Deficiency vitamin D and its relationship to Low Birth

Weight Neonates

Nur Elly1, Ratna Djuwita2

1
Health Polytechnic Ministry of Health Bengkulu, Indonesia;
2
Department of Epidemiology, Faculty of Public Health University of Indonesia,
Depok, Indonesia

Introduction
Birth Weight is an important indicator to assess the survival of a baby. Low
birth weight (LBW) is defined by the World Health Organization (WHO) as weight
at birth less than 2500 g (1). LBW in Indonesia is still a problem because 11.2% of
LBW has an impact on prenatal death (2). LBW is not only a significant predictor
of prenatal mortality and morbidity, but Barker's theory explains that low birth
weight also increases the risk of poor cognitive development and non-
communicable diseases in the future such as diabetes and cardiovascular disease
(1,3).
Based on the Indonesian National Basic Health Research in 2013, the
national LBW prevalence was 10.2%. For Bengkulu Province, the LBW is 9.7%
which is the highest in Sumatra Island (4). In Asian countries, LBW is mostly
associated with intrauterine growth retardation compared to prematurity as in
developed countries and Africa (5). In developing countries, maternal malnutrition
is the main factor contributing to poor pregnancy outcomes.(6)
Vitamin D (25 (OH) D is one of the essential minerals that have various
functions of the body's physiological processes. One of its primary functions is to
maintain serum calcium levels in a healthy physiological range to support multiple
metabolic functions, regulation of bone transcription, and metabolism (7). Another
critical role is to modify the immune system and regulate cell proliferation and
differentiation (8). Adequate vitamin D concentration during pregnancy is needed
for growth and mineralization of the developing fetal bone (7). Vitamin D
deficiency in pregnant women results in neonatal insufficiency (9) and is often
associated with adverse birth outcomes (10). Vitamin D status in pregnant women
is positively correlated with 25 (OH) D concentrations in umbilical cord blood
because vitamin D fetus is entirely dependent on the mother (11–13).
Studies in pregnant women show a high prevalence of deficiency and
insufficiency of vitamin D, including in the tropics, although it is always
illuminated by the sun throughout the year. Data on the prevalence of vitamin D
deficiency in several tropical regions of Asia: Vietnam 60% (14), Thailand 75.5%
(15) and Malaysia 77.5% (16). Data on the prevalence of vitamin D status in
Indonesia is minimal. To describe vitamin D status among non-pregnant women
aged 18-40 years in Jakarta, of 126 mothers 63% with vitamin D (25 (OH) D) status
<50 nmol / L (17). Among women from 18 to 40 years, garment workers in
Sukabumi showed 94.8% deficiency of vitamin D (<50 nmol / l) (18). Another
study among first-trimester pregnant women in Jakarta showed that vitamin D
deficiency reached around 90% (19).
Although there is growing evidence that vitamin D deficiency and
insufficiency are associated with late pregnancy outcomes, evidence of a correlation
of hypovitaminosis D with potential risk for neonatal risk is limited and less
consistent. Therefore this study aimed to assess the relationship between vitamin D
status and body weight at birth after being controlled with calcium concentration,
maternal characteristics, nutritional status, and maternal dietary intake.

