Cod Liver Oil, the Ratio of
Vitamins A and D, Frequent Respiratory Tract Infections, and Vitamin D
Deficiency in Young Children in the United States. Ann Otol Rhinol &
Laryngol 2010;119:64-70. By Linday LA, Umhau JC, Shindledecker RD, Dolitsky JN, Holick MF.
This paper is a response to "Cod liver oil, vitamin A
toxicity, frequent respiratory infections, and the vitamin D deficiency
epidemic." Ann Otol Rhinol & Laryngol 2008;117:864-70.
Commentary on "Breastfeeding Does
Not Protect Against Urinary Tract Infection in the First 3 Months of Life, but
Vitamin D Supplementation Increases the Risk by 76%." Clinical
Pediatrics 2010;49:93-4. By Linday LA, Shindledecker RD, Greer, FR,
Dr. Linday and colleagues disagree with the way the statistics
were performed in the original paper, and they therefore disagree with the
Supplements and Pediatric Upper Respiratory Tract Illnesses [letter]. J
Allergy Clin Immunol 2006;117:953-4. By Linday LA.
Upper respiratory tract illnesses are a common cause of
exacerbations of asthma; Dr. Linday therefore suggests that evaluation of the
study dietary supplements for children with asthma is warranted.
Plasma 25-hydroxyvitamin D levels
in young children undergoing placement of tympanostomy tubes. Ann Otol Rhinol
By Linday LA, Shindledecker RD, Dolitsky JN, Chen TC, Holick MF.
Objective: To report
plasma 25-hydroxyvitamin D [25(OH)D] levels of 16 young children undergoing
ambulatory surgery for placement of tympanostomy tubes.
Methods: We previously
obtained blood samples from young children undergoing ambulatory surgery, and
reported that they had lower blood levels than adults of eicosapentaenoic acid
(an omega-3 fatty acid), vitamin A, and selenium. Plasma frozen continuously
at -80º was available from 16 subjects undergoing placement of tympanostomy
Results: Mean age =
3.7 years (± 1.6 SD); median = 2.9 years; range = 1.9-7.4 years. 62% were
male; half were white and half Hispanic; 62% were private patients; parents
reported half were taking vitamin supplements; none had a history of rickets.
None had 25(OH)D levels <10 ng/mL; 50% had 25(OH)D levels < 20 ng/mL
(deficient in adults); another 31% had levels from 21-29 ng/mL (insufficient
Conclusion: Vitamin D
is essential for the production of endogenous anti-microbial peptides, and has
been linked to seasonal, epidemic influenza A. However, the level of 25(OH)D
needed to prevent infection with various human pathogens has not been defined.
In view of increasing bacterial resistance and emerging new pathogens, further
research on the relationship of infection to 25(OH)D and other nutritional
factors is warranted.
Note: In October 2010, Dr.
Linday will be an invited speaker at the American College of Nutrition (ACN)
51st Annual Symposium on Advances in Clinical Nutrition, to be held at the New
York Academy of Medicine in New York City.
Dr. Linday's INTERNATIONAL presentations at the Vth IAPO (Interamerican
Association of Pediatric Otorhinolaryngology) International Symposium on
Pediatric Infectious Diseases in Ear, Nose and Throat; São Paulo, Brazil,
October 19-21, 2007.
March 8, 2006: Sam Brooke Visiting Professor in Dietary Supplements at Wake
Forest University Medical School in Winston-Salem, North Carolina.
Dr. Linday’s chapter, "Nutritional supplements and upper
respiratory tract illnesses in young children living in the U.S.A.,"
has been published in "Preventive
Nutrition: The Comprehensive Guide for Health Professionals, Third Edition,
edited by A. Bendich and RJ Deckelbaum, Humana Press Inc.,
Totowa NJ, 2005.
wrote to the United States Department Agriculture (USDA) on December 15, 2003
and proposed that the supplements used in these studies be made available
through WIC (Special Supplemental Nutrition Program for Women, Infants,
and Children). Click the following link to read her letter (you will need
Adobe Acrobat Reader to access this information):
ABSTRACTS OF PREVIOUSLY PUBLISHED PAPERS:
TITLE: Effect of daily cod liver oil and a multivitamin-mineral with
selenium on upper respiratory tract pediatric visits by young, inner-city,
Latino children: Randomized pediatric sites.
