BNF for Children 2011-2012

482 9.6.4 Vitamin D BNFC 2011–20129 Nutrition and bloodMetabolic disorders (tyrosinaemia type III; transienttyrosinaemia of the newborn; glutathionesynthase deficiency; Hawkinsinuria). By mouthNeonate 50–200 mg daily, adjusted as necessaryChild 1 month–18 years 200–400 mg daily in 1–2divided doses, adjusted as necessary; up to 1 gdaily may be requiredAscorbic Acid (Non-proprietary)Tablets, ascorbic acid 50 mg, net price 28 = £1.79;100 mg, 28 = £1.42; 200 mg, 28 = £1.42; 500 mg (label:24), 28 = £2.34Excipients may include aspartameBrands include Redoxon c DInjection, ascorbic acid 100 mg/mL, net price 5-mLamp = £4.39Excipients include metabisulphite9.6.4 Vitamin DNote The term Vitamin D is used for a range of compoundsincluding ergocalciferol (calciferol, vitamin D 2 ), colecalciferol(vitamin D 3 ), dihydrotachysterol, alfacalcidol (1a-hydroxycholecalciferol),and calcitriol (1,25-dihydroxycholecalciferol).Asymptomatic vitamin D deficiency is common in theUnited Kingdom; symptomatic deficiency may occur incertain ethnic groups, particularly as rickets or hypocalcaemia,and rarely in association with malabsorption.The amount of vitamin D required in infancy is relatedto the stores built up in-utero and subsequent exposureto sunlight. The amount of vitamin D in breast milkvaries and some breast-fed babies, particularly if pretermor born to vitamin D deficient mothers, maybecome deficient. Most formula milk and supplementfeeds contain adequate vitamin D to prevent deficiency.Simple, nutritional vitamin D deficiency can be preventedby oral supplementation of 400 units of ergocalciferol(calciferol, vitamin D 2 ) or colecalciferol (vitaminD 3 ) daily, using multi-vitamin drops (section 9.6.7),preparations of vitamins A and D (section 9.6.1), manufactured‘special’ solutions, or as calcium and ergocalciferoltablets (although the calcium and other vitaminsin supplements are unnecessary); excessivesupplementation may cause hypercalcaemia.Inadequate bone mineralisation can be caused by adeficiency, or a lack of action of vitamin D or its activemetabolite. In childhood this causes bowing and distortionof bones (rickets). In nutritional vitamin D deficiencyrickets, initial high doses of ergocalciferol orcolecalciferol should be reduced to supplementaldoses after 8–12 weeks, as there is a significant risk ofhypercalcaemia (see caution below). However, calciumsupplements are recommended if there is hypocalcaemiaor evidence of a poor dietary calcium intake. Asingle large dose of ergocalciferol or colecalciferol canalso be effective for the treatment of nutritional vitaminD deficiency rickets.Poor bone mineralisation in neonates and young childrenmay also be due to inadequate intake of phosphateor calcium particularly during long-term parenteralnutrition—supplementation with phosphate (section9.5.2.1) or calcium (section 9.5.1.1) may be required.Hypophosphataemic rickets occurs due to abnormalphosphate excretion; treatment with high doses of oralphosphate (section 9.5.2.1), and hydroxylated (activated)forms of vitamin D allow bone mineralisationand optimise growth.Nutritional deficiency of vitamin D is best treated withcolecalciferol or ergocalciferol. Preparations containingcalcium and colecalciferol are also occasionally used inchildren where there is evidence of combined calciumand vitamin D deficiency. Vitamin D deficiency causedby intestinal malabsorption or chronic liver diseaseusually requires vitamin D in pharmacological doses,such as ergocalciferol in doses of up to 40 000 unitsdaily; the hypocalcaemia of hypoparathyroidism oftenrequires higher doses in order to achieve normocalcaemiaand alfacalcidol is generally preferred.Vitamin D supplementation is often given in combinationwith calcium supplements for persistent hypocalcaemiain neonates, and in chronic renal disease.Vitamin D requires hydroxylation, by the kidney andliver, to its active form therefore the hydroxylated derivativesalfacalcidol or calcitriol should be prescribed ifpatients with severe liver or renal impairment requirevitamin D therapy. Alfacalcidol is generally preferred inchildren as there is more experience of its use andappropriate formulations are available. Calcitriol is unlicensedfor use in children and is generally reserved forthose with severe liver disease.Important. All patients receiving pharmacologicaldoses of vitamin D or its analogues should have theirplasma-calcium concentration checked at intervals(initially once or twice weekly) and whenever nauseaor vomiting occur.ERGOCALCIFEROL(Calciferol, Vitamin D 2 )Cautions see notes above; monitor plasma-calciumconcentration in patients receiving high doses and inrenal impairment; interactions: Appendix 1 (vitamins)Contra-indications hypercalcaemia; metastatic calcificationPregnancy high doses teratogenic in animals buttherapeutic doses unlikely to be harmfulBreast-feeding caution with high doses as may causehypercalcaemia in infant—monitor serum-calciumconcentrationSide-effects symptoms of overdosage include anorexia,lassitude, nausea and vomiting, diarrhoea,constipation, weight loss, polyuria, sweating, headache,thirst, vertigo, and raised concentrations ofcalcium and phosphate in plasma and urineLicensed use Calcium and Ergocalciferol tablets notlicensed for use in children under 6 yearsIndication and doseSee also notes aboveNutritional vitamin-D deficiency rickets. By mouthChild 1–6 months 3000 units daily, adjusted asnecessaryChild 6 months–12 years 6000 units daily,adjusted as necessaryChild 12–18 years 10 000 units daily, adjusted asnecessary