Guidance On Vitamin D Deficiency/insufficiency (Page 4 of 9) in pdf

Investigation and treatment of Vitamin D deficiency / insufficiency in children

Is patient a child (<18 years of age) with one of the following (in the context of child’s age)?

Vitamin D

• tetany

testing not

• reluctance to bear weight

required at

• leg bowing or knock knees

this stage

• impaired linear growth

• skeletal deformity

Give

• muscle pain or weakness

appropriate

• bone pain

Lifestyle

• proximal myopathy

advice

• low serum calcium or high ALP

Yes

Exclude other

Have other causes for symptoms been excluded?

causes of

symptoms then

restart pathway

Yes

Carry out tests for suspected vitamin D deficiency: 25-OHD, Ca

, ALP, PO

, also U+Es, LFTs, FBC. PTH is elevated in vitamin D deficient states but routine

measurement not indicated.

Do any of the following apply?

Refer to specialist in secondary care.

• 25-OHD < 25nmol/L

• aged one year or under

•

Where appropriate, consider commencing treatment in primary

Yes

• bone deformities (including rickets)

care until patient is seen by specialist (see below for treatment

• malabsorption

recommendations)

• renal stones

• chronic renal disease, severe liver disease, lymphoma, metastatic cancer,

•

Patient should only be transferred back to primary care with a

parathyroid disorders, sarcoidosis, TB

treatment plan

• Atypical biochemistry (e.g. low vit D and hypercalcaemia)

• Pregnancy or breastfeeding

If specialist advice/input deemed necessary in clinician’s judgement discuss with secondary care specialist and consider referral if indicated. If not treat in

line with recommendations below

Assess need for treatment based on total serum 25-OHD level

25-OHD < 25nmol/L

25-OHD 25 - 49nmol/L

25-OHD 50 - 75nmol/L

Appropriate

Nutritional supplement (*)

Refer to specialist but where appropriate consider commencing

Lifestyle

treatment in primary care until seen by specialist – see above (*)

advice

< 6 months: calciferol 200-400 IU daily

> 6 months: calciferol 400-800 IU daily

Prescribe: PO colecalciferol 3000 IU/ml liquid

Available Products

Doses as per BNF for children:

- Healthy Start Vitamins [colecalciferol 300 IU per 5 drops]

1-6 months: 3,000 IU daily for 8-12 weeks

- Abidec® (vitamins A, B, C, D) drops:

6 months-12 years: 6,000 IU daily for 8-12 weeks

[0.6ml contains ergocalciferol 400 IU, vitamin A 1333 units]

12-18 years: 10,000 IU daily for 8-12 weeks

- Dalivit® (vitamins A, B, C, D) drops:

[0.6ml contains ergocalciferol 400 IU, vitamin A 5000 units]

+ Give appropriate lifestyle advice

Routine monitoring of 25-OHD not necessary

See Monitoring below

- Check Ca & vitamin D levels after 8-12 weeks

Refer to appropriate

Repeat loading dose

specialist in secondary care

Has patient responded to treatment?

- Consider non-compliance

Yes

Nutritional supplement

Once 25-OHD levels are optimal place on nutritional supplementation & appropriate lifestyle advice. See nutritional supplement box above.

•

MONITORING

Check serum calcium levels 4 weekly and 25-OHD levels 8-12 weekly for patients on high (treatment) dose of vitamin D

•

Check for allergies (some products may contain peanut (arachis) oil, sunflower oil or soya oil.

•

Alfacalcidol & calcitrol should only be used in patients who cannot activate vitamin D and should therefore not be used for the routine treatment of primary

•

vitamin D deficiency/insufficiency, as they carry a higher risk of toxicity and require long-term monitoring.

Advise of the symptoms of hypercalcaemia (nausea, abdominal pain, thirst, polyuria etc) and advise to stop vitamin D

•

Page 4 of 9

supplements and seek medical advice if these occur.