AUTHORS: Linday LA, Shindledecker RD, Tapia-Mendoza J, Dolitsky JN
JOURNAL: Annals of Otology, Rhinology & Laryngology 2004, Volume 113,
Number 11 (November), pages 891-901
We studied the effect of daily supplementation with lemon-flavored cod
liver oil and a children's multivitamin-mineral supplement containing selenium
on the number of pediatric visits by young, inner-city, Latino children from
late autumn of 2002 through early spring of 2003. Two private pediatric
offices with similar demographics, located 1.1 miles apart in upper Manhattan,
New York City, were randomized to a supplementation site and a medical records
control site. Ninety-four children (47 at each site), 6 months to 5 years of
age, were enrolled. The mean age of the supplementation group was 2.03 years
(SD, +/- 1.04 years); that of the control group was 2.08 years (SD, +/- 1.10
years). Children > or = 1 year of age in the supplementation group received 1
teaspoon of lemon-flavored cod liver oil per day and one half-tablet of a
children's multivitamin-mineral; the starting dose was halved for children < 1
year of age. The supplements were given from enrollment through May 1, 2003.
The primary outcome measure was the number of upper respiratory tract
pediatric visits during the follow-up/supplementation period. The
supplementation group had a statistically significant decrease in the mean
number of upper respiratory tract visits over time (p = .042; r = 0.893; y =
0.602 - 0.002x); the medical records control group had no change in this
parameter (p = .999; r = 0.0006; y = 0.259 + 1.43 x 10(-6)x). The supplements
were well tolerated; per parental report, 70% of children completed the 5- to
6-month course of cod liver oil. Use of these nutritional supplements was
acceptable to the inner-city Latino families and their young children, and was
associated with a decrease in upper respiratory tract pediatric visits over
time; this approach therefore deserves further research and attention.
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TITLE: Nutritional supplements as adjunctive therapy for children with
chronic/recurrent sinusitis: Pilot research.
AUTHORS: Linday LA, Dolitsky JN, Shindledecker RD
JOURNAL: International Journal of Pediatric Otorhinolaryngology 2004,
Volume 68, Number 6 (June), pages 785-793
OBJECTIVE: Inflammation and edema of the sinonasal mucosa are important in
the pathophysiology of sinusitis. Based on the similarities between otitis
media (OM) and sinusitis, and our previous research on OM, we hypothesized
that nutritional supplements would be effective adjunctive therapy for the
treatment of children with chronic/recurrent sinusitis. METHODS: We performed
a 4 month, open-label, dose-titration study; subjects were enrolled from late
January to early March 2003. Each subject served as his own control. Study
supplements were a lemon-flavored cod liver oil and a children's
multivitamin-mineral with selenium, prescribed in escalating doses; at higher
doses, fish oil was substituted for cod liver oil. Subjects were private
pediatric otolaryngology outpatients with a clinical diagnosis of
chronic/recurrent sinusitis, whose symptoms were refractory to treatment with
antibiotics. RESULTS: Our four subjects were Caucasian males, ranging in age
from 4.2 to 9.8 years, with chronic/recurrent sinusitis for at least 3 years
prior to entry in the study. Three subjects had a positive response; one
subject dropped out for administrative reasons. Four, six, and eight weeks
after beginning study supplements, the responders had decreased sinus
symptoms, fewer episodes of acute sinusitis, and fewer doctor visits for acute
illnesses. Their parents reported that they had begun to recover from upper
respiratory illnesses without complications, which was unusual for these
children, as was improvement in springtime; their improvement had previously
been limited to the summer months or periods of home-schooling. CONCLUSIONS:
Use of flavored cod liver oil and a multivitamin-mineral with selenium as
adjunctive therapy for children with chronic/recurrent sinusitis is an
inexpensive, non-invasive intervention that clinicians can use for selected
patients, pending the performance of definitive, large, well-controlled
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TITLE: Lemon-flavored cod liver oil and a multi-vitamin/mineral
supplement for the secondary prevention of otitis media in young children:
AUTHORS: Linday LA, Dolitsky J, Shindledecker R, Pippenger CE
JOURNAL: Annals of Otology, Rhinology & Laryngology 2002, Volume 111,
Number 7 (July), pages 642-652
We measured blood levels of fatty acids, vitamin A, and trace metals in
children undergoing ambulatory surgery for placement of tympanostomy tubes and
a comparison group of children having other ambulatory surgical procedures; we
then performed a small, outpatient, secondary prevention study using
nutritional supplements chosen on the basis of these blood levels. Study
subjects had lower levels of red blood cell eicosapentaenoic acid (EPA) than
adult controls. Consistent with previous reports, levels of vitamin A were
£ 40 mg/dL for 69%
of our subjects, and plasma selenium values for children were lower than
published values for adults. We then studied one otitis media (OM) season; 8
children (0.8 to 4.4 years of age), received one teaspoon of lemon-flavored
cod liver oil (containing both EPA and vitamin A) and 1/2 tablet of a
selenium-containing children's chewable multi-vitamin/mineral tablet, per day.
