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This guideline is designed for use by paediatricians in secondary care and in the community.
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 |
Height and weight
Left wrist X-ray
Serum - U&E’s, calcium, LFT, FBC, PTH, 25(OH)D
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
@12 weeks
Consider alternative diagnoses and referral to Metabolic Bone Clinic if
Commonest - |
Nutritional Vit D deficiency +/- Ca deficiency |
Remember - |
Malabsorption |
May be confused with - |
Skeletal dysplasia |
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
12 weeks |
Serum UE’s, Ca, P, ALP, PTH |
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
Preparation |
Form |
Concentration |
Abidec (multivits) |
liquid |
400u/0.6ml |
*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.
Preparation |
Form |
Concentration |
Alliance calcium |
liquid |
2.50 mmol calcium/5ml |
Preparation |
Form |
Concentration |
Accrete D3 |
tablet |
600mg calcium and 400iu vit D |
Last reviewed: 31 January 2016
Next review: 30 June 2021
Author(s): H McDevitt, A Mason, MG Shaikh, J Wong, SF Ahmed
Approved By: Clinical Effectiveness
Reviewer Name(s): Endocrine Service, RHC