Vitamin D Levels in Umbilical Cord and It's Impact on Infant and Children's Health (VITADi Study)
Conditions: Vitamin D Deficiency
Sponsor: Hasanuddin University

 
 
 
 
 
 
 
 
 
VITAMIN D LEVELS IN UMBILICAL CORD AND ITS IMPACT ON 
INFANT AND CHILDREN’S HEALTH: A COHORT STUDY (VITADi 
STUDY) 
 
April 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

VITAMIN D LEVELS IN UMBILICAL CORD AND ITS IMPACT ON INFANT AND 
CHILDREN’S HEALTH: A COHORT STUDY (VITADi STUDY) 
 
Protocol 
 
Responsible Personnel 
 
Principal Invesitagor Contact Information 
Name: Sri Hardiyanti Putri 
Title: MD 
Institution: Department of Pediatrics, Faculty of Medicine, Hasanuddin University 
Address: Jln. Perintis Kemerdekaan KM 11 Makassar, South Sulawesi, Indonesia, 90245 
Telephone: +628114499339 
Email: srihardiyantiputri@gmail.com 
 
Other Contact 
Name: Bahrul Fikri 
Title: MD, PhD 
Institution:  Allergy  and  Immunology  Division,  Department  of  Pediatrics,  Faculty  of  Medicine, 
Hasanuddin University 
Address: Jln. Perintis Kemerdekaan KM 11 Makassar, South Sulawesi, Indonesia, 90245 
Telephone: +62(411)584461 
Email: bahrulfikri@unhas.ac.id 
 
Summary: 
 
This study is a cohort study that aims to assess the relationship between Vitamin D levels 
in infants and children, and the risk of anemia, atopic dermatitis, diarrhea and cardiovascular 
disorders in newborn. The subjects of this study are 100 women who met the inclusion criteria, 
which are in their third semester of pregnancy and agree to be included in this study with their 
babies. These subjects then will be examined for their weight, height and upper arm 
circumference using standardized CEBA digital scale, and blood sampling will also be done to 
these  women  to  measure  their  vitamin  D  levels,  calcium,  parathyroid  hormone,  ferritin,  Fe 
serum, IL-16, and IL-10. When subjects give birth, the babies will also be included in this study. 
Anthropometric examination will also be done on the babies, to measure their birth weight, birth 
length, and head circumference. Blood samples will also be taken from their umbilical cord to 
assess their complete blood count, ferritin, Fe serum, vitamin D levels, vitamin D receptors, IL-6 
and IL-10. All subjects then will be monitored, and home visits will be done when the babies reach 
3 months old and 6 months old. An assessment of the incidence of diarrhea, atopic dermatitis, 
and an assessment of cardiovascular disorders (checking pulse and blood pressure) will be carried 
out during the visit. At the end of the study, venous blood sampling will be taken to see levels of 
Vitamin D, calcium, parathyroid hormone, routine complete blood count, serum Fe, and ferritin, 
then data analysis is performed. 
 

 
Introduction: 
 