During this OM season, study subjects received antibiotics for OM for 12.3%
± 13.4 (p<0.05; mean ±
SD) fewer days during supplementation than before supplementation. Larger,
controlled trials are warranted to assess the utility of cod liver oil (of
acceptable purity and taste) and a children's multi-vitamin/mineral
preparation containing selenium, both for the prevention of OM and for the
acceptance of delayed prescription of antibiotics for this disorder.
Objectives: Part I: Measure blood levels of fatty acids, vitamin
A and trace metals in children undergoing ambulatory surgery for placement of
tympanostomy tubes (TT) and a comparison group (COMP) having other ambulatory
surgical procedures. Part II: Perform a small, out-patient, secondary
prevention study using nutritional supplements chosen on the basis of the
results of Part I. Study design: Part I: Perform the above blood
level analyses. Part II: Setting: Out-patients in a private pediatric
group practice. Eligibility: Children with at least one episode of otitis
media (OM) from 9/1 to 11/30/2000. Determine whether the daily administration
of one teaspoon of lemon-flavored cod liver oil and 1/2 tablet of a
selenium-containing children's chewable multi-vitamin/mineral preparation
would decrease the percentage of days antibiotics were prescribed for OM from
9/1/2000-3/31/2001. Results: Part I: Fatty Acids: Study
subjects had lower levels of red blood cell (RBC) eicosapentaenoic acid (EPA)
than adult controls. Mean RBC EPA values were: 1) TT=0.31%
± 0.02% (SE), (n=16); 2) COMP=0.31% ± 0.04%
(SE), (n=5); and 3) Adult Controls=0.48% ± 0.4%
(SE), (n=6); (p=0.007, Kruskal-Wallis ANOVA by Ranks). Vitamin A:
Consistent with previous reports, levels for 69% of our subjects (27/39) were
£ 40 m g/dL, the level
needed for normal dark adaptation; 15% (6/39) had sub-optimal levels (£
30 m g/dL, >20 m g/dL).
Selenium: There was no statistically significant difference between the
mean plasma selenium for study subjects (TT=110 ng/ml ±
16.3 SD; n=39) and the published values for children; children had lower
levels than published values for adults (p<0.005, ANOVA). Part II:
Eight children, 0.8-4.4 years of age, entered the secondary prevention study.
One could not tolerate the taste of cod liver oil; the remaining 7 children
received antibiotics for OM for 12.3% ± 13.4 (SD)
fewer days during supplementation than before (p<0.05, Wilcoxon Matched Pairs
Test). 5/7 subjects had no additional episodes of OM during supplementation,
although it had no apparent effect on established serous middle ear effusions
in two children. Conclusion: Larger, controlled trials are warranted to
assess the utility of cod liver oil (of acceptable purity and taste) and a
children's multi-vitamin/mineral preparation containing selenium, both for the
prevention of otitis media and the acceptability of delayed prescription of
antibiotics for this disorder.
This research was reviewed and approved by the Institutional Review
Board of The New York Eye and Ear Infirmary. Written, informed consent was
obtained from at least one parent before a child entered either study;
assent was obtained from children over 6 years of age.
This work was supported in part by the Department of Otolaryngology of
The New York Eye and Ear Infirmary (New York, NY). MedToxÒ
Scientific, Inc. (St. Paul, MN) donated the vitamin and trace metal
analyses, performed while Dr. Pippenger (a co-author) was a consultant. J.
R. Carlson Laboratories, Inc. (Arlington Heights, IL) donated the
nutritional supplements used in the supplementation studies, but had no
other role in the design or conduct of the studies.
The information on this web site is provided for educational purposes only;
it is a general reference for healthcare consumers and providers; it is not a
prescription for any individual person. It is important that you consult your
child’s qualified healthcare provider before implementing any of the research
discussed on this web site.
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