Vitamin D deficiency

This guideline has been adapted for statewide use with the support of the
Victorian Paediatric Clinical Network

See also

Immigrant Health guideline - Low Vitamin D - Contains detailed

information and background, especially for at-risk migrant and refugee
populations
Background
Assessment
Investigations
Management
Dosing Tables

Background

Vitamin D is essential for bone, muscle and other aspects in health.

Sunlight (UVB) is the most important source of vitamin D (>90%);
Only small amounts are available from diet. The main natural food
source is fish. Breastmilk, despite its other benefits, contains almost no
vitamin D. Infant formula is fortified with Vitamin D.
D3 synthesis in the skin varies due to:

Skin colour: Adults with dark skin (Fitzpatrick types V and VI)
require 3-6 times the amount of UVB compared to people with
light skin.

Skin exposure/clothing.

Season/UVB available - there may not be enough UVB during

winter months in Victoria to maintain adequate vitamin D levels

Note: Sunscreens do not result in low vitamin D.

In the absence of sun exposure, recommended dietary allowances are:

0-12 months old: 400 IU daily

1 - 18 years old: 400-600 IU daily

Assessment
Risk factors:

Lack of skin exposure to sunlight

Dark skin
Medical conditions/medications: obesity, liver failure, renal disease,
malabsorption (incl. cystic fibrosis, celiac disease, inflammatory bowel
disease) medications (incl. isoniazid, rifampicin, anticonvulsants)

In infants: maternal vitamin D deficiency and exclusive breastfeeding

combined with at least one other risk factor.
History:

Non-specific bone / muscular pain; fatigue with exercise

Symptoms of low calcium: muscle cramps, tetany, seizures (rare

beyond 6 months of age)

Time outdoors

Dairy intake

Previous vitamin D levels, previous/current treatments - to reduce risk

of over-dosing

Family understanding of Vitamin D

Exam:

Signs of Rickets (deformity in growing bones)

Delayed dentition, delayed anterior fontanelle closure

InvestigationsInfants:
Infants:

Exclusively breastfed infants with at least one other risk factor

without symptoms/signs - usually appropriate to start supplements
without investigations.

Infants with symptoms/signs need urgent specialist review (see

Management)

In children with one or more Risk Factors for low

vitamin D:

Measure vitamin D, Ca, PO4 and ALP

In those with symptoms/signs of deficiency: also measure parathyroid
hormone
In children with rickets: also measure UECr. Perform X-ray wrist and
clinical photography

Definitions of vitamin D status:

The laboratory test of Vitamin D is 25-hydroxy vitamin D - 25(OH)D.
The recommended level is > 50 nmol/L.
(Note: Some laboratories report levels with a different range)
Severe deficiency
< 12.5 nmol/L
Moderate deficiency
12.5 - 29 nmol/L
Mild deficiency
30 - 49 nmol/L
Sufficient
> 50 nmol/L
Elevated
> 250 nmol/L

Management
Vitamin D deficiency is a common condition requiring long-term
management.
It is ideally self-managed or managed in community health settings.
Children with clinical rickets or abnormal serum calcium require urgent
specialist assessment and management.

Initial Management:
Children and adolescents with low vitamin D

Aim to restore and maintain Vitamin D levels in the normal range ( 50

nmol/L)

Options are either daily low-dose supplements or high-dose

intermittent therapy (50,000IU/dose). See Dosing Table

Multiple low-dose supplements are commercially available.

Drops designed for adults are up to 50 times more concentrated,

leading to risk of overdosing.

See photoboard of supplements and give clear instructions

Ensure adequate Calcium Intake.

Cheese, yoghurt and fortified soy dairy are useful sources of

calcium in children who dislike cow milk. Consider supplements
if poor intake.

Treatment should be paired with health education about sun protection/

sun exposure and encouraging outside activity. Children/young people
with dark skin can tolerate intermittent sun exposure without
sunscreen. Hats/sunglasses are still recommended. See also:Sun
Exposure recommendations and Sunsmart handouts
Infants:

There is inadequate evidence to support high dose treatments in

infants aged < 3 months.
Exclusively breastfed infants of mothers with Vitamin D deficiency, with
at least one other Risk Factor should be given 400 IU daily for at least
the first 12 months of life. Monitor adherence.
Infants on full formula feeds should receive adequate vitamin D from
this source. Those on mixed feeds or solids may have inadequate
intake: consider checking levels or adding daily supplements in babies
with risk factors.
Note: Current practice in Victoria varies widely. Some hospitals treat
infants born to deficient mothers with 50,000 IU at birth. Sometimes a
sticker is placed in the Green child health book.

Dosing tables:
Age
Deficiency level
Treatment (oral doses D3)
Maintenance/prevention in children with ongoing risk factors
Preterm
Mild
200 IU/kg/day, maximum 400 IU/day
200 IU/kg/day, max. 400 IU/day
Moderate or severe
800 IU/day, review after 1 month
< 3 months
(term)
Mild
400 IU/day for 3 months

400 IU daily
Moderate or severe
1,000 IU/day daily for 3 months
3 - 12 months
Mild
400 IU/day for 3 months
400 IU daily
Moderate or severe
1,000 IU/day for 3 months,
OR 50,000 IU stat and review after 1 month (consider repeating dose)
1 - 18 years
Mild deficiency
1,000-2,000 IU/day for 3 months,
OR 150,000 IU stat
400 IU daily,
OR 150,000 IU at start of Autumn
Moderate or severe
1,000 - 2,000 IU daily for 6 months,
OR 3,000 - 4,000 IU daily for 3 months,
OR 150,000 IU stat and repeat at 6 weeks

Notes: There is a wide range of commercially available tablets, capsules and

liquid supplements. See Supplements photoboard

Ongoing Management and Monitoring:

In moderate/severe deficiency, repeat bloods: 25(OH)D, Ca, PO4, ALP

(and PTH if previously elevated) three months after initial diagnosis/
treatment (one month in infants). Further treatment may be required if
25(OH)D is still low.
In mild deficiency, it is usually not necessary to recheck for response to
treatment.
Avoid very frequent testing in patients with known deficiency and
stable risk factors

One practical approach is to test yearly or second-yearly at the

end of Summer (peak annual levels of Vitamin D).

Children with ongoing risk factors need a plan to maintain levels

through Winter/Spring; this can either be through annual dosing
(e.g. in Autumn), or daily supplements over the cooler months
(e.g. April - September). Children with multiple risk factors and/or
severe deficiency may require high dose treatments more than
once a year.
If high dose treatments are required:

Liaise with your local community health centre (many GPs are
high-dose prescribers)

Refer to your local General Paediatric outpatients.

Medical Practitioners can obtain TGA authorisation to treat patients
with high dose Vitamin D (usually 50,000IU D3 capsules).

Further information and authorised prescriber form.

List of pharmacies stocking high dose vitamin D
Consider admission/specialist consultation:

Admission: symptomatic hypocalcaemia (incl. tetany, stridor, seizures)

Specialist review:

clinical rickets

abnormal serum calcium

not responding to high-dose vitamin D supplements

Consider transfer when:

Children requiring care above the level of comfort of the local

hospital.For advice and inter-hospital (including ICU level)
transfers ring the Sick Child Hotline: (03) 9345 7007
Information sheets:

Vitamin D factsheets (English and translated versions)

Vitamin D and UV radiation (SunSmart)

Appendices:

Vitamin D supplements photo board