vitamin D deficiency. High
alkaline phosphatase implies rickets. 25hydroxyVitaminD is measured in nmol/L
in the UK, but in ng/ml in the USA and India. 50nmol/L = 20ng/ml. [14]
Wong-Baker Faces Pain Rating Scale
The Wong-Baker Faces Pain Rating Scale (styled Wong-Baker FACES Pain Rating Scale) is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a
series of faces ranging from a happy face at 0, "No hurt" to a crying
face at 10 "Hurts worst". The patient must choose the face that best
describes how they are feeling.[12]
A pain scale measures a patient's pain intensity or other features. Pain scales are based on self-report,
observational (behavioral), or physiological data. Self-report is considered
primary and should be obtained if possible (since pain is a quale by definition, and therefore assessment based on any set scale of
expected outcomes from similar cases can fail to provide useful clinical data).
Pain scales are available for neonates, infants, children, adolescents, adults,
seniors, and persons whose communication is impaired. Pain assessments are
often regarded as "the 5th Vital Sign."
Each face is for a person who feels happy because he has no pain (no
hurt) or sad because he has some or a lot of pain. Face 0 is very happy because
he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little
more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as
you can imagine, although you don’t have to be crying to feel this bad. Ask the
person to choose the face that best describes how he is feeling.
Aims and Objectives
v To find out vitamin D level among Children who are suffering from
chronic aches& pains (age: >2-16yrs).
v To see the effect on pain after standard supplementation.
v PLACE OF STUDY: AMRI
groups of Hospitals.
v DURATION OF STUDY: June 2013 to May 2014
v KIND OF STUDY: This is
an observational and Prospective study.
Inclusion and Exclusion Criteria
Inclusion Criteria-
v Children of 2-16 years attending
pediatric OPD during my study period.
v Children’s with major complains of
chronic ache & pains,3 months or more than 3 months.
Exclusion Criteria –
v Patients suffering from any congenital
disorder of bones and joints.
Ethical
approval
Since this is an observational study; institutional ethics
committee waived ethical aspects and allowed us to conduct the study in the
hospital premises.
QUESTIONNAIRE
Results
and
Data analysis
During this 10 month study (June 2013 to March 2014) a
total of 107 patients were screened. Out of the 107 patients 104 patients were met
the full inclusion criteria.
5.1CLASSIFICATION OF STUDY POPULATION ACCORDING TO GENDER
Table
5.1.1
Variables
|
Total
Number
|
|
Male
|
54
|
51.92
|
Female
|
50
|
48.08
|
|
|
1.08 : 1
|
_
|
Table
5.2.1 and Figure 5.2.2 show the gender distribution of patients found the male
gender 51.92% and the female 48.08% in the study population. And the ratio is 1.08: 1.
Figure 5.2.1: Gender
Distribution of Patients
The demographic pattern of the study population is given
in figure 5.2. The pie chart shows that the prevalence of male gender was
little more than female in both the study groups.
5.3 CLASSIFICATION OF STUDY POPULATION ACCORDING TO AGE IN
YEARS
Table 5.3.1Age Group Distribution in the
Patients
Age groups
|
Number of Patients
|
Percentage (%)
|
2 Years
|
4
|
3.84
|
3 Years
|
17
|
16.34
|
4 Years
|
17
|
16.34
|
5 Years
|
16
|
15.38
|
6 Years
|
12
|
11.53
|
7 Years
|
12
|
11.53
|
8 Years
|
5
|
4.80
|
9 Years
|
5
|
4.80
|
10 Years
|
2
|
1.92
|
11 Years
|
4
|
3.84
|
12 Years
|
3
|
2.88
|
13 Years
|
3
|
2.88
|
14 Years
|
2
|
1.92
|
15 Years
|
1
|
0.96
|
16 Years
|
1
|
0.96
|
According to the above table 5.3.1 data
statistical analysis shows, the mean age of
these patients was 6.93 years and
Standard Deviation (SD) was 5.83. Test of proportion showed that the proportion of patients in the
age group 3-7 years was significantly higher than the other groups (p<0.01).
From the above table 5.3.1 and figure
5.3.2 it can be observed that maximum number of patients (74) came with the age
groups 3-7 years, which are comparatively higher then other age groups.
