During the last decades Italy (as Europe in general) has experienced a mass migration from countries afflicted by poverty, civil wars and religious fundamentalism. More than 5 million foreigners of about 200 different nationalities reside in Italy, forming the 8.3% of total population. In central-northern regions the percentage is even higher (10.6% of the resident population) [1]. Over 50% of foreign residents come from other European countries (Romania, Albania, etc.). About 70,000 foreigners are pediatric subjects (0-17 years). In 2014, on a total of 8 million hospitalizations for acute care, more than 520,000 involved foreign patients (6.5%) [1]. However, there are huge variations among our regions, with hospitalization rates ranging from 0.3% in Basilicata region to 10% in Emilia Romagna region, with a highest rate in Prato province (17.5%) (Tuscany region) [1]. In this evolving panorama, pediatricians are required to be able to understand the diverse health needs of these new patients that, for age, ethnic origins, traditional customs, religious practices, level of undernutrition dramatically differ from each other. In particular, a different approach is indicated for newly arrived subjects and for long-term residents. Undernutrition during pregnancy, prolonged exclusive breastfeeding, late weaning, restricted diets, abnormal intake of tannins, and chronic diarrhea or parasitic infections are frequently observed in foreign subjects recently moved from Africa, Middle-East and Far East countries. All these circumstances contribute to a high prevalence of iron deficiency anemia, although other micronutrient deficiency may contribute to the anemic state [2]. In general, this new composite population implies for the health care provider, and in particular for the pediatrician, a specific attention aimed at evaluating different nutritional and cultural habits which may elicit new or forgotten diseases. In particular, in the last few years, great attention has been focused on hypovitaminosis D and its health consequences, especially in the pediatric population and, in particular, in those subjects at higher risk for ethnic and cultural reasons. Rickets and osteomalacia represent short-term latency manifestations of plain vitamin D deficiency. Although florid rickets is a relatively rare condition in western countries, over the past few years several papers have reported that it is resurging in Europe [3] and North America [4], in a variety of ethnic groups. Subclinical or asymptomatic hypovitaminosis D are definitely more common, even in the Caucasian population. Several epidemiological studies have shown in recent years that the prevalence of hypovitaminosis D in Italian pediatric population is very high, up to 89% [5, 6]. As for adults, the main source of vitamin D is the endogenous production in the skin triggered by the ultraviolet B irradiation. However the skin synthesis is influenced by a number of factors, including, latitude, season, time of the day, cloud cover and pollution. In addition, individual factors, such as skin pigmentation, clothing, time spent outdoor, use of sunscreens, can strongly interfere with its natural production [7]. Very few natural foods contains substantial amount of vitamin D, so dietary sources accounts for less than 10% of vitamin status. Only fortified foods, including cereals and infant formulas or some dairy products, may account for some dietary supply. At our latitudes people at risk of developing vitamin D deficiency are all those with darker skin, e.g. people from Africa, Middle-East and Asia living in Europe, but also pregnant women and their infants with reduced sun exposure (religious and cultural reasons), infants < 12 months (especially if breastfed), subjects with restricted diets (e.g. macrobiotic, vegetarian, strict vegan), adolescents and those with a high body mass index. Finally, vitamin D levels are frequently insufficient in subjects affected by liver or kidney diseases and in case of chronic therapy with anticonvulsants, glucocorticoids and antifungal drugs [6]. There is increasing evidence that besides calcium metabolism and bone health, vitamin D has beneficial effects on several extra-skeletal tissues. The vitamin D receptor (VDR) is nearly ubiquitously expressed in a variety of tissues such as brain, heart, skin, stomach, pancreas, lymphocytes, gonads, and prostate tissue. In recent years, an impressive number of studies have been performed, on both children and adults, to investigate the preventative and therapeutic effects of vitamin D supplementation on various diseases, such as respiratory infections and flu, cardiovascular diseases, diabetes, asthma, multiple sclerosis, and cancer [8]. Furthermore, inadequate vitamin D levels during pregnancy may have short- and long-term effects on offspring health [9]. New insights on the individual metabolism are coming from studies on different VDR gene polymorphisms that may influence the vitamin D expression and activity in individuals [10, 11]. Even though specific recommendations on the adequate intake aimed at preventing extra-skeletal diseases have not yet been provided, it is mandatory for all health caregivers to look carefully to vitamin status at any age, particularly in subjects at higher risk [6]. While in industrialized countries other vitamin deficits are rare and limited to chronically ill patients or subjects with inadequate nutritional regimens (e.g. vitamin B12 in vegans), they have to be considered when approaching foreign subjects, especially if they have recently moved from poor countries [12]. For example, vitamin A deficiency is very common in