Serum concentration of 25(OH) vitamin D is the best
indicator of vitamin D status. Vitamin-D deficiency is
found in 19-35% of children with IBD ( 43, 44). Serum
25-hydroxy vitamin D concentrations are similar in
children with CD and UC and do not correlate with
lumbar spine bone mineral density ( 44). Vitamin D
levels are lower in children with dark skin and when
levels are drawn in the winter ( 44). A vitamin D level
above 32 ng/mL should be considered the goal for
children and adolescents with IBD ( 44).
Vitamin D levels should be monitored annually
and patients with deficiencies should receive vitamin
Supplementation with relatively high doses of
vitamin D3 has been studied in healthy children.
Providing an average of 2000 IU/day of vitamin D3
appears to be safe ( 45).
Many pediatric IBD programs routinely monitor
bone mineral density in children with IBD, either
by dual-energy X-ray absorptiometry (DXA) or
quantitative computer tomography. Guidelines for the
timing and frequency of monitoring in children do not
exist. It is important to recognize that the techniques
for interpreting DXA scans are different for children
The Institute of Medicine increased the Recommended
Dietary Allowances for calcium in some age groups
in 2010. Up to 70% of Americans over the age of 2
do not meet the recommendations for calcium intake
( 46). Patients with IBD sometimes need to avoid milk
products because of lactose intolerance, but at times
avoid these products unnecessarily. Avoidance of dairy
products makes meeting calcium needs especially
difficult. A standard multivitamin/mineral generally
contains only 100-200 mg of calcium. It is important
to assess calcium intakes of children with IBD and
recommend a calcium supplement if patients are not
meeting their needs. Calcium absorption is highest in
doses < 500 mg. For example, if a patient requires 1000
mg of calcium through supplements, it is advantageous
to provide this as 500 mg twice daily.
Iron deficiency is common in patients with IBD. Anemia
impacts quality of life with symptoms including fatigue
and headaches, but is often not aggressively treated. A
study of 429 IBD patients found anemia present in 19%
of patients and iron deficiency present in 35%. In about
20% of patients anemia was due to iron deficiency, 12%
due to anemia of chronic disease and 68% were a result
of both conditions. Folate or vitamin B12 deficiencies
accounted for less than 5% of causes of anemia ( 47).
It is common for patients who are anemic at the
time of diagnosis to receive therapy to control intestinal
inflammation with the expectation that anemia will
resolve once the IBD is under control. Pels et al found
‘expectant management’ to result in slow hematological
recovery, showing a need for more active treatment
of iron deficiency ( 48). Oral iron is sometimes poorly
tolerated though studies have found it to be no more
difficult for IBD patients to tolerate than other patients
( 49). Finally, gastrointestinal upset is often dose
dependent; consider smaller doses more often over
the day to improve tolerance. An alternative to oral iron
therapy is intravenous infusion of iron. Iron dextran is
safe when appropriately used ( 50) and is more effective
at correcting hemoglobin in IBD patients ( 51).
Assessment of growth, nutrition and pubertal
development should be an integral part of assessing
and monitoring patients with pediatric IBD. Height
velocity is the earliest and most sensitive marker of
growth faltering. Malnutrition should be identified
and managed with supplemental nutrition. Patients
and families should be encouraged to utilize exclusive
EN as a modality of inducing remission in newly
diagnosed patients with CD. Identifying and managing
micronutrient deficiencies is very important, in
particular, ensuring adequate calcium and vitamin D
supplementation will improve bone health in these
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