What is the recommended dosage of vitamin D (Vit D) for pediatric patients?

Vitamin D Dosage Recommendations for Pediatric Patients

For routine supplementation, all infants should receive 400 IU/day of vitamin D starting soon after birth, and children and adolescents should receive 400-600 IU/day, with higher doses required for treatment of documented deficiency. 1, 2

Routine Supplementation by Age Group

Preterm Infants on Parenteral Nutrition

• 200-1000 IU/day (or 80-400 IU/kg/day) is recommended for preterm infants receiving parenteral nutrition 1
• Some evidence suggests as little as 30 IU/kg/day i.v. might be sufficient, though the AAP recommends 200-400 IU/day to achieve target serum 25(OH)D concentrations of 50 nmol/L 1

Term Infants (0-12 months)

• 400 IU/day for all term infants, including exclusively breastfed infants 1, 3
• This dose applies whether receiving parenteral nutrition (40-150 IU/kg/day) or oral supplementation 1
• This recommendation was increased from the previous 200 IU/day based on evidence of continued rickets cases in certain populations 3

Children and Adolescents (1-18 years)

• 400-600 IU/day for routine supplementation 1
• The ESPGHAN Committee on Nutrition and American Academy of Pediatrics recommend 600 IU/day as the total daily intake from all sources for this age group 1
• Children with dark skin should receive 600 IU/day due to increased risk of deficiency 4

Treatment of Documented Vitamin D Deficiency

Loading Phase

• 2,000 IU daily for 12 weeks is the standard treatment regimen for children with severe vitamin D deficiency 2
• Alternative dosing: 50,000 IU every other week for 12 weeks can be used 2
• The goal is to achieve serum 25(OH)D levels above 20 ng/mL (50 nmol/L) 2

Maintenance After Treatment

• 600 IU/day for children ages 1-18 years after the initial 12-week treatment period 2
• Recheck 25(OH)D levels after the treatment period to confirm normalization 2

Safety: Tolerable Upper Intake Levels

The following upper limits should not be exceeded to avoid toxicity 1, 2:

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

Prolonged daily intake up to 10,000 IU appears safe, but serum concentrations >375 nmol/L are associated with acute hypercalcemia and hyperphosphatemia 1, 2

Special Considerations and Monitoring

Parenteral Nutrition Patients

• Monitor periodically for vitamin D deficiency in patients receiving long-term PN 1
• Provide additional supplementation when 25(OH)D levels fall below 50 nmol/L 1
• Consider oral supplementation during partial PN and when weaning from parenteral nutrition 1
• Lipid-soluble vitamins should be given with lipid emulsions whenever possible to minimize losses 1

Clinical Assessment

• Target serum 25(OH)D concentration is >50 nmol/L (20 ng/mL) for sufficiency 1, 2
• At severe deficiency levels, assess for clinical manifestations of rickets 2
• Consider evaluating serum calcium, phosphorus, alkaline phosphatase, and parathyroid hormone to assess for metabolic bone disease 2
• Ensure adequate dietary calcium intake during treatment, as vitamin D improves calcium absorption 2

Common Pitfalls to Avoid

• Do not rely solely on sunlight exposure for vitamin D in infants and young children, as adequate exposure cannot be determined exactly and may increase skin cancer risk 5, 3
• Ensure compliance with supplementation regimens, as inconsistent supplementation is a major cause of treatment failure 2
• Do not use active vitamin D analogs (calcitriol) to treat nutritional vitamin D deficiency; reserve these for specific conditions like chronic kidney disease 2
• Remember that breastfed infants require supplementation, as breast milk alone does not provide adequate vitamin D 3
• Children consuming less than 1 liter of vitamin D-fortified milk per day will likely need supplementation to reach 400 IU daily 6