SYMPOSIUM: NUTRITION

Micronutrients optimal intakes occur in sub-groups of populations causing

adverse effects on health, particularly long term.
Vitamins are subdivided into two groups: fat soluble vitamins
Rita Shergill-Bonner which include A, D, E and K and water-soluble vitamins which
include B and C. Essential minerals are calcium, phosphorus,
magnesium, sodium, potassium, iron, zinc, and fluoride (semi-
Abstract essential). Trace elements considered essential are copper,
Micronutrients are essential dietary components and play a funda- chromium, manganese, molybdenum, selenium and iodine.
mental role in disease prevention. 30 are essential and cannot be syn- The biochemical functions of some micronutrients are
thesised by the body on a daily basis, making dietary sources critical. considerable and some are outlined below (see Table 1):
Micronutrients have an array of biochemical functions which are cen-
tral in the homeostatic regulation of body function. In metabolic path- Origins of micronutrients
ways chemical reactions may not be able to continue along their
Micronutrients are acquired from different sources that are intrinsic
natural path if a crucial micronutrient is lacking. The normal metabolic
within the tissue matrix of the edible parts of plants and animals
regulation of the body will have been disturbed and ill health may
and from the fluid components. Those from extrinsic sources
occur due to the absence of a specific micronutrients.
include specific nutrients that are used in fortification processes;
Several population groups with specific nutritional requirements,
thiamine to white flour, iodine added to salt. The biofortification of
complex socio-economic and environmental circumstances may be
plants during their growth can increase specific nutrient content of
at risk of inadequate micronutrient intakes and not meet their recom-
foods such as iron in rice. Some nutrients are added to foods for
mended requirements levels due to poor consumption or excessive
commercial enhancement and consumer appeal. Also, many in-
losses. This group may benefit from micronutrient supplements. In-
dividuals will consume nutritional supplements in the form of
fants/children are a specific population group who are at risk of micro-
pharmaceutical preparations to boost their individual micro-
nutrient deficiency making adequate intakes essential to ensure
nutrient levels. The growth, storage, processing and cooking of
normal growth and development. The paediatric population will be dis-
food can affect the nutritional content and the bioavailability of
cussed here, with reference to current recommendations for their
nutrients from food items and thus determine the nutrient intake an
micronutrient and supplementation requirements based on current ev-
individual can achieve from the type of diet they consume.
idence available.
Keywords biochemical function; deficiency states; micronutrients; Micronutrient requirements
nutritional requirements; paediatrics; recommendations; supplemen-
tation; vitamins & minerals Establishing precise daily requirements is difficult as there is
considerable individual variation in requirements. Recommen-
dations for the intake of micronutrients in the normal diet have
Introduction been formulated from observational intake studies in healthy
populations, along with some detailed nutrient balance studies,
Micronutrients have the primary function in human metabolism laboratory estimates of blood and tissue status associated with
and physiology in the maintenance, optimisation of health and in particular levels of intake. Variability may occur due to the
the prevention of disease. Adequate intakes are essential in diverse methods employed to assess requirements in different
maintaining the body’s homeostasis, its physiological func- age, sex, chronic disease, pregnancy and specific dietary condi-
tioning and for the normal growth and development of the child. tions. Requirements have been set for the intake of each micro-
The World Health organization (WHO) estimate that in excess of nutrient for a given population below which a clinical deficiency
2 billion people are deficient in important micronutrients; namely state is increasing likely to occur, or above which a toxicity state
vitamin A, iodine, iron and zinc. Micronutrients are essential di- may develop. The precise requirements however, for a particular
etary components and are composed of organic substances (fat and individual are difficult is to determine.
water soluble vitamins), inorganic minerals and trace elements. The Reference Nutrient Intakes (RNI) in the UK, are defined as
Minerals are required in relatively small quantities measured in the intakes of each micronutrient that meet the requirements of
micrograms and vitamins and trace elements are required in larger almost all (97.5%) of the population group. For individual needs
quantities and are measured in milligrams (mg) per day by the the RNI ensures that their requirements are highly likely to be
body. At least 30 are essential and cannot be synthesised by the met, but are likely to be exceeded. The RNIs were developed from
body on a daily basis, making dietary sources critical. They have a the nutritional intake of the healthy population and it can be
variety of functions including tissue structure, enzyme systems, concluded that the typical diet of a healthy population will provide
fluid balance, cellular function and neurotransmissions. the required range and quantity of these nutrients. Within the
Vitamins were first identified from the overt deficiency states healthy population there will be situations where the intake may
that occurred in conditions such as scurvy, beriberi and pellagra, be less than adequate. The national diet and nutrition survey has
as a result of inadequate intakes of specific nutrients. Sub- recognized that the typical UK diet does provide adequate
amounts of micronutrients in the young population aged 4e18
years but that a large number may have intakes lower than the
Rita Shergill-Bonner Bsc (Hons) Dietetics RD PGD Allergy is Principal lower RNI for certain minerals. Individuals in this age group may
Gastroenterology Dietitian at the Evelina London Children’s Hospital, have low intakes of fruit and vegetables but biochemical evidence
London, UK. Conflict of interest: None. of poor status of vitamins is rare. Laboratory tests of micronutrient

