Advances in Pediatric Endocrinology

Dr. Ilene Fennoy

Although the New York State executive order – New York State on PAUSE – was only in effect during the pandemic from March 22 through June 8, 2020, organized sports and outdoor play were avoided during the summer and fall of 2020. This led to decreased sun exposure for many children and, according to researchers in the Division of Pediatric Endocrinology, Diabetes, and Metabolism at NewYork-Presbyterian Morgan Stanley Children’s Hospital, resulted in children presenting with severe vitamin D deficiency and symptomatic hypocalcemia. The research team, including Ilene Fennoy, MD, a pediatric endocrinologist and Professor of Pediatrics at Columbia who served as lead author on the study, hypothesized that this deficiency resulted as an unintended consequence of the stay-at-home orders. In their investigation, the results of which were published in the March 2022 issue of Global Pediatric Health, the researchers presented three case studies of children in New York City with severe vitamin D deficiency and symptomatic hypocalcemia.

Case 1
A 13-year 5-month-old male of Hispanic descent, with a past history of transient hypoglycemia and poor oral feeding, presented to the Emergency Department with a first-time generalized tonic-clonic seizure. His symptoms included lower back pain, diffuse muscle pain, and bilateral hand cramping for 1 month. His diet consisted primarily of bagels, cheese pizza, chicken, and sandwiches. Laboratory studies revealed hypocalcemia in the setting of severe vitamin D deficiency. An electrocardiogram (ECG) showed sinus tachycardia and borderline prolonged QTc. A thoracic spine radiograph revealed mild loss of height in several midthoracic vertebral bodies, indicative of compression fractures. He was treated with 7 IV calcium gluconate boluses, followed by 100mg/kg/day elemental calcium, calcitriol 0.25mcg daily, and 2 doses of ergocalciferol 50,000 international units (IU) during the first week. The patient was discharged on hospital day 3 on 120mg/kg/day elemental calcium, calcitriol 0.25mg daily, and cholecalciferol 10,000 IU daily, with a calcium level of 9.4mg/dl and ionized calcium of 1.13mmol/l. Calcitriol was discontinued after 11 days, and current medications include cholecalciferol 50,000 IU weekly and 100mg/kg/day elemental calcium.

Case 2
An 11-year 9-month-old female of Yemeni descent presented to the Emergency Department with right-sided knee pain of 1 year. She reported a diet of primarily French fries and rice with little dairy and vegetables. She had tenderness to palpation of the anterior and lateral aspects of the right knee with normal gait and range of motion. The patient was post-menarchal with a BMI in the 15th percentile. Initial laboratory studies demonstrated hypocalcemia and vitamin D deficiency. ECG showed a borderline prolonged QTc. She was treated with 2 IV calcium gluconate boluses and a dose of 50,000 IU of ergocalciferol, and then started on enteral replacement of 100mg/kg/day elemental calcium. The patient was discharged on hospital day 4 on ergocalciferol 50,000 IU twice a week and 100mg/kg/day elemental calcium, with a calcium level of 9.1mg/d. The patient’s doses were decreased to ergocalciferol 50,000 IU every 2 weeks and 25 mg/kg/day elemental calcium.

Case 3
A 10-year 9-month-old Black male with a past medical history of autism, eczema, asthma, and food allergies was followed in the rheumatology clinic for 1 year for bilateral knee pain. He was referred to the hospital for hypocalcemia based on outpatient lab results. He had a limited diet with minimal dairy products. His exam was notable for generalized musculoskeletal tenderness and hyperreflexia with a positive Chvostek sign. ECG displayed a borderline prolonged QTc. Left wrist radiograph showed osteopenia and thinning cortices with subperiosteal reactions and fraying of the distal radial and ulnar metaphyses, consistent with rickets. The patient received 2 IV calcium gluconate boluses, 1g magnesium sulfate IV, and 50,000 IU of ergocalciferol. He was then placed on 90mg/kg/day elemental calcium enterally. He was discharged on hospital day 5 on ergocalciferol 10,000 IU daily and 90mg/kg/day elemental calcium, with a stable ionized calcium level of 1.09mmol/l. Doses were decreased to ergocalciferol 8,000 IU daily and 30mg/kg/day elemental calcium with improvement in his laboratory parameters.

Contributing Factors to Symptomatic Vitamin D Deficiency

The Columbia investigators maintain that this case series suggests that the stay-at-home orders and decrease in seasonal sun exposure may have exacerbated vitamin D deficiency and symptomatic hypocalcemia in children who were at increased risk due to the winter months of being indoors, high latitude residence, and having a darker complexion. All three patients had limited dietary calcium intake, were not on vitamin D supplementation, and presented at the end of winter 2021 with severe vitamin D deficiency, symptomatic hypocalcemia, appropriately elevated parathyroid hormone, and urinary retention of calcium. While it is known that vitamin D deficiency can lead to hypocalcemia, the researchers note that few studies and case reports are associated with primary vitamin D deficiency as the cause of hypocalcemia.

Given the severity of hypocalcemia in the described patients and the cost of admissions, the authors recommend that pediatricians reinforce preventative vitamin D supplementation and actively screen and treat vitamin D deficiency in at-risk patients.

They further noted that:

• Children living in population-dense areas such as New York City faced an increased risk of COVID-19 spread that curtailed their safely spending time outside.
• The COVID-19 pandemic in New York City disproportionately affected racial and ethnic minorities, as well as those residing in lower socioeconomic status neighborhoods.
• Children participating in virtual learning throughout the spring and fall of 2020 did not receive the usual summer sun exposure.
• Minority populations have been shown to have access to fewer parks.

The Columbia investigators added, “While larger studies are needed to evaluate the prevalence of vitamin D deficiency and subsequent complications in children affected by stay-at-home orders, this report aims to bring our attention to severe symptomatic vitamin D deficiency. Given the severity of hypocalcemia in the described patients and the cost of admissions, we recommend that pediatricians reinforce preventative vitamin D supplementation and actively screen and treat vitamin D deficiency in at-risk patients.”