refugee children and supplementation is always indicated [13]. Vitamin B12 is another vitamin that often results insufficient in refugees [14]. Vitamin B12 occurs naturally in animal products (e.g., meat, milk, eggs), and deficiency results from inadequate dietary intake (economic, cultural and religious restrictions) or impaired absorption. Plain vitamin B12 deficiency is associated with macrocytic anemia, and occasionally pancytopenia, but it may also present with subtle nonspecific symptoms, such as fatigue, decreased concentration and memory, irritability, depression, or other neurologic manifestations. Other deficits that may be encountered in foreign children recently settled in western countries pertain to thiamine, niacin, vitamins C and E [14]. Among others, dental health represents at all ages a major health issue in both native and migrant subjects. In western countries oral health has dramatically improved since the 1960s. However, poor oral health still represents a problem in certain migrant groups. Frequently observed dental disorders include dental cavities, missing teeth, malocclusion, periodontal disease, abscesses and oral cancer. As pediatricians are responsible for the primary and often sole medical care for migrant children, they should be particularly alert to the risk of oral health problems [15]. In particular, the pediatrician must include oral examination in the daily clinical routine, educate children and their parents on reducing dietary sugar, maintaining good oral hygiene, and using topical fluoride agents (toothpaste and varnishes). After carefully assessing total daily fluoride intake, mainly via bottled or tap water (which in our country present considerable variations in fluoride concentration), oral supplements may be indicated [16]. With the same accuracy, pediatricians must be aware of the risk of acute and chronic toxicity due to excessive fluoride ingestion. Fluorosis, beyond dental disease, has, in fact, several detrimental health effects on several tissues, such as bone, heart, CNS, liver, thyroid and kidneys [17]. For this purpose pediatricians should appropriately educate parents in using a judicious amount of toothpaste, teaching kids not to swallow it, and keeping fluoride drops/tablets out of the reach of children. In this context, the toughest challenge the pediatrician has to cope with, with no doubts, is to overcome language and cultural barriers. More integrated intercultural services, especially outside the hospital, are needed; cultural and linguistic mediators have a central role in helping the immigrants integrate in our culture and ensuring clear and effective communication between health caregivers and children and their parents.

VITAMINS AND FLUORIDE: NEW REQUIREMENTS IN A MULTI-ETHNIC WORLD

FANARO, Silvia
2016

Abstract

During the last decades Italy (as Europe in general) has experienced a mass migration from countries afflicted by poverty, civil wars and religious fundamentalism. More than 5 million foreigners of about 200 different nationalities reside in Italy, forming the 8.3% of total population. In central-northern regions the percentage is even higher (10.6% of the resident population) [1]. Over 50% of foreign residents come from other European countries (Romania, Albania, etc.). About 70,000 foreigners are pediatric subjects (0-17 years). In 2014, on a total of 8 million hospitalizations for acute care, more than 520,000 involved foreign patients (6.5%) [1]. However, there are huge variations among our regions, with hospitalization rates ranging from 0.3% in Basilicata region to 10% in Emilia Romagna region, with a highest rate in Prato province (17.5%) (Tuscany region) [1]. In this evolving panorama, pediatricians are required to be able to understand the diverse health needs of these new patients that, for age, ethnic origins, traditional customs, religious practices, level of undernutrition dramatically differ from each other. In particular, a different approach is indicated for newly arrived subjects and for long-term residents. Undernutrition during pregnancy, prolonged exclusive breastfeeding, late weaning, restricted diets, abnormal intake of tannins, and chronic diarrhea or parasitic infections are frequently observed in foreign subjects recently moved from Africa, Middle-East and Far East countries. All these circumstances contribute to a high prevalence of iron deficiency anemia, although other micronutrient deficiency may contribute to the anemic state [2]. In general, this new composite population implies for the health care provider, and in particular for the pediatrician, a specific attention aimed at evaluating different nutritional and cultural habits which may elicit new or forgotten diseases. In particular, in the last few years, great attention has been focused on hypovitaminosis D and its health consequences, especially in the pediatric population and, in particular, in those subjects at higher risk for ethnic and cultural reasons. Rickets and osteomalacia represent short-term latency manifestations of plain vitamin D deficiency. Although florid rickets is a relatively rare condition in western countries, over the past few years several papers have reported that it is resurging in Europe [3] and North America [4], in a variety of ethnic groups. Subclinical or asymptomatic hypovitaminosis D are definitely more common, even in the Caucasian population. Several epidemiological studies have shown in recent years that the prevalence of hypovitaminosis D in Italian pediatric population is very high, up to 89% [5, 6]. As for adults, the main source of vitamin D is the endogenous production in