PAEDIATRICS AND CHILD HEALTH --:- 1 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002
 SYMPOSIUM: NUTRITION

may occur include stunting (low height-for-age), increased

The biochemical functions of micronutrients morbidity and reduced function in later life. Iron deficiency is
C Trace elements act as cofactors in metabolism and are involved in also associated with psychosocial and economic difficulties,
modulating enzyme activity or form an integral part of enzyme which may also explain some of the children’s functional deficits.
prosthetic group. Zinc, for instance, is a cofactor in over 100
The effect of breast feeding on iron status
enzymes. Selenium is an essential part of selenocysteine within
The concentrations of the minerals iron and zinc in breast milk
the enzyme glutathione peroxidase.
decrease significantly between early and mature milk. The con-
C Vitamins and their metabolites act as coenzymes in metabolism
tent is unaffected by maternal status, diet or supplementation.
and form active complexes within the biochemical reactions.
Breast milk alone cannot achieve iron requirements of infants in
Riboflavin and niacin act as coenzymes in the electron transport
the first six months of life and they are dependent on its iron
chain. Folic acid forms part of methyl group transfer. These re-
stores acquired in the last trimester of pregnancy. It is important
actions are essential to intermediary metabolism, guarantee uti-
that the mother has good stores of iron pre-pregnancy and post
lisation of the major nutrients and thus ensure production of
for breast feeding.
energy, proteins and nucleic acids.
C Many micronutrients have antioxidant properties. Normal free
The age of the child is important
radical formation and the subsequent damaging effect they can
Iron stores will decreased by six months of age in the infant and
cause to cells, can be reduced by mechanisms that include direct
requirements are higher from 6 to 12 months of age as compared
suppression of oxidant activity by tocopherols (vitamin E) or ca-
to the second year of life. The first two years present a vulnerable
rotenoids (vitamin A), or enzyme systems which dispose of the
period for the toddler’s development. Requirements must be
products of oxidation: superoxide dismutase (zinc, copper or
achieved in order to achieve normal growth, brain development,
manganese dependent) and glutathione peroxidase (selenium
development of the central nervous system, motor skill devel-
dependent).
opment, cognitive function and social-emotional development.
C The mineral zinc is incorporated into “finger” enzymes, binding to
Preventive actions should be introduced early to avoid these
DNA and regulating transcription of receptors for steroid hor-
problems. Iron supplementation to correct deficiencies states and
mones and other factors.
exclusive breast feeding until 6 months of age has been recom-
mended by WHO to ensure adequate nutritional intake. Also,
Table 1
continue breast feeding for at least 2 years after infants have
status are rather insensitive. However, the lack of biochemical commenced weaning around the age of 6 months. Complemen-
evidence of deficiency does not imply optimal function. tary weaning with high iron containing foods is essential be-
The recommended requirements for micronutrients must be tween 4 and 6 months of age. Iron fortification of infant follow-
evaluated at regular intervals. In industrialized countries, pro- on formulas and foods may be also required.
vided that the diet is balanced by ensuring the consumption of a
varied diet and in the absence of chronic disease, the majority of Risks and benefits of iron supplementation
needs are covered. Dietary assessment remains the best tool to The majority of studies suggest there are no adverse effects of
assess needs and nutritional deficiencies. iron supplementation. However, universal supplementation is
still hindered by doubts over the detrimental effects of excess
Requirements for different groups iron in children who are not iron-depleted. Iron supplementation
usually has beneficial effects on motor development in children
At risk groups within the UK with IDA under 3 years of age and beneficial effects on cognition
Population groups with complex socioeconomic and environ- function in iron-deficient anaemic school-aged children.
mental circumstances may have inadequate nutrient intakes due Promoting dietary diversity and food processing techniques
to poor consumption of fresh fruit and vegetables and hence with the goal of increasing total iron content and improving the
maybe unable to meet their recommended intakes of micro- bioavailability of non-heme iron are safe and sustainable ways of
nutrients. This group may benefit from micronutrient supple- meeting iron requirements throughout childhood. An effective
ments. Other, at risk groups who are known to have inadequate public health approach to improve the iron status of at risk
intakes or increased requirements include adolescents who may populations is through fortification programs, but these pro-
have increased requirements of specific nutrients such as calcium grammes face many challenges.
but consume low levels of calcium rich foods.

