Nutritional Vitamin D deficiency in children & adolescents, guidelines for the 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 (↓)
Baseline Biochemical/Haematological Investigations
Serum - U&E’s, LFT, bone profile, FBC, Ferritin, PTH, Vitamin D
Summary of Suggested Treatment
| Age | Vit D (12 weeks)* | Calcium 4 weeks** | Single dose (STOSS) | Maintenance |
| <3 months | 2000units od1 | none | NA | 400u |
| 3-12months | 2000-2400units od2 | 500mg | 50 000units4 | 400u |
| 1-12years | 3000-6400units od3 | 500mg – 1000mg | 150 000units4 | 600u |
| >12years | 6000–6400units od3 | 1000mg – 1500mg | 300 000units4 | 600u - 800u |
* range of doses given to allow for use of liquid and solid dose forms; see below
** if hypocalcaemic
1 – suggested formulation 10,000units/ml (e.g. Thorens)
2 – suggested formulations 10,000units/ml (e.g. Thorens) or 2,400units/ml (e.g. Invita D3)
3 – suggested formulation 10,000units/ml (e.g. Thorens)
4 – suggested formulations 25,000u/ml liquid, 20,000unit capsules or 25,000unit tablets
@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 Complex Bone Clinic, RHCG
- Poor response to treatment or doubt about diagnosis
- Persisting abnormality in bone biochemistry (calcium, phosphate, alkaline phosphatise and PTH) if no issues with compliance.
- Persisting/non-improving bony deformities or abnormalities
Dietary history from birth
Exposure to sunlight (child and mother)
Use of drugs and multivitamins
Motor Development
Height & weight, and general nutritional status
Classic signs of rickets
Perform baseline investigations at presentation
Refer to dietician
Left wrist x-ray
Consider cardiac ECHO if cardio-respiratory compromise
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
Treat with a combination of Vitamin D and calcium and then maintenance therapy – (see table above - Summary of suggested treatment)
Once Vitamin D course is complete- continue with maintenance treatment of vitamin D until stopped growing.
If compliance is an issue a single oral or intramuscular dose of 50 -300 000 units may be given every 3 months. Large single doses of oral Vitamin D are generally not available in community pharmacies
If hypocalcaemic or poor calcium diet treatment should be for at least 4 weeks and longer if required.
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.
|
Preparation |
Form |
Concentration |
|
Abidec (multivits) |
liquid |
400u/0.6ml |
*Fultium-D3 Drops, Invita D3 drops/liquid, and Thorens liquid can be mixed with a small amount of children's foods
|
Preparation |
Form |
Concentration |
|
Calvive 1000 (Calcium carbonate 1.75 gram, Calcium lactate gluconate 2.263 gram) |
effervescent tablets |
Equivalent to 1000mg calcium |
|
Preparation |
Form |
Concentration |
|
Accrete D3 One A Day |
Chewable tablet |
1000mg calcium and 880units vit D |
- Munns CF, Shaw N, Kiely M et al. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets Horm Red Paediatr Jan 2016.
- 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.
Last reviewed: 01 February 2022
Next review: 28 February 2025
Author(s): McDevitt H, Mason A.
Approved By: Clinical Effectiveness
Reviewer Name(s): Endocrine Service, RHC