Dr. Valeria Herdea, primary care physician Family medicine, Romanian Association for Pediatric Education in Family Medicine (arepfm)
The sun remains, indisputably, the source of Life on Earth. We all love to be comforted by the sun’s rays, to be pampered by the Light, to enjoy the “Sunbaths”. Regardless of age, gender, social status, beliefs, traditions or historical age, the Sun remains at the center of our existence as the engine of civilization.
A brief analysis of the scientific data of the moment shows us, however, that the joy of being enveloped in sunlight depends on how balanced we are, how much we balance responsible, healthy exposure to the sun or, conversely, how much we we avoid the effects of excessive sun exposure. As a direct result: we can stay healthy or, on the contrary, we can have unwanted health problems.
The benefits of sun exposure:
PHYSICAL – activating the physiological mechanisms of vitamin D synthesis with all its benefits, from a healthy structure of bones and joints to the functioning of the endocrine glands or the protection of the heart.
PSYCHIC – balancing psycho-affective and social integration processes.
Less physically desired effects:
– dehydration, if hydration is not adequate, especially for at-risk groups (children, pregnant women, the elderly, chronic patients);
– sunburn, through prolonged exposure without adequate protection;
– the development, on a predisposing background, of some skin tumors after the uncontrolled exposure to the Sun.
Lack of sun exposure leads to:
– rickets of the child due to vitamin D deficiency. Vitamin D is naturally synthesized in the skin by exposure to the Sun.
– osteoporosis, specific to adulthood, encountered in recent years, both in women and men, with severe impairment of the quality of life of the individual, by demineralization of bones.
GOOD TO KNOW:
The optimal level of vitamin D is 30-60 ng / mL of 25 (OH) D. Its active form is 1.25 (OH) 2 and has the behavior of “classic hormone”.
Vitamin D has a role in:
– Bone remodeling;
– Immunomodulation – inhibits the proliferation of keratinocytes and fibroblasts;
– Inhibits renin production, increases myocardial contractility;
– Increases insulin production;
– Inhibits angiogenesis;
– It is an inducer of apoptosis (cell death).
In practice we encounter various situations:
Reduced vitamin D intake or synthesis:
– children born to mothers with vitamin D deficiency;
– hyperpigmented skin;
– reduced sun exposure;
– low intake of foods rich in vitamin D.
Malabsorption or abnormal bowel function:
– diseases of the small intestine (eg celiac disease);
– pancreatic insufficiency (eg cystic fibrosis);
– biliary obstruction (eg biliary atresia).
Reduced synthesis or increased degradation of 25-OH-cholecalciferol:
– chronic kidney or liver disease;
– administration of drugs: barbiturates (phenobarbital), tuberculostatics.
The secret of maintaining an optimal level of vitamin D remains related to the daily exposure to the beneficial effects of sunlight for at least 30 minutes of a part of 9-18% of the skin surface (eg: 9% front, 9% limbs). The exposure is indicated, in the temperate zone, between 6.00-10.00 or in the afternoon, 17.00-19.00.
10-step algorithm – rickets prophylaxis and treatment / osteoporosis prevention
Some recommendations to identify solutions for maintaining health are included in the Algorithm prepared by family physicians members of the Romanian Association for Pediatric Education in Family Medicine (AREPMF).
1. Antenatal prophylaxis of rickets by administering vitamin D3 to the pregnant woman in the 32nd week of pregnancy.
2. Postnatal prophylaxis of rickets by promoting an adequate hygienic-dietary regime: support of breastfeeding up to 2 years, correct complementary diet, exposure to air from the first week of life.
3. Postnatal prophylaxis of rickets in children up to 18 months, by administration of vitamin D3, daily, in fractional doses (400-800 IU / day), more physiological and which avoids overdose.
4. Postnatal prophylaxis of rickets after 18 months until the cessation of growth (12-15 years), by administering vitamin D3, daily, in the cold months (“R”), fractional doses (400-800 IU / day).
5. The prophylaxis of rickets also brings benefits on the overall state of health: anti-infective and anti-inflammatory role; reduces the risk of allergic asthma; decreases mortality from cardiovascular disease; protective factor for type 1 DM; reduces the risk of breast cancer and colorectal cancer.
6. Identification by anamnesis, antenatal in pregnant women and postnatal in newborns and infants of the situations that may favor the deficiency of vitamin D, calcium or phosphorus and their early correction.
7. Evaluation by clinical examination of the infant aged 3-9 months to identify bone and extraosseous elements that raise the suspicion of a diagnosis of rickets.
8. Paraclinical confirmation (analysis: serum level of vitamin D dosage) and radiological confirmation of the form of rickets: deficiency, resistant vitamin-D or vitamin-dependent D.
9.
A) Initiation of treatment with vitamin D3 and calcium depending on the form of rickets, according to the existing protocol (prophylaxis of anemia and rickets in children IOMC 2010) and correction of associated favorable factors. Caution – insufficiently documented treatment can lead to hypervitaminosis D (medical emergency).
B) The initiation of prevention or therapy applied to the adult is made after the clinical and biological evaluation of the persons through the system of primary medicine or, as the case may be, endocrinologist.
10.
A) In the case of rickets: periodic paraclinical and radiological reassessment considering that healing occurs slowly on average in 3-6 months of treatment, and bone signs disappear late, sometimes 1-2 years after starting treatment.
B) In the case of the identified adult at risk of developing osteoporosis: regular consultation with the family doctor allows the identification of predisposing factors (family history), favorable factors (drug treatments that change the level of vitamin D) or determining factors (lack of sun exposure) , but also the correct counseling of patients to avoid the suffering induced by changes in bone mineralization that may occur with age.
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