Global perspectives National guidance in the UK

Deficiencies of iron, vitamin A, zinc have been shown to The Department of Health (DH) has made several recommen-
particularly affect half of all infants and young children under the dations for various at risk groups who may be at greater risk of
age of two years internationally. Iron deficiency occurs in infants, micronutrient deficiencies or excesses. These include:
children and adolescents due to high requirements during pe-
riods of rapid growth, low dietary intakes and low bioavailability Women of childbearing age/women planning
from dietary sources. Ineffectual iron homeostasis and intake pregnancy
during these critical periods may cause adverse health conse- The expert advisory group on folic acid and neural tube defects
quences, delayed neurodevelopment and cognitive functions. (NTDs) have advised that all women planning a pregnancy
The adverse health consequences of suboptimum iron intake that should take 400 mg folic acid supplementation until the 12th

PAEDIATRICS AND CHILD HEALTH --:- 2 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002
 SYMPOSIUM: NUTRITION

week of pregnancy and to select folic acid fortified foods and serum ferritin levels decrease. It is important therefore to ensure
folate-rich foods. For mother’s with a previous child with NTD or the daily milk intake for a toddler does not exceed 400 mls per
those from families with history of NTD or those with other day (120 mls  3 drinks per day and the rest from dairy
known risk factors (e.g. taking antiepileptic drugs or anti-folate products).
drugs) the Scientific Advisory Committee on Nutrition (SACN) The vitamin A requirements for under five year old children
recommend supplementation of 5 mg (5000 mg) folic acid should are moderately high. NDNS data indicate that a considerable
be taken daily until the 12th week of pregnancy. section of this group do not meet the lower reference nutrient.
Some countries (Canada and USA) have legislated to require Vitamin A is crucial for growth and development of the immune
fortification of flour with folic acid (240 mg/100 g) and this has system. Supplementation is recommended in the UK, ensuring
led to a decrease in the incidence of NTD. In the UK white flour is that excessive intakes are avoided but due to the risk of toxicity.
already fortified with thiamine, niacin, calcium and iron but not Children from poorer economic backgrounds have been
with folic acid, due to the theoretical risk of this masking vitamin shown to have lower intakes of vitamin C perhaps because of
B12 deficiency. lower consumption of fruits and vegetables. Vitamin C is
The DH also recommends excessive intakes of retinol should essential in the absorption of non-haem sources of iron. To meet
be avoided in women of childbearing age as high intakes of Vitamin C requirements it is advised children consume 5 chil-
vitamin A are teratogenic in the periconceptual period. dren’s portions of fruit and vegetables per day.
Vitamin D is crucial for calcium absorption. Information from
SACN indicates that a large proportion of women of childbearing Presentation of micronutrient deficiency
age (women with dark pigmented skin and who cover up with
Typical nutritional deficiency presents with a multifaceted set of
clothing, and those that live in areas of low exposure due to
characteristic signs and symptoms. Advanced clinical deficiency
season and latitude) have suboptimal serum vitamin D concen-
disease usually occurs as an endpoint of a prolonged history of
trations. In infancy Vitamin D deficiency is associated with poor
inadequate consumption. Primary vitamin deficiency occurs
maternal vitamin D status and can manifest with poor dentition,
when the dietary intake is inadequate and falls below the re-
poor skeletal growth, rickets and hypocalcaemic tetany. Breast
quirements. Secondary deficiency arises when the dietary intake
fed infants are at higher risk as breast milk contains low levels of
is adequate but the utilization by the body is defective (i.e.
vitamin D, the concentrations of which depend on maternal