Table 5.4.1
Reason for Doctor visit
|
|
Percentage (%)
|
Complain for aches & pains
|
11
|
10.57 %
|
Other
issues
|
93
|
89.43 %
|
Figure 5.4.2
Table
5.4.1 and figure 5.4.2 shows that only 10.57% patients were came at pediatric
O.P.D with aches & pains complain. But 89.43 % patient came mainly for other
issues.
5.5 SITE
OF PAIN
Table
5.5.1
SITE OF PAIN
|
Number of Patients
|
Percentage (%)
|
Lower Limb
|
93
|
89.42 %
|
Upper Limb
|
2
|
1.92%
|
|
|
9
|
8.66%
|
|
|
|
|
Figure
5.5.2
According
to table 5.5.1 and figure 5.5.2 major number of patients were suffering from lower
limb pains (89.42%). Moderately 8.66% patients were suffering from lower and
upper booth limbs or other pain and very little number (1.92%) of patients are
complained about only upper limb pain.
5.6 ONSET
OF PAIN
Table 5.6.1
Onset Of Pain
|
Total
Number of Patients
|
Percentage
(%)
|
Less then 3 Months
|
38
|
36.54 %
|
More then 3 Months
|
66
|
63.46%
|
Figure 5.6.2
Among
the 104 patients 38 patients (36.54%) had been suffering for aches & pains
from 3 months or near about 3 months, rest of the 66 patients (63.46 %) having
pain more then3 months. Most of the patients had
onset of pain after 3 months. Table
5.6.1 and Figure 5.6.2 shows the percentage of onset of pain history.
5.7 PATTERN OF PAIN
Table
5.7.1
|
|
Total Number of Patients
|
Percentage (%)
|
Continuous
|
13
|
12.5%
|
Intermittent
|
91
|
87.5%
|
Figure
5.7.2
Above table 5.7.1 and figure
5.7.2 are shows 12.5 % patients (13) continuously and 87.5 % patients (91) Intermittently suffering for
pain.
5.8 DIURNAL VARIATION OF PAIN
Table
5.8.1
|
|
Number of Patients
|
Percentage (%)
|
After Exercise
|
33
|
31.73 %
|
Specific Time
In a Day
|
Morning
|
0
|
0%
|
19.24%
|
Evening
|
2
|
1.92%
|
Night
|
18
|
17.32%
|
Non- Specific
|
51
|
49.03%
|
Figure
5.8.2
The table 5.8.1 and figure 5.8.2
explain the diurnal variation of pain. 31.73 % patients (33) had complained for
pains after exercise. 17.32% patients (18) at night and 1.92 % patients (2) at
evening were also suffering for pains. Major number of patients (49.03 %) was
not mentioning the specific time.
5.9 DIET
Table 5.9.1
Diet
|
Number
of Patients
|
Percentage
(%)
|
Non-veg
|
96
|
92.3
|
Veg
|
8
|
7.7
|
Figure 5.9.2
Table 5.9.1 and figure 5.9.2 are showing
the diet among the patients. 96 patients (92.3%) were non-vegetarian and rests
of the 8 patients (7.7%) were found took vegetarian diet in their food habit.
5.10 INITIAL VITAMIN-D
LEVEL (D1) TEST
Table
5.10.1
INITIAL VITAMIN-D LEVEL (D1) [ng/ml][9]
|
Number
of Patients
(n= 77)
|
Percentage
(%)
|
Pain Assessment Wong Baker Faces Scale
|
Sever Deficiency: 10 or less
|
3
|
3.89
|
(5)- Hurts
worse
|
Deficiency: 20 or less
|
39
|
50.64
|
(2)- Hurts a
little more ; (3) - Hurts even more; (4)- Hurts a whole lot; (5)- Hurts worse
|
Insufficiency: 20 to 29
|
31
|
40.25
|
(2)- Hurts a
little more
|
|
|
4
|
5.19
|
(1)- Hurts a
little bit
|
Figure
5.10.2
Among the 104 patients 77 patients
(74.03%) were done the vitamin – D level test. According to table 5.10.1 and
figure 5.10.2 found 3.89% children were below the Sever Deficiency (10 ng/ml or
less), 50.64% were in the Deficiency (20ng/ml or less) , 40.25% were in the Insufficiency
(20 ng/ml to 29ng/ml) and 5.19% were under the sufficiency (30 ng/ml to 80
ng/ml) levels . Their pain intensity was evaluated through a questionnaire
using the Wong-Baker Faces Pain Rating Scale for pain assessment.