Materials and Methods

This study uses a cross-sectional design study conducted in the City of
Bengkulu in January-April 2018. 144 mothers-born babies were selected using the
Consecutive sampling technique. Inclusion criteria were: single pregnancy,
maternal gestational age ≥35 weeks (based on the last menstrual period/fundus high
examination or examination Ultra Sound Graff), having a Maternal and Child
Health Book (MCH) containing maternal health history records, babies born ≥ 37
Sunday. Exclusion criteria were: mothers suffering from chronic diseases (diabetes,
hypertension, parathyroid disorders, liver, heart or kidney disease), infectious
diseases (tuberculosis, malaria, HIV-AIDS), taking drugs that affect the metabolism
of vitamin D (including glucocorticoids and seizures), babies born with congenital
malformations.
Infant birth weight was measured in the first hour of birth with Seca brand
scales (type 231/231 Corp Hamburg, Germany), the accuracy was 0.01 gr. Vitamin
D status of cord blood was measured using 25 (OH) D concentration parameters.
Approximately 2 ccs of blood were taken from the umbilical cord vein from the
side of the maternal placenta as soon as the umbilical cord was cut. Blood collection
is done after signing written informed consent. Blood samples were centrifuged at
1500 rpm for 15 minutes and stored at -20 °C until the analysis was carried out. 25
(OH) D concentration was measured by the Electro Chemiluminescence Immuno
Assay (ECLIA) method of competitive protein binding assay using the standard
measuring instrument CobasElecsys 411 (Roche Diagnostics, Mannheim,
Germany) with traceability standardized against LC-MS / MS. Serum vitamin D
specimens were examined at Kimia Farma Laboratory which used to check
samples, have been accredited and have ISO 9001: 2015. The reference values used
by the laboratory are also values recommended by the US Endocrine Society's
Clinical Guidelines Subcommittee. deficiency is Vitamin D defined as 25 (OH) D
≤20 ng / mL or ≤50 nmol / L, insufficiency if 25 (OH) D is 21-29 ng / mL or 52.5-
72.5 nmol / L and sufficient 25 (OH) D is ≥ 30 ng / mL or ≥75 nmol / L (20).
Specifically, the cut off of vitamin D in neonates is absent (21).
Calcium, maternal characteristics, nutritional status, and maternal dietary
intake were variables collected as potential confounders. Calcium derived from
cord blood serum was measured by photometer using the Ion Selective Electrode
(ISE) method. Interviews are used to collect maternal characteristics such as age
and parity. Maternal nutritional status, namely height and height of the father, was
measured using microtoise with a maximum capacity of 200 cm and the nearest
accuracy of 0.1 cm. Body weight during pregnancy was weighed using a Camry
brand digital scale weighing 200 kg and the closest 0.01-gram accuracy. Weight
gain is calculated by reducing body weight during pre-pregnancy maternal weight
pregnancy written on maternal MCH books. Maternal nutritional status was defined
by assessing hemoglobin levels using capillary blood with the methodcyanmet
hemoglobin. Data for maternal nutrition: that is the intake of nutrients macro
(energy, protein, and fat) obtained by using Recall 2x 24 hours on different days,
intake of micronutrients (Fe and Zinc) were collected by food frequency
questionnaire (FFQ) semi-quantitative. Nutritional intake was calculated using soft
ware Nutri Survey 2007.
Data analysis included univariate: mean, standard deviation, minimum-
maximum and percentage. Bivariate with independent t-test and Pearson
correlation. Multivariable using multiple linear regressions. P <0.05 was considered
statistically significant. The analysis was carried out using SPSS for window
version 21.
Results
Characteristics of infants were mostly women (55.6%). Infants with LBW
(<2500) grams were ten babies (6.9%), the lowest birth weight was 2200 gr, and
the largest was 4200 gr. The mean concentration of vitamin D 25 (OH) D was 27.6
ng / mL, vitamin D deficiency at 25 (OH) D (≤20ng / mL) was 25.7%, insufficiency
25 (OH) D(21-29 ng / mL) is 36.8% and the adequacy of 25 (OH) D (> 30ng / mL)
is 37.5%. The average calcium concentration is 10.1 mg / dL.
Based on maternal characteristics, the average maternal age was 27 years
eight months, 11 people (7.6%) aged <20 years and 15 people (10.3%)> 35 years
old were classified as at risk. The maternal parity is an average of 2 children. The
average maternal height is 153.9 cm, and father is 164.6 cm. The average
hemoglobin level of maternal blood is 10.6 mg%. The average maternal weight gain
during pregnancy is 12.7 kg. The average maternal nutritional intake per day:
energy 1682.1 kcal, protein 59.5 grams, fat 53.2 grams, Fe 11.2 mg, zinc 11.5 mg
(see Table 1).
In table 2, presents the difference in mean baby birth weight between two
vitamin D status categories. Non-sufficient vitamin D if 25 (OH) D <30 ng/mL and
sufficient if 25 (OH) D ≥ 30 ng/mL (20). The average birth weight is greater in
infants with higher vitamin D concentrations or vice versa.
In multivariate analysis, potential confounding variables included as
candidates (p = 0.25) were calcium, maternal age, maternal height, maternal weight
gain, during pregnancy, hemoglobin, energy intake, protein intake, and iron intake.
The average infant birth weight was significantly different between vitamin D
sufficient and vitamin D non-sufficient (p = 0.004).
Table 3. is a regression model that shows a significant difference in mean
birth weight between two vitamin D status categories. After being controlled by
calcium, hemoglobin in maternal blood and energy intake, the average infant birth
weight 135.3 g was more significant in infants with sufficient umbilical cord
vitamin D than non-sufficient vitamin D (95% CI = 15.3 - 255.3, p = 0.027).