digestion, absorption, transport or cellular metabolism).
vitamin D status. Breast fed infants can maintain normal vitamin
Studies from SACN investigating the National Diet and
D status in the early postnatal period only if their mothers’
Nutrition Surveys (NDNS) from 1992 to 2001 and 2008 to 2009,
vitamin D status is normal and/or the infants are exposed to
determined that consumption of fruits and vegetables were
adequate amounts of sunlight. UNICEF UK emphasise that a baby
inadequate, with only 39% of 1 ½ to 4 ½ year olds consuming
born deficient in vitamin D will not restore their levels from
green leafy vegetables, 50% eating apples, pears and bananas
breast milk alone.
and only 25% eating citrus fruits. The dietary micronutrient
Breast feeding mothers and adolescents intake of children in the UK is therefore likely to be inadequate.
Calcium also becomes essential and calcium loss during lactation As part of the ‘Welfare Food Scheme’ in the 1940s, vitamins
is estimated to be 210 mg/day. Lactating women should have at A, C and D were considered to be at risk of deficiency in the
least 1250 mg calcium daily and young women/adolescents child’s diet and it was thus advised that these vitamins should be
should have 1500 mg daily. This can be achieved through dietary routinely supplement in a child’s diet up to the age of 5 years.
sources and calcium fortified foods. The uptake of supplementation was patchy across the country
and the scheme first came up for review in 1999 and was sub-
Children sequently transformed into the ‘Healthy Start’ project, launched
An RNI for vitamin D, of 10 mg/d (400 IU/d), is recommended for in 2006, which advised for supplementation of under 4 years of
the UK population aged 4y and above. This is the average amount age to be essential, using ‘Healthy Start children’s vitamin drops.
needed by 97.5% of the population to maintain a serum 25(OH)D
concentration 25 nmol/L when UVB sunshine exposure is min- Micronutrient status at birth
imal. It refers to average intake over a period of time (e.g., a week) The fetus will obtain the majority of its micronutrients re-
and takes account of day to day variations in vitamin D intake. The quirements from its mother, with the water soluble B vitamins
RNI of 10 mg/d (400 IU/d) proposed for the general UK population and C being actively transported across the placenta throughout
(aged 4y and above) includes pregnant and lactating women and the pregnancy and the fat soluble vitamins A, D and E being
population groups at increased risk of having a serum 25(OH)D transferred at the end of the pregnancy. Vitamin K however, is
concentration <25 nmol/L. A separate RNI is not required for only transferred in small quantities. Vitamin K is offered to all
these groups. SACN felt the data were insufficient to determine new born infants as an injection or oral supplement to prevent
RNIs for infants and children aged under 4 years. As a precaution, a deficiency.
‘Safe Intake’ of vitamin D is recommended for these ages: in the
range 8.5e10 mg/d (340e400 IU/d) for ages 0 up to 1y (including Micronutrient deficiencies in children
exclusively breast fed and partially breast fed infants, from birth);
and 10 mg/d (400 IU/d) for ages 1 up to 4y. Multiple micronutrient deficiencies
In healthy children aged 2e5 years as their intake of cow’s In contrast to single nutrient deficiencies e.g. iron, vitamin D, folate,
milk increases, the levels of 25-hydroyvitamin D increase and and vitamin B12 deficiencies, severe multiple deficiency states are

PAEDIATRICS AND CHILD HEALTH --:- 3 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002
 SYMPOSIUM: NUTRITION

uncommon in Western Europe. Single nutrient deficiencies are Milder forms of deficiency, often of multiple micronutrients,
usually simple to identify (see Table 2). Their occurrence can be are more common and can be complex to recognise and diag-
confirmed clinically and with laboratory tests, and deficiencies are nosis. An individual may develop the deficiency progressively,
simple to correct with the appropriate supplements. going through a series of biochemical and physiological