5.11 DURATION OF PATIENTS TAKING VITAMIN-D
SUPPLEMENT.
Table
5.11.1
Duration
|
Total Number of Patients
|
Percentage (%)
|
Less then 8 weeks
|
26
|
25%
|
8 weeks
|
77
|
74.03%
|
More then 8 weeks
|
1
|
0.07%
|
Figure 5.11.2
The vitamin-D supplement standard course duration is 8 weeks. But
during the study we found 74.03 % patients were took vitamin D supplement
during 8 weeks. 25% patients were took vitamin D less then 8 weeks as well as
0.07% were continued the supplement more then 8 weeks.
5.12 REPEAT VITAMIN -D LEVEL AFTER TREATMENT (D2)
Table
5.12.1
REPEAT VITAMIN -D LEVEL (D2)
[ng/ml]
|
Total
Number of Patients(n=14)
|
Percentage
(%)
|
Sever Deficiency: 10 or less
|
Nill
|
0%
|
Deficiency: 20 or less
|
Nill
|
0%
|
Insufficiency: 20 to 29
|
2
|
14.29%
|
Sufficiency: 30 to 80
|
12
|
85.71%
|
Figure 5.12.2
After vitamin D supplementation only 14 patients
were done the repeat vitamin-D level tests among the 104 patients. Table 5.12.1
and figure 5.12.2 shows after vitamin-D supplementation major percent of
patient’s vitamin D level were remarkably increased. 85.71% patients were
reached the sufficiency level, rest of them (14.29%) in the insufficiency
level.
Response of Serum Vitamin D Levels for Supplementation.
Figure 5.12.3
Figure 5.12.3 shows comparison between vitamin D level before supplementation
and after supplementation.
5.13 PATIENT’S RELEVANT HISTORY
Table
5.13.1
Relevant History
|
Number
of Patients
|
Medication
|
Asthma
|
6
|
Steroid
|
Nephrotic syndrome
|
4
|
Steroid
|
Figure 5.13.2
Among the 104 patients only 10 patients
(9.61%) had various relevant histories like Asthma and Nephrotic syndrome. They
were continuously receives steroidal medications.
Table
5.14.1
Relevant History
|
Number
of Patients
|
Medication
|
No Pain
|
Pain was back
|
Asthma
|
6
|
Steroid
|
5
|
1
|
Nephrotic syndrome
|
4
|
Steroid
|
2
|
2
|
Among the 10 patients who were continuously received
steroidal medication were suffered for aches & pains. After vitamin D
supplementation 7 patients (70%) had no pain complain; only 3 patients (30%)
have still pains.
5.15 VISUAL ANALOG SCALE
(PAIN ASSESSMENT WONG BAKER FACES SCALE) [12]
Table
5.15.1
Scale parameters
|
Scale 1 (Before taking Vitamin D)
|
Scale 2 (After taking Vitamin D)
|
Total
Number of Patients
|
Percentage
(%)
|
Total
Number of Patients
|
Percentage
(%)
|
(0) - No hurt
|
0
|
0
|
100
|
96.15
|
(1)- Hurts a little bit
|
5
|
4.81
|
0
|
0
|
(2)- Hurts a little more
|
65
|
62.5
|
3
|
2.88
|
(3) - Hurts even more
|
14
|
13.46
|
1
|
0.96
|
(4)- Hurts a whole lot
|
15
|
14.42
|
0
|
0
|
(5)- Hurts worse
|
5
|
4.81
|
0
|
0
|
Figure 5.15.2 PAIN ASSESSMENT WONG BAKER FACES SCALE
Figure 5.15.3 PAIN
ASSESSMENT WONG BAKER FACES SCALE
5.16 TOTAL PATIENT CONDITION
AFTER TAKING VITAMIN-D SUPPLEMENT
Table
5.16.1
PATIENT CONDITION
|
Number
of Patients those who doneInitial
Vitamin-D Level test & found
low vitamin-d level(73).
|
All
Patients (104)
|
Number
of Patients
|
Percentage
(%)
|
Number
of Patients
|
Percentage
(%)
|
No Pain
|
70
|
95.89
|
100
|
96.15
|
|
|
3
|
4.10
|
4
|
3.85
|
Figure
5.16.2
Table
5.16.1 and Figure 5.16.2 shows among the 77 patients (Those who had done
initial vitamin-D level test.) 70 test report found low vitamin D level (<10
-29 ng/ml) results. Only 3 patients’ results reached the sufficient level (30
-80 ng/ml).
