Nutritional Vitamin D deficiency in children & adolescents, management of

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

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

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

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

**if hypocalcaemic

@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

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

Height & weight
General nutritional status
Classic signs of rickets

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

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)

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

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

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

*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.