Discussion
The results of this study note that the average 25 (OH) D is 27.6 ng / mL. In
tropical regions such as India, the average cord blood vitamin D is 20.07 ng / mL
(22), which is much lower than the summer study in Hawaii, where the average
vitamin D cord is 27.1 ng / mL (23). Using the US Endocrine Society cut-off, the
recommended vitamin D concentration is ≥ 30 ng / mL. In our study, it was known
that non-sufficient proportion (<30 ng / mL) was 62.5% (25.7% deficiency and
insufficiency 36.8%). Even this result is not much different from the vitamin D non-
sufficient proportion in the summer in Hawaii which is 68% (19% deficiency and
49% insufficiency) (23). In India, the non-sufficient percentage is much higher at
83% (deficiency 63% and 20% insufficiency) (22). If we only analyze by
comparing the average value of vitamin D 25 (OH) D, in three countries there is
almost no significant difference, which describes the average vitamin D status of
the umbilical cord as non-sufficient.
Umbilical cord D vitamin status describes maternal vitamin D status (11–13)
because maternal vitamin D is the only source of fetal vitamin D that easily enters
the fetus through the placenta (14). Therefore low maternal vitamin D levels have
implications for low fetal vitamin D status. Although the city of Bengkulu is a
tropical region located at 30045'- 30059 'LS (south latitude) - 102014'-102022'BT
(East Longitude) which is illuminated by the sun throughout the year, only a small
portion of mothers (37.5%) who had a sufficient vitamin D level. This study
supports previous research through a systematic review that vitamin D deficiency
is common and has become an epidemic of public health problems around the world
in all age groups, especially women and children (24.25), including in countries
with sun-rich exposures throughout the year such as the Middle East (12).
Low concentrations of vitamin D can be affected by limited exposure to
sunlight as the primary source of vitamin D and low food intake as a source of
vitamin D (26). In this study, the factors that might cause high vitamin D deficiency
was not studied. However, the phenomenon of female behavior in Bengkulu which
tends to limit itself from sun exposure, pigmentation of the dark skin, using
sunscreen to whiter skin and wearing clothes that cover most of the body when out
of the house can limit vitamin D synthesis through the maternal skin. For further
studies, these factors need consideration.
Our study proves a significant association between vitamin D status and
birth weight. The average birth weight was 135.3 gr in infants with vitamin D status
≥ 30ng / ml compared to vitamin D status <30ng / ml. These results can be attributed
to the important role of vitamin D status in determining the transfer of vitamin D
and calcium from the mother to the fetus across the placenta. An adequate amount
of vitamin D increases transfer efficiency and calcium absorption to the fetus.
Without vitamin D, only 10 to 15% of the diit calcium can be absorbed. (7,27).
In women when 25-hydroxyvitamin D levels increase from an average of
20 to 32 ng / mL, the interaction of 1,25-dihydroxy vitamin D (an active form of
vitamin D) with vitamin D receptor (VDR) increases the efficiency of calcium
transport to the intestine by 45 up to 65% and absorption of calcium 30 to 40% (7).
With these data, 25-hydroxyvitamin D levels from 21 to 29 ng / mL (52-72 nmol /
L) can be considered to indicate relative deficiencies of vitamin D, and levels of 30
ng / mL or higher indicate the recommended vitamin D limit (20 ).
Growing evidence suggests that vitamin D deficiency during pregnancy can
interfere with fetal growth and cause a series of adverse pregnancy outcomes. This
evidence shows the same results as us. Studies in South India show that there is a
significant difference in the average birth weight of infants based on the
concentration of vitamin D in cord blood. The lower levels of vitamin D, the lower
the average birth weight of the baby (22). Studies in Iran prove a significant
relationship between vitamin D deficiency in pregnant women with LBW (28).
Several studies in China, showed that both mother and neonate at Beijing had
normal levels of 25 (OH) D (> 30 ng/ml) and severe vitamin D deficiency in
mothers and neonates had a higher risk of LBW with an average baby weight birth
3354.8 g at birth was among neonates with <25 nmol / l and 3640 gr among
neonates with vitamin D ≥ 25nmol (11). Maternal vitamin D status was positively
associated with infant birth weight, after adjusting for confounders, birth weight
increased by 69 g / ml by an increase of 25 (OH) D less than 20 ng/ml (29). Maternal
vitamin D deficiency significantly increases the risk of neonatal low birth weight
by 2.8 times (13).
The case is slightly different from the results of a study in Anhui China
which showed an inverse U-shape relationship between birth weight on cord D
vitamin status. There was an increase in birth weight of 61 g at a concentration of
<40 nmol / L but decreased 68.5 g at a concentration of 40-70 nmol / L (30).
Even though the results are diverse, but many other shreds of evidence
support the positive relationship of vitamin D and birth weight. Results
Randomized Clinical Trial (RCT) by giving vitamin D supplementation to pregnant
women (gestational age 24-26 weeks) who are deficient and insufficient vitamin D
<30ng / ml of25 (OH) D, showed that vitamin D supplements increased maternal
blood vitamin D levels and fetal growth such as length of body weight and neonatal
head circumference (27). A meta-analysis conducted on 13 RCTs also showed the
benefits of vitamin D supplementation during pregnancy which increased
circulating levels of 25 (OH) D during labor by 66.5 nmol / L, body weight 107.6
g and length at birth by 0.3 cm ( 31). These results are reinforced by other meta-
analyses that reported from three experimental studies (Brooke 1980; Marya 1988
and Sablok 2015) involving 493 pregnant women who received vitamin D
supplements during pregnancy had fewer babies with birth weight below 2500 g
than pregnant women who did not accept intervention (32).
As far as the authors know, this study is the first study in Indonesia to assess
the relationship between vitamin D blood cord status and weight at birth. Our
research has several strengths. First, we use the umbilical cord. By utilizing
umbilical cord blood, we can evaluate the actual vitamin D status of the baby born
which is transferred by the mother to the fetus. Second, weight measurement at birth
is done by the same trained midwife and uses the same measuring instrument.
Conclusion
Vitamin D status has an impact on infant birth weight. The average baby's
weight at birth was more significant in infants with vitamin D sufficient than non-
sufficient vitamin D. Therefore this public health problem needs to be an urgent
concern. Efforts to increase sun exposure and intake of foods rich in vitamin D need
to be considered to improve maternal vitamin D.
Longitudinal studies and interventions further regarding dosage, duration of
supplementation and side effects, vitamin D supplementation need to be done to
improve vitamin D status in pregnant women which has implications for vitamin D
status from the fetus to minimize the incidence of LBW.