Figure
5.16.3
Figure
5.16.4
Table 5.16.1 and figure 5.16.3 shows,
97.11% patients had no more aches and pains complaint (after vitamin-D
supplement). But 2.89 % patient’s pain was again back. 2.89 % patient’s
relevant history. We found 66.66% are suffering for nephrotic syndrome or asthma
and continuously taking steroidal medications. Figure 5.16.4 also shows after
vitamin-D supplementation we found 95.89% patients had no more aches and pains
complaint in the second group. The difference between two groups ‘No pain’
& ‘pain is back’ result is very minimum, 0.26% and 0.25%. Test of proportion showed that the proportion
of patients those who had no more pain complaint after received vitamin D
supplement was significantly higher than the other groups.
Discussion
In this
observational and prospective study, we include 104 patients those who were
fulfill the inclusion criteria. This was based on questionnaire data
collection. It was mainly an observational study and we
had collected data of 104 patients those were attending pediatric O.P.D within the period of June 2013 to
March 2014. 54 numbers of male patients and 50 numbers of females were enrolled
in our study. The male and female ratio was 1.08: 1. So it is observed that the gender
variation does not affect the patients those who came with the complaint of
aches and pains.
Our results showed that, among the age groups of 2 years to 16
years maximum number of children from 3
years to 7 years age groups came with aches and pains complaints. It was
observed that between the 3 to 7 years of age groups, children frequently came
to the doctor for vaccination and other related issues. So we got a large
number of patients from those age groups. The
mean age of patients was 6.93 years and
Standard Deviation (SD) was 5.83. 10.57% patients came with the complaints of aches
and pains. But 89.43 % patients actually came with other issues.
According to a study “Growing pains, or recurrent
lower limb pains, are the most common cause of musculoskeletal pain in children
and affect up to 49.4% of children. The pain usually occurs in the late day or
night and is diagnosed by exclusion of other disorders.” “Because children with
growing pains are often vitamin D insufficient and deficient, the authors
proposed the pain is due to less dense bones as a result of having a low
vitamin D status. In this state abnormal pressure on sensory nerves of the bone
can occur, causing pain.”
(Morandi
G, Maines
E, Piona
C, Monti
E, Sandri
M, Gaudino
R, Boner
A, Antoniazzi
F---
Department of Life and Reproduction Sciences, Pediatric Clinic, Giambattista
Rossi Hospital, Italy)[10]
In
our study major number of patients suffered from lower limb
pain (89.42%).Moderately 8.66% patients were suffered from both lower and upper limbs or other pains and very
little number (1.92%) of patients were complied about only upper limb pain.
36.54% patients had been suffered for aches & pains for 3 months or near
about 3 months. The rest of the 63.46 % patients having pain more then 3 months and 12.5 % patients (13) regularly and 87.5 % patients (91)
irregularly suffered from pains. The diurnal variation of pain was at
non-specific time in a day (49.03%).31.73 % and 17.32% patients had complained
for pain after physical exercise and at late night.
Recommended dietary allowances of
Vitamin D in children is approximately 600 IU (15 mcg). Generally in Indian
non- vegetarian food habit vitamin D is found as follows; liver & beef, 3
ounces = 42 (IUs per serving), egg(yolk) 1 large = 42 (IUs per serving) etc.
are very poorest source. Although swordfish (3 ounces = 566 IU), cod liver oil
(1 tablespoon = 1360 IU ), salmon (3 ounces = 447 IU), tuna fish etc do
not generally include in Indian diet.[11] But milk is the good source of
vitamin D. During the study we found among the 104 patients, 96 patients
(92.3%) are non- vegetarian and the rest of 8 patients (7.7%) are found taking
vegetarian diet in their food habit. So we conclude that Indian vegetarian or
non- vegetarian food habit dos not affect much in children’s vitamin D level.
