India receives a great deal of sunshine and has a great deal of vitamin D deficiency. Both statements are true, and the gap between them explains most of the confusion.
Why sunshine is not enough here
Vitamin D is made in skin exposed to UVB. Several things reduce that in practice across urban India:
- Melanin is an effective natural sunscreen. More pigmented skin needs substantially longer exposure to make the same amount.
- Urban living. Indoor schooling, indoor play, screens, air pollution that scatters UVB, and buildings that shade the streets.
- Clothing and custom, which for entirely valid reasons often leave little skin exposed.
- Diet. Very few natural foods contain meaningful vitamin D, and fortification in India is patchy and inconsistent.
- Exclusive breastfeeding without supplementation. Breast milk is a superb food that is genuinely low in vitamin D.
The result is that biochemical deficiency is common across Indian paediatric populations, including in sunny cities.
Who genuinely benefits from routine supplementation
There is good consensus on these groups:
- All infants, from birth through the first year, whether breastfed or formula-fed, typically 400 IU daily. Formula contributes some, but not usually enough on its own in the early months.
- Children and adolescents at higher risk: very limited sun exposure, obesity, darker skin with an indoor lifestyle, malabsorption (coeliac disease, cystic fibrosis, inflammatory bowel disease), chronic liver or kidney disease, and children on anticonvulsants or long-term steroids. Typically 600 IU daily as maintenance, sometimes more.
- Children with proven deficiency, who need a treatment dose first and maintenance afterwards.
Beyond these, a reasonable everyday intake of 400–600 IU daily for children and adolescents is sensible and safe, and is what most paediatric guidance recommends.
Where the over-treatment happens
Three habits cause most of the harm I see.
Very high monthly or weekly “mega-doses” given indefinitely. A 60,000 IU sachet has a legitimate place in a supervised treatment course for confirmed deficiency. It has no place as an unmonitored monthly habit continued for years, and the mistake of giving it weekly instead of monthly is easy to make and genuinely dangerous.
Treating a number rather than a child. A mildly low 25(OH)D level in a well child with normal calcium, normal alkaline phosphatase, normal growth and no bone symptoms usually needs ordinary maintenance dosing and sunlight, not a treatment course.
Forgetting calcium. Vitamin D helps the gut absorb calcium. If dietary calcium is very low, which is common in Indian children who drink little milk, vitamin D alone will not heal rickets. Nutritional rickets in India is frequently a calcium deficiency as much as a vitamin D one.
When to actually test
Testing every child is not useful and not recommended. Test when there is a reason:
- Bone symptoms: bowed legs, wrist or ankle swelling, delayed walking, a rickety rosary, bone pain, unexplained fractures
- Poor growth, or growth that has slowed
- Malabsorptive conditions or relevant long-term medication
- A biochemical clue that has already turned up, such as a raised alkaline phosphatase, a low calcium or phosphate
And when you do test, test properly: 25(OH)D together with calcium, phosphate, alkaline phosphatase and PTH. The vitamin D number in isolation answers very little. An X-ray of the wrist or knee settles the question of rickets far better than any single blood value.
What good practice looks like
- Infants supplemented from birth, every day, without fail.
- Children encouraged outdoors, for their eyes, their bones, their sleep and their mood, all of which happen to benefit from the same intervention.
- Dietary calcium taken seriously: milk, curd, paneer, ragi, sesame, green leafy vegetables, small fish eaten with bones.
- Deficiency treated properly, with a defined course, a defined dose and a follow-up test, then dropped to maintenance.
- No indefinite mega-dosing without a reason and without monitoring.
Vitamin D is genuinely important and genuinely under-supplied in Indian children. That is a reason to give it thoughtfully, not enthusiastically.
Doses here are general paediatric guidance and not a prescription. Children with rickets, malabsorption, kidney or liver disease need individualised treatment from their doctor.