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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 (↓)

Vitamin D serum levels Deficiency <30 nmol/l
Insufficiency 30-50 nmol/l
Sufficiency >50 nmol/l

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

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 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
History

Dietary history from birth

Exposure to sunlight (child and mother)

Use of drugs and multivitamins

Motor Development

Examination

Height & weight, and general nutritional status

Classic signs of rickets

Action

Perform baseline investigations at presentation

Refer to dietician

Left wrist x-ray

Consider cardiac ECHO if cardio-respiratory compromise

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 - 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

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.

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 (not exhaustive, prescribe generically where possible)

Preparation

Form

Concentration

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

liquid
liquid
tablet
capsule 
drops
drops
liquid
liquid
capsule
tablet

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
25,000units

*Fultium-D3 Drops, Invita D3 drops/liquid, and Thorens liquid can be mixed with a small amount of children's foods

Calcium preparations available

Preparation

Form

Concentration

Calvive 1000 (Calcium carbonate 1.75 gram, Calcium lactate gluconate 2.263 gram)
Calcium 500mg effervescent tablets (calcium carbonate 1.25g)

effervescent tablets 
effervescent tablets

Equivalent to 1000mg calcium
Equivalent to 500mg calcium

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

Preparation 

Form

Concentration

Accrete D3 One A Day
Adcal D3 Dissolve

Chewable tablet 
Effervescent tablets

1000mg calcium and 880units vit D
600mg calcium and 400units 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: 01 February 2022

Next review: 28 February 2025

Author(s): McDevitt H, Mason A.

Approved By: Clinical Effectiveness

Reviewer Name(s): Endocrine Service, RHC