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Guidance for Vitamin D deficiency in Children

MID ESSEX LOCALITY


MID ESSEX LOCALITY

Caution: This guidance is not applicable to children with renal failure (eGFR <30mL). Seek specialist advice.
Why is vitamin D Important? Vitamin D is an essential nutrient needed for healthy bones, and to control the amount
of Calcium in our blood. Vitamin D deficiency can cause seizures and cardiomyopathy in infants, rickets and poor growth
in children and muscle weakness at any age.
Dietary sources of vitamin D include oily fish (herrings, sardines, mackerel, salmon, tuna) liver, meat, fortified
cereal/milk, margarine.
The Department of Health Chief Medical Officers (CMO) and NICE PH56 highlights the risk of Vitamin D deficiency in
infants and young children from 6 months to 5 years of age and recommends vitamin supplementation until they reach
5 years old. See table below on advice and management.
Risk factors could include:
Black /ethnic minority patients with darker skin of South Asian, African, Caribbean or Middle Eastern descent
Maternal deficiency in pregnancy and breastfeeding
Prolonged breastfeeding even if mother has sufficient Vitamin D
Limited exposure to sunlight e.g. concealing clothing, immobility, long term inpatients
Intestinal malabsorption, liver or renal disease
Insufficient dietary intake of vitamin D
Medications e.g. anticonvulsants / cholestyramine /rifampicin / glucocorticoids / antiretrovirals
Signs and symptoms of deficiency:
Infants: seizures, tetany and cardiomyopathy
Children: aches and pains; myopathy causing delayed walking; rickets with bowed legs, knock knees, poor growth and
muscle weakness.
Adolescents: aches and pains, muscle weakness, bone changes of rickets or osteomalacia
When is monitoring necessary? Vitamin D is not routinely monitored in children. See table. Both clinical
symptoms and risk factors must be present before measuring Vitamin D levels (25OHD). The reduced sunlight hours
during October to April mean over half of the population may have insufficient levels at some point.
Patient characteristics Advice and management
Healthy, no risk factors, symptom free No investigations required, lifestyle advice, consider prevention therapies
All infants and young children from 6 No investigations required, lifestyle advice and recommend all to take
months to 5 years of age. vitamin D supplementation containing 7 micrograms 8.5 micrograms
Infants exclusively breastfed from 1 month which can be purchased or obtained through the Healthy Start scheme.
See link to vitamin D supplements for at Risk Groups
Other risk factors only (see above), no Lifestyle advice
symptoms Consider long term preventative therapies
Risk factors AND symptoms/signs Lifestyle advice and investigations
Therapeutic intervention, long term preventative treatment
Ensure all likely causes of the symptoms are investigated before retesting/ treating. Do not overlook the underlying
condition.
Treatment see table overleaf
If a child is diagnosed with Vitamin D deficiency the rest of the family should be screened and treated as necessary. First
line lifestyle and dietary advice must always be given. If treatment is necessary, Colecalciferol (D3) is the preferred
treatment as there is some evidence that it raises vitamin D levels to a greater extent than ergocalciferol (D2). Doses are
equivalent.
Lifestyle advice
If
Inthey remain
the UK theresymptomatic,
is insufficientisUVB
it actually Vitamin D wavelength
of the necessary related? between October and March to generate vitamin D. Sun
exposure for vitamin D production has to be balanced against the risk of skin cancer. It is advised that getting small
amounts of incidental sunlight, as you might get through daily activities, without getting a heavy tan or burning, may
help to boost vitamin D levels. Long exposure can break down Vitamin D, reducing the benefit and increasing the risk of
skin cancer. Where casual sunlight exposure is not practical in children (especially under 5) is it essential for vitamin D
supplements to be taken. Pharmacies and health food stores sell a variety of vitamin D products or they can be obtained
through the Healthy Start Scheme. Vitamin D can also be obtained through diet. Some foods Page
VitDDeficiencyChildrenGUI201511v2.0FINAL are fortified
1 of 3 with vitamin D
(for example some yoghurts, margarine and cereals) and others, such as oily fish, are naturally rich in vitamin D.
Guidance for Vitamin D deficiency in Children
MID ESSEX LOCALITY
MID ESSEX LOCALITY
Treatment for deficient and insufficient levels of Vitamin D
Vitamin D3 Conversions 1mcg = 40 international units (units) 2.5nmol/L = 1ng/mL
Offer dietary & lifestyle advice routinely to all patients irrespective of Vitamin D status
Vitamin D Management Product to prescribe Monitoring
Levels (RCPCH) for
children & status Intestinal malabsorption Named patient liquid specials of
or in chronic liver
vitamin D (unlicensed) for children
disease: seek specialist
advice should NOT be routinely prescribed.