the skin triggered by the ultraviolet B irradiation. However the skin synthesis is influenced by a number of factors, including, latitude, season, time of the day, cloud cover and pollution. In addition, individual factors, such as skin pigmentation, clothing, time spent outdoor, use of sunscreens, can strongly interfere with its natural production [7]. Very few natural foods contains substantial amount of vitamin D, so dietary sources accounts for less than 10% of vitamin status. Only fortified foods, including cereals and infant formulas or some dairy products, may account for some dietary supply. At our latitudes people at risk of developing vitamin D deficiency are all those with darker skin, e.g. people from Africa, Middle-East and Asia living in Europe, but also pregnant women and their infants with reduced sun exposure (religious and cultural reasons), infants < 12 months (especially if breastfed), subjects with restricted diets (e.g. macrobiotic, vegetarian, strict vegan), adolescents and those with a high body mass index. Finally, vitamin D levels are frequently insufficient in subjects affected by liver or kidney diseases and in case of chronic therapy with anticonvulsants, glucocorticoids and antifungal drugs [6]. There is increasing evidence that besides calcium metabolism and bone health, vitamin D has beneficial effects on several extra-skeletal tissues. The vitamin D receptor (VDR) is nearly ubiquitously expressed in a variety of tissues such as brain, heart, skin, stomach, pancreas, lymphocytes, gonads, and prostate tissue. In recent years, an impressive number of studies have been performed, on both children and adults, to investigate the preventative and therapeutic effects of vitamin D supplementation on various diseases, such as respiratory infections and flu, cardiovascular diseases, diabetes, asthma, multiple sclerosis, and cancer [8]. Furthermore, inadequate vitamin D levels during pregnancy may have short- and long-term effects on offspring health [9]. New insights on the individual metabolism are coming from studies on different VDR gene polymorphisms that may influence the vitamin D expression and activity in individuals [10, 11]. Even though specific recommendations on the adequate intake aimed at preventing extra-skeletal diseases have not yet been provided, it is mandatory for all health caregivers to look carefully to vitamin status at any age, particularly in subjects at higher risk [6]. While in industrialized countries other vitamin deficits are rare and limited to chronically ill patients or subjects with inadequate nutritional regimens (e.g. vitamin B12 in vegans), they have to be considered when approaching foreign subjects, especially if they have recently moved from poor countries [12]. For example, vitamin A deficiency is very common in refugee children and supplementation is always indicated [13]. Vitamin B12 is another vitamin that often results insufficient in refugees [14]. Vitamin B12 occurs naturally in animal products (e.g., meat, milk, eggs), and deficiency results from inadequate dietary intake (economic, cultural and religious restrictions) or impaired absorption. Plain vitamin B12 deficiency is associated with macrocytic anemia, and occasionally pancytopenia, but it may also present with subtle nonspecific symptoms, such as fatigue, decreased concentration and memory, irritability, depression, or other neurologic manifestations. Other deficits that may be encountered in foreign children recently settled in western countries pertain to thiamine, niacin, vitamins C and E [14]. Among others, dental health represents at all ages a major health issue in both native and migrant subjects. In western countries oral health has dramatically improved since the 1960s. However, poor oral health still represents a problem in certain migrant groups. Frequently observed dental disorders include dental cavities, missing teeth, malocclusion, periodontal disease, abscesses and oral cancer. As pediatricians are responsible for the primary and often sole medical care for migrant children, they should be particularly alert to the risk of oral health problems [15]. In particular, the pediatrician must include oral examination in the daily clinical routine, educate children and their parents on reducing dietary sugar, maintaining good oral hygiene, and using topical fluoride agents (toothpaste and varnishes). After carefully assessing total daily fluoride intake, mainly via bottled or tap water (which in our country present considerable variations in fluoride concentration), oral supplements may be indicated [16]. With the same accuracy, pediatricians must be aware of the risk of acute and chronic toxicity due to excessive fluoride ingestion. Fluorosis, beyond dental disease, has, in fact, several detrimental health effects on several tissues, such as bone, heart, CNS, liver, thyroid and kidneys [17]. For this purpose pediatricians should appropriately educate parents in using a judicious amount of toothpaste, teaching kids not to swallow it, and keeping fluoride drops/tablets out of the reach of children. In this context, the toughest challenge the pediatrician has to cope with, with no doubts, is to overcome language and cultural barriers. More integrated intercultural services, especially outside the hospital, are needed; cultural and linguistic mediators have a central role in helping the immigrants integrate in our culture and ensuring clear and effective communication between health caregivers and children and their parents.
Vitamins, fluoride, supplementation, migration, children, infants
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