Download Guidance for Vitamin D deficiency in Children MID

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:
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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
Healthy, no risk factors, symptom free
All infants and young children from 6
months to 5 years of age.
Infants exclusively breastfed from 1 month
Advice and management
No investigations required, lifestyle advice, consider prevention therapies
No investigations required, lifestyle advice and recommend all to take
vitamin D supplementation containing 7 micrograms – 8.5 micrograms
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
remain
it actually
Vitamin D wavelength
related? between October and March to generate vitamin D. Sun
Inthey
the UK
theresymptomatic,
is insufficientisUVB
of the necessary
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
are fortified
VitDDeficiencyChildrenGUI201511v2.0FINAL
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
Levels (RCPCH) for
children & status
Management
Product to prescribe
Intestinal malabsorption
or in chronic liver
disease: seek specialist
advice
Named patient liquid ‘specials’ of
vitamin D (unlicensed) for children
should NOT be routinely prescribed.
Monitoring
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.
<25 nmol/L
Deficiency -High dose
corrective
supplementation
required for 3 months
Age 1-6months
3,000units daily
0.3ml daily – supply 1ml oral syringe
Age 6 months – 12 years
6,000units daily
0.6ml daily – supply 1ml oral syringe
Age 12-18 years
10,000units daily
followed by
maintenance (see
below)
25-50nmol/L
Insufficiency
Treat for 8 weeks
then followed by
maintenance
(see below)
0-6 months
400units once daily
6 months – 18 years
800units once daily
0-1 month
400units once daily
Maintenance
1month- 18 years
400-1,000units once daily
1ml daily – supply 1ml oral syringe
In children able to swallow solid
dosage forms please prescribe:
Sunvit D3 tablets 10,000units
Prior to Treatment:
Vitamin D level (25OHD)
Renal Profile, Bone Profile
(Ca, Phosphate, Alk
Phosph), LFTs, FBC +/Ferritin
Repeat Vitamin D (25OHD),
calcium and ALP levels
after 3 months
2 drops daily
4 drops daily
In children able to swallow solids:
Desunin® tablets 800units or
Fultium D3® 800units capsules
2 drops daily
Thorens ®
10,000units/ml
Oral drops:
In children able to
swallow solids:
400units – 2 drops
Colecalciferol tabs
600units – 3 drops
N/A
800units - 4 drops
Desunin® tablets
800units or Fultium
D3® 800units
capsules
Sunvit D3 1,000unit
tablets
1,000units - 5 drops
No routine monitoring is
required for
maintenance doses, unless
symptoms re-occur or do
not resolve
Children should be
encouraged to maintain an
adequate calcium intake
through good sources of
calcium in their diet.
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.
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Guidance for Vitamin D deficiency in Children
MID ESSEX LOCALITY
MID ESSEX LOCALITY
Title
Document
reference
Updated by
Consulted
with
References:
Guidance for Vitamin D deficiency in children
VitDDeficiencyChildrenGUI201511v2.0FINAL
Natalie Leong, Pharmacist Mid Essex CCG
Dr Manas Datta, Consultant Paediatrician, MEHT. Dr Sharon Lim, Consultant Paediatrician,
MEHT. Claire Fitzgerald, Paediatric Pharmacist. Jane Pearce, Paediatric Dietician
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/10vitamin-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
Date approved
Next review
date
Previous version
November 2014
MMC
November 2015
November 2017
Key Changes
Updated format, addition of guidance from RCPCH and doses from Childrens BNF
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