Clinical update

Spotting nutritional vitamin D deficiency in children

National Osteoporosis Society report clarifies vitamin D deficiency test for children

National Osteoporosis Society report clarifies vitamin D deficiency test for children

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Essential information

Nutritional vitamin D deficiency can lead to rickets, impaired growth, muscle weakness, cardiomyopathy and seizures in children.

Public Health England recommends daily vitamin D supplements for all babies from birth to one year of 8.5-10 micrograms per day. Babies receiving infant formula do not require supplements if receiving more than 500mL per day. Children from one to four years should consume 10 micrograms per day.

What’s new?

Updated vitamin D clinical guidance aims to provide healthcare professionals with clarity on which children to test for deficiency and which patients to treat.

The National Osteoporosis Society published the guidance on children and young people to tackle confusion among professionals on how to deal with vitamin D deficiency.

The new publication could potentially mean a reduction in the number of supplements prescribed by setting out which patients to target and supporting decision-making, particularly in primary care, about ordering blood tests.

The document also gives reassurance about toxicity levels, to allow healthcare professionals to feel confident when making treatment decisions.

Signs and symptoms

Signs of vitamin D deficiency include rickets, which can cause bowed legs, knock knees, wrist swelling and delayed teeth eruption. Other signs of deficiency include unexplained bone pain for more than three months, muscular weakness, tetany (intermittent muscular spasms), seizures and infantile cardiomyopathy.

Causes and risk factors

Deficiency risks are higher among children with diets that contain insufficient calcium, such as vegans or those with low dairy intake. Children with limited sun exposure, including children who wear veils, and those with limited time outdoors, including children with limited mobility, are at higher risk.

Children with dark skin may not get enough vitamin D from sunlight. Those taking anticonvulsants that induce liver enzymes and children with relatives who have proven vitamin D deficiency are also at higher risk.

How you can help your patient

Provide preventive advice to parents about dietary sources of vitamin D and multivitamin supplements. Foods rich in vitamin D include oily fish, eggs, meat, milk, margarine, some breakfast cereal, infant formula and fortified yogurt.

Routine testing for vitamin D deficiency is not recommended and should be restricted to those with a clear indication for measurement.

Measurement of plasma 25(OH)D is the best way to estimate vitamin D status.

Recommended treatment is oral preparations of vitamin D3 given daily for 8-12 weeks.

Many children with vitamin D deficiency have poor dietary calcium intake and may need to increase calcium intake through diet or supplements.

Expert comment

Alison Doyle, clinical and operations director at the National Osteoporosis Society and a registered nurse

‘This guidance is timely as there is considerable clinical interest in vitamin D and young people, partly due to a resurgence of symptomatic vitamin D deficiency and reports of children with rickets or hypercalcaemic symptoms.

'There has also been an increase in the number of requests to measure vitamin D levels, showing that many individuals in the UK have suboptimal levels. 

‘It is important that nurses working with children recognise the signs and symptoms for vitamin D deficiency, know which groups are at higher risk, understand who should have their levels tested and what the treatments are.

'This is all set out in the guidance, including when children should be referred for specialist care.

‘Many children with low vitamin D levels will also have low calcium levels too, usually from low dietary intake. The guideline has a simple guide on the calcium intake for age and a useful list of calcium rich foods.’


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