4.1.25-OH Vit D (Vitamin D)

  • Serum 25-OH Vitamin D <25 nmol/L is considered deficient.
  • Serum 25-OH Vitamin D 25-50 nmol/L is considered insufficient.

4.1.1. Vitamin D Deficiency.

  • Baseline blood tests: Ca/Mg/PO4; ALP; PTH; Albumin; 25-OH Vit D;
  • X-Ray Knee or wrist to assess for Rickets.
  • Referred to local Paediatrician with support from Paediatric Endocrinology at Sydney Children’s Hospital.
  • Treatment options:
  • There is the option for a single high dose of Vitamin D (STOSS Therapy) via Sydney Children’s Hospital.
  • Treatment course of oral Vitamin D for 3 months (see below).
  • Measure Ca2+ levels and treat if Hypocalcaemic.
  • If evidence of Rickets on X-Ray, need repeat X-Ray at 6 months to look for healing.
  • If treated with STOSS and the 1 month post-treatment bloods (Vitamin D, PTH and ALP) are not normalised, will need repeat STOSS therapy.
  • Treatment of Vitamin D Deficiency:
  • < 1 month old:
  • Treat with 25µg/day (1000IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).
  • 1-12 month old:
  • Treat with 75µg/day (3000IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).
  • 12 month old:
  • Treat with 125µg/day (5000IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).

4.1.2. Vitamin Insufficiency.

  • < 1 month old:
  • Treat with 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).
  • 1-12 month old:
  • Treat with 25µg/day (1000IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).
  • 12 month old:
  • Treat with 25-50µg/day (1000-2000IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3) for 3 months.
  • Follow-up with maintenance dose of 10µg/day (400IU) of Ergocalciferol (vitamin D2) or Cholecalciferol (vitamin D3).
  • Measure Ca2+ levels and treat if Hypocalcaemic.

4.1.3 Adult Vitamin D Recommendations.

  • Target range of normal is ≥75nmol/L.
  • Normal daily intake is approximately 1000-2000IU.
  • Use during pregnancy: Maximum dose of 1000IU daily, then increase to desired high dose treatment post-partum. Do not use preparations containing Vitamin A, which may cause foetal toxicities.
  • Maximum single dose is 600,000IU.
  • Recommended Calcium intake of 1200mg/day.
  • Insufficiency (50-75nmol/L):
  • Treat with 400-1000IU/day.
  • Recheck Vitamin D levels in 3 months then 12 months.
  • Deficiency (<50nmol/L):
  • High dose Vitamin D required – refer to specialist centre.
  • Dosage of 50,000IU/month
  • Loading dose of 50,000IU/day for first 10 days if Vitamin D <25nmol/L.

4.1.4. Oral Vitamin D Preparations.

  • Ergocalciferol (vitamin D2) – Ostelin Vitamin D.
  • 25µg Soft Gel Capsules.
  • Pack of 60 for $14.65
  • Pack of 250 for $49.00
  • Cholecalciferol (vitamin D3) – Ostevit-D.
  • 25µg Chewable tablets.
  • Pack of 90 for $13.50
  • Pack of 250 for $31.75

4.1.5. Monitoring of Vitamin D Deficiency and Insufficiency.

  • Month One after commencement of treatment:
  • Serum Calcium, Magnesium and Phosphate.
  • ALP
  • 25-OH Vitamin D
  • PTH
  • Month Three after commencement of treatment:
  • Serum Calcium, Magnesium and Phosphate.
  • ALP
  • 25-OH Vitamin D
  • PTH
  • Annually:
  • 25-OH Vitamin D

4.1.6.Hypocalcaemia.

  • Hypocalcaemia: Corrected Calcium <2.25 mmol/L
  • If symptomatic with tetany or seizures, will need urgent referral to local hospital with Paediatric services for admission and management with parenteral Calcium.
  • If asymptomatic, requires replacement with:
  • Calcium:40-80 mg/kg/day in 4-6 divided doses.
  • Calcitriol: 50-100 ng/kg/day in 2-3 divided doses.
  • Continue treatment until Corrected calcium levels normalise.
  • Dietary advice to ensure adequate calcium intake.
  • Oral calcium formulation:
  • Sandocal – Calcium Carbonate, Calcium Lactate Gluconate.
  • 1000mg effervescent tablets, scored.
  • Pack of 10 for $7.68.
  • Caltrate Tablets – Calcium Carbonate.
  • 600mg equiv Calcium, Tablet, scored.
  • Pack of 60 for $12.73.
  • Pack of 120 (Restricted benefit for Hypocalcaemia) for $12.70.

4.5.1.Iron Deficiency Anaemia.

  • Diagnosis:
  • Serum Ferritin <15µg/L
  • MCV <80 fL if ≥13 years old or <75 fL if <13 years old.
  • ± Hb <110 g/L
  • Haemoglobin Electrophoresis (HbEPG) should be performed to exclude Thalassemia and other Haemaglobinopathies.
  • Treatment:
  • Iron supplementation:
  • Fergon 0.3-0.45ml/kg daily for 3 months. Then repeat FBC and Iron studies.
  • Given with meals.
  • Dietary advice:
  • Encourage early introduction of iron-rich foods (especially haem iron).
  • Encourage enhancers with the iron-rich meal (vitamin C-rich foods, meat).
  • Reduce inhibitors with the iron-rich meal (tannin, fibre).