Acknowledgments
We express our gratitude for the support of the 2018 University of Indonesia
Student Final Assistance Grants Fund and the Learning Tasks of the Health Human
Resources Development Agency of the Ministry of Health of the Republic of
Indonesia. We also thank fellow midwives, obstetricians and gynecologists and
mothers for their collaboration in supporting this research data. Likewise in Kimia
Farma clinical laboratory for analysis of vitamin D and calcium. Thank you to Dr.
Besral, SKM, MSc as a data analysis consultant.

Ethical Approval
This study was approved by the Health Research Ethics Committee of the
University of Indonesia's Faculty of Public Health Number: 483 / UN2.F10 /
PPM.00.02 / 2017 dated 25 August 2017.

Competing Interest
Autos does not need to reveal anything.

Table:

Table 1. Characteristics: baby born umbilical cord blood vitamin D and

pregnant women
 Variable Mean ± SD p
Newborn baby 48.7 ± 1.87
- Short (<48 cm) (n = 45)
- Normal (> 48 cm) (n = 99)
Blood cord
Vitamin D (25 (OH) D) 27.6 ± 9.5
- Deficiency (≤20 ng / ml) (n = 38)
- Insufficiency (21-29 ng / ml) (n = 52)
- Sufficiency (≥30 ng / ml) ( n = 54)
Potential confounders
- Calcium (mg / dl) 10.1 ± 1.8 0.0001 *
characteristics
- Maternal age(years) 27.8 ± 5.7 0.90
- Parity (children) 2 ± 1.2 0.319
- High maternal (cm) 153.9 ± 4.2 0.001 *
- High father (cm) ) 164.6 ± 5.7 0.558
Nutritional Status Maternal
- Hemoglobin (mg%) 10.5 ± 1.3 0.0001 *
- Maternal weight gain (kg) 12.7 ± 2.6 0.0001 *
Intake of nutrients
- Energy intake (k.cal) 1682.2 ± 279.1 0.001 *
- Protein intake (gr) 59.5 ± 14.1 0.233
- Fat intake (gr) 53.2 ± 19.8 0.584
- Intake of Fe (mg) 11.5 ± 4.7 0.388
- Zinc Intake (mg) 11.5 ± 4.4 0.374
* <0.05
Table 2. Mean Weigth at birth data based on Vitamin D Vitamin D status

25 (OH) D status at birth Weight (g) p

n Mean SD 0004
Non Sufficienct (<30 ng / mL) 90 3018.5 ± 372.7
Sufficienct (≥30 ng / mL) 54 3211.4 ± 410.2

Table 3. Regression Model Birth length is

95.0% CI for β
Variable Β p Lower bound Upper bound
Vitamin D 135, 3 0.027 15.3 255.3
Calcium 52.3 0.001 20.8 83.8
Hemoglobin 72.5 0.2 0, 002 28 117
Energy Intake 0.020 0.041 0.046