Management of Vitamin D Deficiency in Children

Management of Vitamin D Deficiency in Children

Vitamin D insufficiency is defined by 25-OHD levels 25-75 nmol/L.

Vitamin D deficiency is defined by 25-OHD levels < 25 nmol/L.

Risk Factors for Vitamin D deficiency

·  Skin pigmentation

·  Inadequate exposure to sunlight

·  Exclusive breast-feeding

·  Maternal vitamin D deficiency

·  Anticonvulsant therapy

·  Malabsorption

Clinical features

·  Rickets: thickening of wrists and ankles, rachitic rosary, bow legs, floppiness, delayed closure of fontanelle, dental deformities

·  Delayed gross motor milestones

·  Bone pain, muscle weakness, poor growth

Investigations

·  Calcium, phosphate, Alkaline phosphatase (ALP)

·  Urea and electrolytes

·  25-OHD level

·  Parathyroid hormone

Dose and Administration

Treatment for Vitamin D deficiency (25-OHD level <25nmol/L)

Colecalciferol or Ergocalciferol
Infant 1 to 6 months / 3,000 units daily
6 months to 12 years / 6,000 units daily
Over 12 years / 6,000 to 10,000 units daily or 50,000 units ONCE weekly if there is a compliance issue

Treatment for Vitamin D insufficiency and Maintenance dose (once the deficiency has been rectified e.g. 25-OHD25nmol/L)

Colecalciferol or Ergocalciferol
Infant 1 to 12 months / 400 units daily
1 year to 12 years / 400 - 600 units daily
Over 12 years / 800 -1000 unit daily

Ergocalciferol can be given as an intramuscular dose of 300,000 units every 3 months for adolescents where compliance is a problem.

Monitoring

The aim of treatment should be to reach a total Vitamin D level of >75nmol/L.

·  Serum calcium and 25-OHD levels should be measured every two to three months while on treatment dose.

·  Serum calcium and 25-OHD levels should be measured once at 3 months after starting of maintenance dose, further monitoring depending upon result.

Who/When to refer to secondary care

·  Children with hypocalcaemia, whether symptomatic or not

·  Rickets with deformities

·  If the response to treatment is poor (usually compliance issues)

·  If there is diagnostic uncertainty

Safety of vitamin D preparations

High doses of vitamin D supplements can be toxic (resulting in hypercalcaemia and renal failure). This is only likely to occur if high dose formulations are taken over a prolonged period of time.

Symptoms of overdose: anorexia, nausea, vomiting, diarrhoea, constipation, lassitude, vertigo, polyuria, thirst, sweating, headache and weight loss.

Patient who are symptomatic and hypercalcaemic should have their management discussed with specialist clinicians without delay.

Contraindication

Vigantoletten® tablets contain soya oil, and are contraindicated for patients with allergies to this ingredient.

Dekristol® capsules contain arachis (peanut) oil, and are contraindicated for patients with nut allergies.

Sourcing information

Licensed preparations are:

1.  Abidec® and Dalivit® oral drops (contain 400units of ergocalciferol in 0.6mL)

2.  Ergocalciferol injection 7.5mg (300,000 units)

3.  Pro D3®, available as colecalciferol capsules and liquid (1000units, 10,000units and 20,000units capsules and 100unit/drop in 20mL bottle)

Unlicensed preparations are:

1.  Product: Colecalciferol 300,000 units/mL injection (Vitamin D3 Streuli®) Pack size 10 x 1mL Price: £15.22

Supplier: Mawdsley (01302553000)

2.  Product: Colecalciferol 50,000 units capsules (D3-50®). Pack size: 100. Price £18.48

Supplier: IDIS (01932824100)

3.  Product: Colecalciferol 20,000 units capsules (Dekristol®) Pack size: 50. Price £10.76

Supplier IDIS (01932824100)

4.  Product: Colecalciferol 1,000 units dispersible tablet (Vigantoletten®) Pack size: 90. Price £5.88

Supplier: IDIS (01932824100)

5.  Product: Colecalciferol 3,000 unit/mL oral liquid Pack size: 30mL Price: £36

Supplier: Sterling Specials

6.  Product: Colecalciferol 10,000 unit/mL oral liquid Pack size: 10mL Price: £10.03

Supplier: Durbin

Note: Prices quoted correct at time of publishing.

Liquid preparations should not be routinely prescribed as they are expensive and have a short shelf life (usually one to two months from the date of manufacture).

Over the Counter options

There are many OTC options available from community pharmacies and health food shops than those listed.

(1)Solgar (www.solgar.com)

Vitamin D3 – various preparations

Strengths vary from 10mcg (400 units) to 55mcg (2,200 units).

15mcg and 55mcg capsules are suitable for vegetarians.

(2)Holland and Barrett (0247 624 4400)

10mcg (400 units) and 25mcg (1,000 units) strengths available

Not suitable for vegetarians/vegans. Not Kosher or Halal.

References

·  Vitamin D deficiency in children and its management: Review of current knowledge and recommendations

Madhumita Misra, Daniele Pacaud, Anna Petryk, Paulo Ferrez Collett-Solberg, Michael Kappy & on behalf of the Drug & Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society

Pediatrics 2008; 122; 398-417

·  Vitamin D: Expert Opinion

By Jeremy Allgrove BSPED November 2009

·  Vitamin D: Deficiency, Dependency and Toxicity

By Larry Johnson Merck Manual Professional 2007

·  Treatment & prophylaxis guidelines for vitamin D deficiency in infants, children and adolescents by

Nicola Bridges Chelsea & Westminster Hospital , Imperial Healthcare NHS Trust

·  Michael F et al. Evaluation, Treatment and prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab, July 2011, 96(7)

·  Vitamin D guidance Barts & The London Clinical Effectiveness Group January 2011

Prepared by: Dr Hakeem, Consultant Paediatrician Page 2 of 3

Approved date: Feb 2012

Review date: Feb 2014