Vitamin D is essential for development, growth and the maintenance of the bone. (Huang 
et al., 2021) Although the main role of vitamin D is to maintain calcium homeostasis, vitamin D 
also  has  many  roles  in  various  organ  system,  including  the  immune  system.  The  presence  of 
vitamin D receptor (VDR) expression in immune system experimentally proves that vitamin D also 
plays an essential role in innate and adaptive immune system. Vitamin D is involved in immune 
system through intracellular VDR in monocyte/macrophage, T cells, B cells, natural killer cells 
(NK), and dendritic cells (DC). (Cyprian et al., 2019) 
The presence of vitamin D receptors in the immunologic system, confers huge influence 
on  the  incidence  of  infectious  diseases  and  allergies,  such  as  diarrhea  and  atopic  dermatitis. 
(Aluisio et al., 2013) (El Taieb, 2013, Kim JM, 2016) Epidemiological literature also explains that 
both vitamin D deficiency and insufficiency contribute to the incidence of cardiovascular disease 
and the incidence of metabolic syndrome, namely hypertension, obesity, insulin resistance and 
glucose intolerance. (Adams & Hewison, 2010) Several epidemiological studies and clinical trials 
also have found that vitamin D plays a role in iron homeostasis and erythropoiesis, hence the 
causal relationship with anemia. (Uwaezuoke, 2017) 
The vitamin D levels of the intrauterine fetus is completely influenced by maternal vitamin 
D  levels.  25-OH  Vitamin  D  will  go  through  the  placental  barrier  and  then  into  the  baby's 
circulatory system with a half-life of about 2 months. (Wierzejska et al., 2017) There are several 
factors that influence vitamin D levels, such as maternal nutritional status, intake of calcium and 
phosphorus, maternal body mass index, and socioeconomic factors, meanwhile the main sources 
of vitamin D are sun exposure, food intake, supplementation, and fortified foods. (Holick, 2007) 
Indonesia  is  a  tropical  country  with  high  levels  of  sun  exposure,  but  in  fact  vitamin  D 
deficiency is still a problem that persists in the country. Data shows that children aged 2-12.9 
years in Indonesia experience vitamin D insufficiency as much as 45.1%. (Koon Poh et al., 2016) 
The prevalence of pregnant women suffering from vitamin D deficiency is also quite high. (Adams 
& Hewison, 2010; Ayu Krisna Cahyaning Putri et al., nd; Cerami, 2017) This also increases the 
incidence of this micronutrient deficiency in newborns which can affect the growth and 
development  of  children  later.  Lack  of  vitamin  D  can  also  increase  the  likelihood  of  children 
suffering from several diseases later in life. By looking at the importance of vitamin D, researchers 
are interested in assessing the extent of the influence of maternal vitamin D levels on neonatal 
vitamin D levels, and how this vitamin D status affects the physical condition of the child later. 
This study also aims to see the effect of sun exposure on children's physical status. 
 
Objectives: 
1. General Objectives 
a. To assess the relationship between neonatal vitamin D levels to the risk of 
anemia, atopic dermatitis, diarrhea, and cardiovascular disorders in 
newborns.  
2. Specific Objectives 
a. To determine the third trimester pregnant women who do not have chronic 
infectious diseases and hypertension.  

b. Measure the weight, height, and upper arm circumference of third trimester 
pregnant women.  
c. Measure  vitamin  D  levels,  calcium,  parathyroid  hormone,  ferritin,  serum 
iron, routine blood, IL-16, and IL-10 in third trimester pregnant women.  
d. Measure  weight,  body  length,  head  circumference  of  newborns  (whose 
mothers have been selected as research subjects) 
e. Measure vitamin D levels, vitamin D receptors, IL-6, and IL-10 from umbilical 
cord blood of newborns (whose mothers have been selected as research 
subjects).  
f. Monitor  weight,  body  length,  head  circumference  when  the  baby  is  3 
months old.  
g. Monitor  weight,  body  length,  head  circumference  when  the  baby  is  6 
months old.  
h. Measure levels of vitamin D, calcium, parathyroid hormone, ferritin, serum 
iron, routine blood, IL-6, and IL-10 when the baby is 6 months old.  
i. Measure IgE levels when the baby is 6 months old.  
j. Assess the incidence of diarrhea frequency in infants during monitoring.  
k. Assess the incidence of atopic dermatitis in infants during monitoring. 
l. Assess the incidence of hypertension during monitoring.  
m. Check the levels of vitamin D, ferritin, hemoglobin, and reticulocytes when 
the baby is 6 months old.  
n. Compare  vitamin  D  levels  in  the  umbilical  cord  blood  of  newborns  with 
vitamin D levels at the age of 6 months. 
 
Trial Design: 
Observational study 
 
Study Population 
Women in third trimester of pregnancy in Makassar, Surabaya, Mataram who are selected 
during the screening test. 
 
Number of Samples 
100 samples. 
 
