Consider giving IM ergocalciferol 300,000 IU two injections spaced by 3 months if there are concerns regarding absorption (e.g. in malabsorption). Usually between 1000-2000 IU colecalciferol per day depending on weight, e.g. Holland and Barrett Vitamin D3 25 microgram tablets, 1-2 tablets a day, or colecalciferol (Dekristol) 20,000 IU capsules, one capsule every 2 weeks. Higher doses may be required e.g. if the patient is taking drugs that accelerate Vitamin D metabolism or if there are concerns regarding absorption. Maintenance should be continued so long as risk factors for Vitamin D deficiency are present. D3 is generally preferred as D2 may be less potent than D3, unit for unit. If the patient is being given supplementation for osteoporosis and osteopenia, they should also receive 1000 mg of supplemental calcium daily, as calcium and vitamin D supplementation is effective in reducing the risk of hip fracture. Vitamin D alone is not effective in reducing hip fractures.
Calcium supplements alone appear to be associated with a higher risk of heart attack and stroke and are therefore not recommended. Pregnant and lactating women should be given calcium and 400 IU Vitamin D daily. Up to 10000 IU per day is not toxic when given for up to 5 months. Measure 25-hydroxyvitamin D, PTH, calcium after 3 months and 6-monthly thereafter to ensure that hypercalcaemia does not occur. Aim for 25-hydroxyvitamin D 'replete' level, with calcium and PTH levels within reference ranges. If in doubt, please refer to secondary care for advice. Prices of vitamin D:Vitamin D costs 2014Despite recommendations from public health authorities for people to consume their vitamin D through pills rather than sun exposure, a new study casts doubt on the value of vitamin D supplements. The randomized controlled trial assigned 230 postmenopausal women 75 years old or younger to get either high-dose vitamin D supplements (50,000 IU every two weeks), low-dose vitamin D supplements (800 IU daily) or placebo pills.
All of the women had low levels of circulating vitamin D when they entered the study. After a year, the women getting the high dose of 100,000 IU each month had raised their blood levels of vitamin D. There were no measurable differences among the groups on anything that counts, though: bone density, muscle mass, muscle function and falls were the same in all the groups. This study does not offer evidence supporting the use of vitamin D supplements for bone health or fall prevention in older women. Those are the key reasons many people take this vitamin, so it may be time to re-think that strategy. JAMA Internal Medicine, online Aug 3, 2015You have tried to access content that requires a subscription to BMJ Best Practice. Or log in via: Institutional number (access code) Haven't got a subscription? Full access to BMJ Best Practice content Download and access the APP Claim CME/CPD Certificates for your learning on BMJ Best Practice Add bookmarks and notes to topics of interest
Sign up for free trial Treatment for rickets may be administered gradually over several months or in a single-day dose of 15,000 mcg (600,000 U) of vitamin D. [5] If the gradual method is chosen, 125-250 mcg (5000-10,000 U) is given daily for 2-3 months until healing is well established and the alkaline phosphatase concentration is approaching the reference range. Because this method requires daily treatment, success depends on compliance. If the vitamin D dose is administered in a single day, it is usually divided into 4 or 6 oral doses. An intramuscular injection is also available. Vitamin D (cholecalciferol) is well stored in the body and is gradually released over many weeks. Because both calcitriol and calcidiol have short half-lives, these agents are unsuitable for treatment, and they bypass the natural physiologic controls of vitamin D synthesis. The single-day therapy avoids problems with compliance and may be helpful in differentiating nutritional rickets from familial hypophosphatemia rickets (FHR).
In nutritional rickets, the phosphorus level rises in 96 hours and radiographic healing is visible in 6-7 days. Neither happens with FHR. If severe deformities have occurred, orthopedic correction may be required after healing. Most of the deformities correct with growth. A consultation with a pediatric endocrinologist is recommended. Human milk contains little vitamin D and contains too little phosphorus for babies who weigh less than 1500 g. Infants weighing less than 1500 g need special supplementation (ie, vitamin D, calcium, phosphorus) if breast milk is their primary dietary source. Recommending a vitamin D supplement from the first week of life for susceptible infants who are breastfed is safe and effective and, therefore, should be considered. The United States Institute of Medicine recommends an upper level of intake of 1000 IU/d and 1500 IU/d in infants aged 0-6 months and 6-12 months, respectively. An adequate intake of 400 IU/d has been suggested for infants aged 0-12 months.
The recommended daily allowance is 600 IU/d thereafter. [7] The US Endocrine Society’s Clinical Practice Guideline suggests 400-1000 IU/d may be needed for children younger than 1 year; they also recommend 600-1000 IU/d for children aged 1 year or older. [8] Internationally, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition also suggests an oral supplement of 400 IU/d until age 1 year. Adequate ultraviolet light or 10 mcg (400 IU) orally (PO) daily of a vitamin D preparation and an adequate dietary supply of calcium and phosphorus prevent rickets.As little as 20 min/d of ultraviolet light to the face of a light-skinned baby is sufficient; however, significantly longer periods of exposure are necessary for children with increased skin pigmentation. Zmora E, Gorodischer R, Bar-Ziv J. Multiple nutritional deficiencies in infants from a strict vegetarian community. Am J Dis Child. McKay CP, Portale A. Emerging topics in pediatric bone and mineral disorders 2008.
Lowdon J. Rickets: concerns over the worldwide increase. J Fam Health Care. Chapman T, Sugar N, Done S, Marasigan J, Wambold N, Feldman K. Fractures in infants and toddlers with rickets. Shah BR, Finberg L. Single-day therapy for nutritional vitamin D-deficiency rickets: a preferred method. Casey CF, Slawson DC, Neal LR. VItamin D supplementation in infants, children, and adolescents. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Ross AC, Taylor CL, Yaktine AL, Del Valle HB eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: National Academies Press; Pramyothin P, Holick MF. Vitamin D supplementation: guidelines and evidence for subclinical deficiency. Braegger C, Campoy C, Colomb V, et al. Vitamin D in the healthy European paediatric population. J Pediatr Gastroenterol Nutr. Greer FR. Issues in establishing vitamin D recommendations for infants and children. Am J Clin Nutr. 2004 Dec. 80(6 Suppl):1759S-62S.