Function and deficiency states of micronutrients

Nutrient Function Deficiency

Vitamin A C Maintenance of the structure & functional C Skin integrity loss

integrity of epithelial tissue and immune C Increased risk of infection
system C Poor eyesight and night vision
C Normal functioning of retina & night vision C Loss of appetite
C Antioxidant C Embryonic abnormalities
Vitamin C Metabolism of fat, carbohydrate, protein, C B1 e Beriberi, muscle weakness, depres-
B1 e Thiamine alcohol sion, nerve tingling
B2 e Riboflavin C Energy metabolism C B2 e cheilosis, angular stomatitis, poor
B3 e Niacin concentration & memory,
B6 e Pyridoxine C B3 e Pellagra, depression, sores on
B12 e Colalamins tongue
Biotin C B6 e anaemia, skin sensitivity
Folate C B12 Pernicious anaemia, depression, nerve
tingling, numbness
C Folate e anaemia, neural tube defects
Vitamin C C Antioxidant C Scurvy
C For maintenance of tissue structure & im- C Poor wound healing
mune system C Muscle and joint pain
C Synthesis of collagen
C Helps with iron uptake
Vitamin D C Calcium homeostasis C Rickets/bone deformities
C Increase absorption of calcium & C Hypocalcaemic tetany in children
phosphate C Poor growth
C Bone pain
Calcium C Mineralisation of bones & teeth C Lower peak bone density
C Nerve transmission C Poor growth
C Blood clotting C Tetany
C Hormone function
Iron C Component of haemoglobin & myoglobin C Pallor
C Normal growth and development C Poor appetite
C Immune function C Increased risk of infection
C Fatigue
C Sore month/tongue
Zinc C Involved in metabolism of proteins, car- C Poor growth
bohydrates, lipids & nucleic acids C Poor wound healing
C Structural component and integrity of cell C Immune function impaired
membranes C Impaired fertility
C Wound healing
Iodine C Synthesis of thyroxine C Thyroid goitre
C Normal brain development C Increased risk of infection
C Required for thyroid hormone production C Prevention of cretinism, Goitre and
hypothyroidism
C Neurocognitive problems
Phosphorous C Energy metabolism C Calcification of soft tissue abnormal
C Bone mineralisation C Tetary
C Bone pain
C Weakness, lethargy
C Anorexia

