Presentation and treatment of Vitamin D deficiency

Arch Dis Child 2012;97:A115 doi:10.1136/archdischild-2012-301885.274
British Association of General Paediatrics/British Society for Paediatric Endocrinology & Diabetes
N Subbaraya, N Lygo, J Forster, S Shenoy
Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
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Summary by VitaminDWiki

After 8 weeks of treatment (how much vitamin D is not stated in abstract)
7% still < 20 nanograms
30% of infants got to range of 80-200 nanograms

Comments by VitaminDWiki

1. BNF should consider reducing the treatment for infants
2. They appear to have no maintenance dose – just 8 weeks of treatment, with no follow-up
   Doubt that the treatment given without maintenance does will provide ANY benefit after 1 year.

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Aim To evaluate the adequacy and safety of current recommended dosage of Vitamin D (VitD) treatment in children diagnosed with vitamin D deficiency (vitDD) and role for routine follow-up VitD levels following treatment.

Method Retrospective audit of all children (0-16 years) diagnosed to have VitDD and received treatment, according to local guidelines, during 18 month period (Jan 2010-June 2011). Data on demographics, investigation, treatment and follow-up VitD levels were analysed. Dose of Cholecalciferol was that recommended in children's British National Formulary (cBNF).

Results 137 children fulfilled the criteria. 28% < 6 months age at diagnosis, 22% over 12 years and 50% within 6 m – 12 years age group. 80% (N=117) were South Asian (SA) ethnicity. There was equal distribution of cases throughout the year. 47% had no other underlying medical issues. 44% (N=60) were asymptomatic. 34 infants <6 months age were asymptomatic and diagnosed to have VitDD during prolonged jaundice screening.

Bone pain was the most frequent presenting symptom amongst those symptomatic.

53% were severe deficient (VitD < 15 nmol/l), 32% deficient (15-30 nmol/l) and 15% insufficient (30-50 nmol/l).
{VitaminDWiki: that is, 100% met the criteria, whatever that was. Perhaps < 20nanograms}
There was no significant difference in the severity of deficiency between asymptomatic and symptomatic groups. All received treatment for 8 weeks duration except 9% for 6 weeks (all had insufficiency rather than deficiency). 83% (N = 84) had followup VitD levels after treatment. 93% achieved levels within ‘ideal’ range (50-150 nmol/l) whilst 7% failed to achieve (compliance issue identified in all). 6 of the 20 children under 6 months age had followup level above the ideal range up to 200 nmol/l but not toxic level (> 500 nmol/l).

Conclusions VitDD is very common in children of SA ethnicity. Children with severe VitDD can be asymptomatic. Dose of Cholecalciferol recommended in cBNF for a period of 8 weeks to correct VitDD is safe to use except those under 6 months where a 6 week course is adequate. Routine followup VitD levels after treatment is not necessary unless compliance with treatment is considered and in those children <6 months age until further evidence of safety in this age group.
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Some of what UK pediatricians might need to learn

The UK might know some of the following – but such information is not available outside of the UK

• Identify additional groups of children who are also at high risk
  not just dark skin (e.g. excess fat)
• Test for a rare allergic reaction to vitamin D before giving high doses.
• Dose size should increase with the number of high risk categories a child is in
• Also provide some cofactors, not just vitamin D
• Followup with maintenance doses after the loading dose.

See also VitaminDWiki

• Overview Dark Skin and Vitamin D
• 82 % of black US adults < 20 ng of vitamin D – Jan 2011
• 88 % of African immigrants to Melborne had < 20 ng of vitamin D
• All items in Europe 233 items
• All items in Skin Color and vitamin D 467 items
• Vitamin D insufficiency in UK youths – 37X more likely if dark skin – July 2011
• All items in category Youths and vitamin D 174 items
• All items in category Pregnancy 918 items
• 5 out of 6 UK dark skinned kids who were vitamin D deficient had no symptoms – May 2012
• Day care vitamin D grant being offered in the UK – July 2012