What is the recommended treatment for pediatric vitamin D deficiency?

Treatment of Pediatric Vitamin D Deficiency

For children with vitamin D deficiency, treatment should include an initial loading dose of 2,000 IU daily or 50,000 IU every other week for 12 weeks, followed by maintenance therapy of 600 IU daily for children 1-18 years of age. 1

Diagnosis and Classification

• Vitamin D deficiency is defined as a serum 25-hydroxyvitamin D level <20 ng/mL (50 nmol/L) 2, 3
• Vitamin D insufficiency is defined as a serum 25-hydroxyvitamin D level of 20-30 ng/mL (50-75 nmol/L) 4, 3
• Severe vitamin D deficiency is considered at levels <25-30 nmol/L (10-12 ng/mL), which significantly increases risk for rickets and osteomalacia 4

Treatment Regimens Based on Deficiency Severity

Severe Deficiency (25(OH)D <20 ng/mL)

• Initial loading dose options:
  • 2,000 IU of vitamin D daily for 12 weeks 1
  • 50,000 IU every other week for 12 weeks 1
  • Alternative: 4,000 IU/day orally for 12 weeks 1

Mild Deficiency/Insufficiency (16-30 ng/mL)

• 2,000 IU daily or 50,000 IU every 4 weeks 1

Maintenance Therapy

• Infants 0-12 months: 400 IU/day 1, 5
• Children 1-18 years: 600 IU/day 4, 1
• Preterm infants: 200-400 IU/day 4

Monitoring Recommendations

• Recheck 25(OH)D levels after the 12-week treatment period to confirm normalization 1
• Once normalized, monitor levels every 6-12 months, especially during winter months 1
• Consider evaluating serum calcium, phosphorus, alkaline phosphatase, and parathyroid hormone levels to assess for metabolic bone disease 1

Special Considerations

• Children with risk factors for vitamin D deficiency may need higher or more frequent supplementation 6:

  • Dark skin
  • Limited sun exposure
  • Skin-covering clothing
  • Intestinal malabsorption
  • Cholestasis
  • Renal insufficiency
  • Certain medications (rifampicin, antiepileptic drugs)
  • Obesity
  • Vegan diet

• For patients on parenteral nutrition (PN):

  • Monitor periodically for vitamin D deficiency 4
  • Provide additional supplementation for patients with 25(OH)D levels <50 nmol/L 4
  • Consider oral supplementation for patients on partial PN and during weaning from PN 4

Safety and Upper Limits

• Tolerable upper intake levels by age 1:

  • Infants 0-6 months: 1,000 IU/day
  • Infants 7-12 months: 1,500 IU/day
  • Children 1-3 years: 2,500 IU/day
  • Children 4-8 years: 3,000 IU/day
  • Children and adolescents 9-18 years: 4,000 IU/day

• Prolonged daily intake up to 10,000 IU appears safe, but serum concentrations >375 nmol/L are associated with hypercalcemia and hyperphosphatemia 4

Clinical Pearls and Pitfalls

• Cholecalciferol (vitamin D3) appears to have higher bioefficacy than ergocalciferol (vitamin D2) for treating deficiency 1
• Ensure adequate dietary calcium intake during treatment, as vitamin D improves calcium absorption 1
• Avoid using active vitamin D analogs to treat nutritional vitamin D deficiency 1
• Inconsistent supplementation may lead to treatment failure 1
• The goal of treatment is to achieve serum 25(OH)D levels above 20 ng/mL (50 nmol/L) 4, 1