Inclusion Criteria 
a. Pregnant Women 
o Women in third trimester of pregnancy  
o Agree  to  take  blood  samples  and  are  willing  to  include  their  babies  as 
samples for the next study.  
b. Infants  
o Babies born from mothers who are willing to be included in the study  
o Aterm  
o Birth weight > 2500 grams 
 

Exclusion Criteria  
a. Pregnant women  
o History of abortion in previous pregnancy 
o Suffering from hypertension or preeclampsia  
b. Infants  
o Infants with congenital abnormalities at birth  
o Infants with acute infection at birth 
 
Procedures: 
1. Sampling will be preceded by giving explanations to the parents, then parents will fill and 
sign the informed consent paper if they agree to participate in this study.  
2. All pregnant women who met the requirements as research subjects will be recorded by 
their name, age, parity, birth history, and history of illness.  
3. Anthropometric  measurements  will  be  performed  on  pregnant  women  who  met  the 
criteria, including body weight using standardized digital CEBA scales, height, and upper 
arm circumference.  
4. The pre-analytic in this study is the preparation of tools and materials to take 3 cc of blood 
serum samples (2 tubes for 1 patient), purple capped tubes (with EDTA) for routine blood 
count tests, and red tubes for ferritin, Fe serum, vitamin D levels, calcium, parathyroid 
hormone, IL-6, and IL-10.  
5. After the mother gives birth, the baby who are qualified based on the inclusion criteria 
will also be included.   
6. Birth weight, birth length and head circumference will be measured.   
7. The pre-analytic in this study is the preparation of tools and materials for blood and serum 
sampling, collection of infants blood samples from the umbilical cord and children from 
venous blood (2 tubes for 1 patient), purple capped tubes (with EDTA) for routine blood 
count tests, and red tubes for ferritin, Fe serum, vitamin D levels, vitamin D receptors, IL-
6, and IL-10. The amount of blood samples taken for the purple closed tube is 1.5 ml and 
for the red tube is 1.5 ml (which is the minimum value for each tube for examination).   
8. Monitoring will be carried out until the baby is 6 months old. Visits will be made when the 
baby reach 3 months and 6 months old. Anthropometric status measurements will be 
done on infants to measure their weight, length, and head circumference, then we will 
determine the nutritional status by plotting to the WHO curve. There will be interviews 
with the parents/caregivers regarding complaints of diarrhea and signs of allergies such  
red rash and an assessment based on Hanifin Rajka's criteria will be made.  
9. At the age of 6 months, a blood sample will be taken again. The pre-analytic in this study 
is the preparation of tools and materials for blood and serum sampling, collection of blood 
samples for infants from the umbilical cord and children from venous blood (2 tubes for 
1 patient), purple capped tubes (with EDTA) for routine blood tests, and red tubes for 
examination of ferritin, serum Fe, levels of vitamin D, IL-6, and IL-10. The number of blood 
samples taken for the purple closed tube is 1.5 ml and for the red tube it is 1.5 ml (which 
is the minimum value for each tube for examination).   

10. Unpleasant sensations like  pain during blood sampling and fear of being stabbed with a 
needle will be minimalized by using experts in this field, such as laboratory assistant and 
a doctor as a companion.  
 
Workflow 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
Data Analysis 
The  collected  data  are  grouped  based  on  the  purpose  and  type  of  data,  then  the  suitable 
statistical methods are used, namely:  
a. Univariate analysis 
Used to describe the characteristics of the basic data, in the form of frequency, mean 
value, standard deviation, and range.  
b. Bivariate analysis  
1) Wilcoxon test: Used to analyse data with independent variables with an 
ordinal/numeric  scale,  the  data  are  not  normally  distributed  and  have  different 
variances.  
Baby is born (examination on birth weight, birth length, head circumference and 
umbilical cord blood will be taken to assess vitamin D level) 
Filling out the questionnaire, examination on body weight, length, upper arm 
circumference, vitamin D levels, vitamin D, calcium, parathyroid hormone, 
complete blood count, Fe serum and ferritin 
Follow Up 
Monitoring until baby reach 3 months of age 
Monitoring until baby reach 6 months of age (blood samples will be taken) 
Analysis 
Women in the third semester of pregnancy in Makassar, Surabaya and Mataram 

2) Mann  Whitney  test:  Non-parametric  test  to  compare  ordinal  or  numeric  scale 
variables  whose  data  are  not  normally  distributed  and  have  different  variances 
between two unpaired groups.  
 
The results of the hypothesis test are determined as follows:  
1) Not meaningful if p-value > 0.05  
2) Significant if p ≤ 0.05  
3) Very meaningful if p < 0.01 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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