The standard Serum vitamin D [25(OH)
D] levels are as follows, Severe
Deficiency: 10 or less (ng/ml) ,
Deficiency: 20 or less (ng/ml), Insufficiency: 20 to 29 (ng/ml) , Sufficiency:
30 to 80(ng/ml)[9].During the study period, 77 patients were done the initial
vitamin – D level tests, among them
3.89% children were in Severe Deficiency, 50.64% were in Deficiency ,
40.25% were under Insufficiency and 5.19% were under sufficiency. But After
vitamin –D supplementation only 14 patients were done the repeat vitamin D
level tests among the 104 patients. After 8 weeks of the completion of
vitamin-D supplementation, one/two months later, we collected the data “Present
patient condition”. We found major percent of patients’ vitamin D levels were
remarkably increasing. 85.71% patients reached the sufficiency level and the
rest of them (14.29%) were below insufficiency level. we used Wong-Baker Faces Pain Rating Scale for pain assessment.[10] Table 5.10.1 showed that those patients had Severe Deficiency of vitamin
D and Wong Baker Faces Scale (Before taking Vitamin D) showed reading 5 (Hurts
worse) in this manner vitamin D deficient patient’s Scale showed reading 2
(Hurts a little more) ; 3 (Hurts even more); 4 (Hurts a whole lot) and also 5
(Hurts worse). Those who belong to Insufficiency level showed reading 2 (Hurts
a little more). After vitamin D supplementation Wong Baker Faces Scale (After
taking Vit D) showed 96.15 % reading 0 (No
hurt) and very few (2.88% & 0.96%) reading 2 (Hurts a little more) and 3 (Hurts even more).
During the
study we followed up the duration
of patients taking vitamin-D supplementation. The vitamin-D supplement standard
course duration is 8 weeks. We found 74.03 % patients were taking vitamin-d
supplement during 8 weeks. 25% patients took vitamin D less then 8 weeks as
well as 0.07% were continuing the supplement more then 8 weeks. Most of the
vitamin D administered orally (drops) once a week 6000 units. Only two patients
received vitamin D through the parenteral routes 600000 units (inj.) every two
weeks.
Table 5.13.1 shows only 10 patients
(9.61%) have various relevant history like Asthma and Nephrotic syndrome. 10 patients
were continuously received steroids. Among all patients, after completed the
vitamin-D supplement course we found 97.11% patients had no more aches and
pains complaint. But 2.89 % patients’ pain was again back after a few months
when medication (vitamin-D) was stopped. After studying the 2.89 % patients
relevant history we found 75% were suffering for nephrotic syndrome or asthma
and continuously taking steroidal medications. Figure 5.16.4 also showed
comparison between total numbers of patients (104) those who came with aches
and pains complaint and among them 73 patients those who underwent vitamin-D
level test. After taking vitamin-D supplement course we found 95.89% patients
had no more aches and pains complaint in the second group. The difference
between two groups ‘No pain’ & ‘pain is back’ result is very minimum, 0.26%
and 0.25%.
So we conclude after those result and
analysis, after standard vitamin – D supplementation resulting elevate
vitamin-D levels as well as maximum number of patients had no more aches and
pains complaint.
Conclusion
Vitamin D is essential for strong bones because it helps the body use calcium from the diet. Traditionally, vitamin D
deficiency has been associated with rickets, a disease in which the bone tissue doesn't properly mineralize,
leading to soft bones and skeletal deformities cause’s aches and pains. During the study period we found many children
coming with aches and pains complaints. Among them a large number of
children’s’ vitamin D level was below the Sufficiency level (<30 ng/ml).
After receiving proper vitamin D supplementation we found 96.15% patients had
no more aches and pains complaint. But we faced some limitations during the
study. Serum vitamin D level test is very costly (near about Rs. 1000 to 1500).
So for this reason maximum number of parents did not do the repeat vitamin-D
level tests after the patients had no more complaints about aches and pains. On
the other hand, this study is based on the urban areas, where we observed
parents were very much conscious about their children’s’ diet, health and
vitamin supplementations. If we include patients from more rural areas, the applicability
of study might be increased. However, it is concluded with respect to the
results and analysis after the vitamin D supplementation, it was clinically
proved that major percentage of patents had no more aches and pains.
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[9]"Vitamin
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[10] “Significant association among
growing pains, vitamin D supplementation, and bone mineral status: results from
a pilot cohort study”
Department of Life and
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University of Verona, Piazzale Ludovico Antonio Scuro, 10, 37134, Verona,
Italy.( [PubMed)
[12] http://www.wongbakerfaces.org/