Thorens cholecalciferol 10,000units/ml oral drops is the licensed product of choice. Thorens is supplied with a dropper
syringe for doses in drops. For doses in ml please ensure a 1ml oral syringe is supplied. Drops are olive oil based.
Age 1-6months Prior to Treatment:
<25 nmol/L 3,000units daily 0.3ml daily supply 1ml oral syringe Vitamin D level (25OHD)
Age 6 months 12 years Renal Profile, Bone Profile
Deficiency -High dose 6,000units daily 0.6ml daily supply 1ml oral syringe (Ca, Phosphate, Alk
corrective Phosph), LFTs, FBC +/-
Age 12-18 years Ferritin
supplementation
10,000units daily 1ml daily supply 1ml oral syringe
required for 3 months
In children able to swallow solid
followed by Repeat Vitamin D (25OHD),
dosage forms please prescribe:
maintenance (see calcium and ALP levels
Sunvit D3 tablets 10,000units after 3 months
below)
0-6 months
25-50nmol/L 400units once daily 2 drops daily
Insufficiency 6 months 18 years
Treat for 8 weeks 800units once daily 4 drops daily
then followed by In children able to swallow solids: No routine monitoring is
Desunin tablets 800units or required for
maintenance
Fultium D3 800units capsules maintenance doses, unless
(see below)
symptoms re-occur or do
0-1 month
not resolve
400units once daily 2 drops daily

Thorens In children able to


10,000units/ml swallow solids: Children should be
Maintenance
Oral drops: encouraged to maintain an
1month- 18 years 400units 2 drops Colecalciferol tabs adequate calcium intake
400-1,000units once daily 600units 3 drops N/A
through good sources of
calcium in their diet.
800units - 4 drops Desunin tablets
800units or Fultium
D3 800units
capsules
1,000units - 5 drops Sunvit D3 1,000unit
tablets

After treatment children who were deficient or insufficient should continue long term low dose supplements until
completion of growth unless lifestyle changes (diet/sun exposure) are assured.

VitDDeficiencyChildrenGUI201511v2.0FINAL Page 2 of 3
Guidance for Vitamin D deficiency in Children
MID ESSEX LOCALITY
MID ESSEX LOCALITY

Title Guidance for Vitamin D deficiency in children


Document VitDDeficiencyChildrenGUI201511v2.0FINAL
reference
Updated by Natalie Leong, Pharmacist Mid Essex CCG
Consulted Dr Manas Datta, Consultant Paediatrician, MEHT. Dr Sharon Lim, Consultant Paediatrician,
with MEHT. Claire Fitzgerald, Paediatric Pharmacist. Jane Pearce, Paediatric Dietician
References: Guide for Vitamin D in childhood. Royal College of Paediatrics and Child Health October 2013
http://www.rcpch.ac.uk/system/files/protected/page/vitdguidancedraftspreads%20FINAL%2
0for%20website.pdf

Childrens BNF
https://www.medicinescomplete.com/mc/bnfc/current/PHP14137-vitamins.htm

Vitamin D guidance Summary guidance by the Clinical Effectiveness Group of Barts and The
London School of Medicine and Dentistry January 2011
http://www.blizard.qmul.ac.uk/ceg-resource-library/clinical-guidance/clinical-guidelines/10-
vitamin-d-january-2011/file.html

British Association of Dermatologists: Vitamin D and the Sun


British Phototherapy Group/ British Association of Dermatologists, 2013
http://www.bad.org.uk/for-the-public/skin-cancer/vitamin-d

Approved by MMC
Date approved November 2015
Next review November 2017
date

Previous version Key Changes


November 2014 Updated format, addition of guidance from RCPCH and doses from Childrens BNF

VitDDeficiencyChildrenGUI201511v2.0FINAL Page 3 of 3

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