Table 2

PAEDIATRICS AND CHILD HEALTH --:- 4 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002
 SYMPOSIUM: NUTRITION

consequences and subsequently resulting in severe depletion of It may not be possible to meet nutritional requirements for
one or several micronutrients. The metabolic or physiological micronutrients when an individual is following a limited diet.
consequences of such a suboptimal status are not always Food allergies can have a negative effect on growth and food
apparent but the assumption remains that this impaired meta- intake. Food substitutes may not provide adequate replacement
bolism is likely to have detrimental effects on long term health of specific nutrients such as calcium in dairy free substitute
such as poor bone minimisation. These specific ‘subclinical de- milks. If the number of foods being avoided is large, the range of
ficiencies’ can occur in localised tissues and can cause patho- alternative may be limited and so fail to ensure nutritional ade-
logical changes. The duration for development of a subclinical quacy. Also, an individual’s food preference may mean food
deficiency varies for individual micronutrients, and is dependent substitutes are not accepted and their use may become monot-
upon the nature and amount of body stores. onous and so compliance may be reduced.
Individuals with subclinical deficiency states of trace elements The poor availability and high cost of substitutes can affect
and vitamins are at increased risk of impaired immune function. compliance. Subsequently, micronutrient supplements will be
Chronic poor nutritional status can therefore present with an required to ensure dietary adequacy. Cow’s milk and milk
individual becoming acutely unwell with severe infection. products are the main source of calcium and vitamin D. If these
are removed the consequences on micronutrient intake and en-
Zinc deficiency ergy can be substantial. Whereas, if foods such as peanuts, tree
It is estimated that a third of the world’s population is deficient in nuts and fish are removed these rarely compromise nutritional
zinc. This may be exacerbated through diarrhoea; several studies intake. Multiple food allergies further compromise the nutritional
have indicated that zinc and vitamin A supplementation in intake of the child. Studies showed that the calcium intake of
children can reduce the prevalence of persistent diarrhoea and children who had cows’ milk protein allergy had lower calcium
dysentery and reduce the duration of childhood infections. than controls. Only when the children received a calcium sup-
Zinc is an essential micronutrient as it is fundamental plement did serum calcium correspond to the control group. This
required for many specific enzymes. It serves as a structural ion demonstrates the importance of dietary assessment and subse-
in transcription factors and as a structural component within quent supplementation of relevant micronutrients. In another
many organs. It has a main role in reproductive physiology, study younger infants who were placed on a cows’ milk exclu-
immune modulation, growth and development. It is bound to sion diet were found to have lower weight-for-length growth than
blood plasma and is transported by albumin and transferrin, infants who were not on an exclusion diet, perhaps a reflection of
which then transport iron and copper, thus affecting their bio- inadequate nutritional intake. No catch-up growth was seen at 2
logical function if deficient. To date many studies have shown years of age.
zinc fortification can significantly improve plasma zinc concen-
trations. Perhaps, mass fortification of zinc may be required to Prevention of micronutrient deficiencies
prevent deficiency states.
Strategies for resolving micronutrient deficiencies for diverse
population groups have been suggested by government pro-
Poor health as a trigger for micronutrient deficiency
grammes and local public agencies and include food based pro-
In disease states the nutritional status of an individual is
jects; increasing the energy, protein and micronutrient content of
affected by a combination of increased requirements and
food, micronutrient fortification of food products and adding
inadequate intake due to anorexia. It is important to identify
powders to food at home, taking nutritional supplements, and
situations where micronutrient status can be impaired. Sup-
fortification of staple food (flour, cereals, salt, water and oil). It is
plementary feeding (enteral/parenteral nutrition) may not pro-
important to target specific groups within the population. To
vide adequate quantities of protein, energy and micronutrients,
fortify complementary foods for weaning from 6 months of age
causing deficiency states. Increased requirements occur during
and specific cereals used by toddlers and the adolescent popu-
catabolism and when coupled with acute infection, surgery, or
lation. A systemic review found that multiple micronutrient
trauma can cause increased energy expenditure and protein
fortification of milk and cereals was an effective method to
breakdown. Increased requirements for water soluble vitamins
reduce anaemia of toddlers up to age of 3 in developing
and trace elements, which act as coenzymes in metabolic
countries.
pathways and trace elements will transpire. Trace element de-
ficiencies also arise when patients become anabolic, after a
Conclusion
prolonged period of catabolism. Increased requirements for all
nutrients will occur in children during growth periods of The precise micronutrient requirements remain difficult to
anabolism. establish and an area of deliberation. Despite this ambiguity
Loss of body fluids will cause a loss of certain micronutrients clinicians and experts must use the appropriate tools to accu-
such as iron as a result of blood loss. Diarrhoea can be a cause of rately assess dietary intake, anthropometric and biochemical
zinc deficiency and cause a cycle of worsening diarrhoea as a status of individuals in order to assess requirements, taking into
result of zinc deficiency. Excessive vomiting can cause potassium account other influencing factors such as ill-health. De-
loss which can be life threatening. Fistula losses and losses from velopments in the technology allowing the accurate measure-
burn exudates, or dialysis, can lead to depletion of water soluble ment of body composition and in balance studies will allow
vitamins, trace elements and sodium too. It is important to better understanding of requirements. Thus, allowing more pre-
guarantee that individuals obtain an adequate intake from their cise nutritional requirements to be established and recommen-
food, supplements or IV fluids replacement. dations made for specific population groups and individuals.

