Nutritional Vitamin D deficiency in children & adolescents, management of

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Scope

This guideline is designed for use by paediatricians in secondary care and in the community.

Working Definition of Rickets

Raised Alkaline Phosphatase (ALP) and classic X-ray changes

Classic biochemical picture - Ca (/), P(/), ALP(), PTH (/), 25HCC ()

Vitamin D serum levels:  

Deficiency <30 nmol/l
Insufficiency 30-50 nmol/l
Sufficiency >50 nmol/l

Baseline Investigations

Height and weight
Left wrist X-ray
Serum - U&E’s, calcium, LFT, FBC, PTH, 25(OH)D

Summary of Suggested Treatment

Age

Vit D (12 weeks)* 

Calcium  4 weeks** 

Single dose

Maintenance dose 

<3 months

2000u od

none

Not applicable

400u

3-12 months

2000u -2400u od

500mg

50 000u

400u

1-12years

3000- 6400u od

500mg – 1000mg

150 000u

600u

>12yrs

6000u – 6400u od

1000mg – 1500mg

300 000u

600u - 800u

* range of doses given to allow for use of liquid and solid dose forms

**if hypocalcaemic

Follow Up

@12 weeks

  • Serum UE’s, Ca, P, ALP, PTH, Dietetic review
  • If biochemistry improved change to maintenance
  • Discharge to GP on maintenance vitamin D – to continue until the child stops growing.

Consider alternative diagnoses and referral to Metabolic Bone Clinic if

  • Poor response to treatment or doubt about diagnosis, particularly if the PTH remains high, despite adequate vitamin D supplementation
  • Repeated low serum calcium
  • Persisting low serum phosphate or low/high alkaline phosphatase
  • Underlying complex medical disorders
  • Bony deformities or abnormalities
Differential Diagnosis

Commonest - 

Nutritional Vit D deficiency +/- Ca deficiency

Remember - 

Malabsorption
Phosphate Deficiency
Liver Disease
Renal Disease
Anticonvulsant Therapy
Hypophosphataemic Rickets
Hypo & Pseudohypoparathyroidism
Vit D Dependent Rickets (I & II)
Renal Tubular Disorders
Tumour-induced

May be confused with -  

Skeletal dysplasia

 

History

Dietary history from birth
Exposure to sunlight (child and mother)
Use of drugs and multivitamins
Motor Development

Examination

Height & weight
General nutritional status
Classic signs of rickets

Action

Perform baseline investigations at presentation. 
Refer to dietitian
Consider starting Vit D replacement at presentation if suspicion high.

Baseline Investigations

Height
Weight
Left wrist X-ray
Serum - U&E’s, Calcium, LFT, FBC, PTH, 25HCC 
Classic biochemical picture - Ca (↔/↓), P(↔/↓), ALP(↑), PTH (↔/↑), 25HCC (↓)

Notify Dr Helen McDevitt (helenmcd@doctors.org.uk)         Consider Echocardiogram

Treatment

Treat with a combination of Vitamin D and calcium and then maintenance therapy – (see table above)

Vit D (cholecalciferol or ergocalciferol):

Age <3 months 2000 units once daily, calcium not required due to exclusive milk diet

Age <6 months 2000 units once daily and calcium

Age >6months -12 years 3000-6400 units once daily and calcium

Once Vitamin D course is complete- continue with maintenance treatment of vitamin D until stopped growing.

Adolescents 12-18 years

Vit D (cholecalciferol or ergocalciferol) 6000 units once daily

Once vitamin D course is complete - continue with maintenance treatment of vit D & calcium tablet daily.

If compliance is an issue a single oral or intramuscular dose of 50 -300 000 units may be given every 3 months, with calcium (~30mg/kg/d) for 12 weeks. Large single doses of oral Vitamin D are generally not available in community pharmacies or district general hospitals.

Calcium therapy (may need to be adjusted according to response)

If hypocalcaemic or poor calcium diet treatment should be for at least 4 weeks and longer if required – this should be assessed with dietitian input.

Follow up

12 weeks   

Serum UE’s, Ca, P, ALP, PTH
Ensure dietetic review was done
Expect improvement in biochemistry and motor milestones
Reduce Vit D to maintenance (as multivits or combined with Ca – see combination products) 
Expect improvement in x-ray appearance 
Discharge to GP on Vit D – to continue until at least the age of 5yrs, preferably until the child stops growing.

Consider alternative diagnoses and referral to Metabolic Bone Clinic as per list above

Remember 

In young infants and older adolescents, the classic findings of rickets (XR changes and deformities) may be absent despite profound Vitamin D deficiency

Other siblings and parents, especially, mother may also be Vit D deficient and vit D supplementation (400 units/600 units) may be beneficial

Iron deficiency anaemia often accompanies Vit D deficiency

Vitamin D preparations available

Preparation

Form

Concentration

Abidec (multivits) 
Dalivit (multivits)
Desunin
Fultium D3
Fultium D3*
Invita D3*
Thorens*
Invita D3*
Fultium D3

liquid
liquid
tablet
capsule 
drops
drops
liquid
liquid
capsule

400u/0.6ml
400u/0.6ml
800u
800u
2,740u/ml (200u = 3drops)
2,400u/ml (67u = 1drop)
10,000u/ml
25,000u/ml
20,000u

*In infants, children and adolescents Fultium-D3 Drops, Invita D3 drops/liquid, and Thorens liquid can be mixed with a small amount of children's foods, yogurt, milk, cheese or other dairy products. The drops/liquid must not be mixed into a bottle of milk or container of soft foods in case the child does not consume the whole portion, and consequently does not receive the full dose. Also it can be mixed with a spoonful or a small amount of cold or lukewarm food immediately prior to use.

 

Calcium preparations available

Preparation

Form

Concentration

Alliance calcium 
Cacit
Sandocal 1000

liquid
effervescent tablets 
effervescent tablets

2.50 mmol calcium/5ml
500mg/12.5mmol calcium per tablet
100mg/25mmol calcium per tablet

Combination products available (for maintenance treatment if still hypocalcaemic/low calcium in diet)

Preparation 

Form

Concentration

Accrete D3
TheiCal D3

tablet
Chewable tablet 

600mg calcium and 400iu vit D
1000mg calcium and 880iu vit D

References
  1. Munns CF, Shaw N, Kiely M et al. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets Horm Red Paediatr Jan 2016.
  2. Arundel P & Shaw N. Vitamin D and bone health: a practical clinical guideline for management in children and young people. National Osteoporosis Society June 2015.
Editorial Information

Last reviewed: 31 January 2016

Next review: 31 January 2019

Author(s): H McDevitt, A Mason, MG Shaikh, J Wong, SF Ahmed

Approved By: Clinical Effectiveness

Reviewer Name(s): Endocrine Service, RHC