PAEDIATRICS AND CHILD HEALTH --:- 5 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002
 SYMPOSIUM: NUTRITION

This will ensure the correct quantities of micronutrients are Maguire JL, Lebovic G, Kandasamy S, et al. TARGet kids!; collabo-
consumed so preventing inadequate and excessive intakes. A ration. Pediatrics 2013 Jan; 131. 2012e1973.
National Institute for Health and Clinical Excellence. Improving the
nutrition of pregnant and breasting feeding mothers and children in
FURTHER READING low income households. NICE public health guidance 11. 2008.
Bath SC, Steer CD, Golding J, et al. Effect of inadequate iodine status London: NICE [Online] Available: www.nice.org.uk/PH011.
in UK pregnant women on cognitive outcomes in their children: National Institute for Health and Clinical Excellence. Antenatal care,
results from the Avon Longitudinal Study of Parents and Children routine care or the healthy pregnant woman. 2008. London: Royal
(ALSPAC). Lancet 2013; 382: 331e7. College of obstetricians and Gynaecologists Press, http://www.
CMO. Vitamin D advice on supplements for at-risk groups. 2012, nice.org.uk/nicemedia/pdf/CG062NICEguidelines.pdf.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_ NIH consensus panel on optimal calcium intake. NIH consenses
digitalassets/@en/documents/digitalassets/@dh/@en/documents/ conference. Optimal calcium intake. J Am Med Assoc 1994; 272:
digitalasset/dh_132508.pdf [Accessed Feb 2012]. 1942e8.
Das JK, Kumar R, Salam RA, Bhutta ZA. Systematic review of zinc Panel of Dietary Reference Values, Department of Health. Dietary
fortification trails. Ann Nutr Metab 2013; 62(suppl 1): 44e56. reference values for food energy and nutrients for the United
Department of Health. Report of the panel on dietary reference values of Kingdom. London: HMSO, 1991.
the committee on medical aspects of food policy (COMA). Dietary Report on the working group on the weaning diet of the committee
reference values for food energy and nutrients foe the United Kingdom. on medical aspects of food policy (COMA). Weaning and the
Report on health and social subjects 41. London: HMSO, 1991. weaning diet. Report on health and social subjects. London :
Department of Health and Social Security. Vitamin a and pregnancy. HMSO.
PL/CMO (90) 11, PL/CNO(90). London: HMSO, 1990. Sarma KV, Udaykumar P, Balakrisha N, et al. Effect of micronutrient
Department of Health. Present day practice in infant feeding: third report. supplementation on health and nutritional status of schoolchildren:
Report on health and social subjects 32. London: HMSO, 1988. growth and morbidity. Nutrition 2006; 22. SB-14.
Fiocchi A, Brozek J, Schu € nemann H, et al. World Allergy Organisation Scientific Advisory Committee on Nutrition. Vitamin D and health.
(WAO), Diagnosis and rationale for action against cows’ milk allergy Position statement by the scientific advisory committee on nutri-
(DRACMA) guidelines. Pediatred Allergy Immunol 2010; 21(suppl tion. 2016. London, http:/www.sacn.gov.uk/pdfs/sacn_position-
21): 1e25. vitamin-d-2007-05-07.pdf.
Food Standards Agency. National diet and nutrition survey young people UNICEF UK. Baby friendly initiative statement on vitamin D supple-
aged 4 to 18 years, 1997. London: The Stationery Office, 2000. mentation for breastfed babies. 2011 [Online]. Available: http://
Hoare J, Henderson L, Bates CJ, et al. The national diet and nutrition www.unicef.org.uk/BabyFriendly/News-and-Resaeach/News/
survey: adults aged 19e64. London: The Stationery Office, 2004. UNICEF-UK-Baby-Friendly-Initative-Statement-on-vitamin-D-
Grantham-McGregor S, Baker-Henningham H. Ann Nestle 2010; 68: supplementation-for-breastfed-babies/.
105e19. World Health Organization, UNICEF. Global strategy for infant and
Isolauri E, Siitas Y, Salo M, Isosomppi R, Kaila M. Elimination diet in young child feeding. 2003. Geneva: WHO. Available at: www.
cow’s milk allergy: risk for impaired growth in young children. unicef.org/nutrition [accessed 18 October 2013].
J Pediatr 1998; 132: 1004e9.

PAEDIATRICS AND CHILD HEALTH --:- 6 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shergill-Bonner R, Micronutrients, Paediatrics and Child Health (2017), http://dx.doi.org/10.1016/
j.paed.2017.04.002