What is the recommended management for vitamin D deficiency in pediatrics?

Management of Vitamin D Deficiency in Pediatrics

For children with vitamin D deficiency, treat with 2,000 IU daily for 12 weeks (or 50,000 IU every other week for 12 weeks), then maintain with 400-600 IU daily based on age. 1

Treatment Approach Based on Severity

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

• Administer 2,000 IU daily for 12 weeks or alternatively 50,000 IU every other week for 12 weeks 1
• For children younger than 1 year, smaller doses are likely sufficient, though specific pediatric dosing is not well-established 2
• The treatment goal is achieving serum 25(OH)D levels above 20 ng/mL (50 nmol/L) 1

Moderate Deficiency/Insufficiency (25[OH]D 16-30 ng/mL)

• Treat with 2,000 IU daily or 50,000 IU every 4 weeks 2, 1
• Continue for 12 weeks until levels normalize 1

Mild Deficiency (25[OH]D 5-15 ng/mL)

• Use 4,000 IU daily for 12 weeks or 50,000 IU every other week for 12 weeks 1

Maintenance Therapy After Repletion

Once 25(OH)D levels reach ≥30 ng/mL, transition to age-appropriate maintenance dosing:

• Infants 0-12 months: 400 IU daily 1, 3, 4
• Children and adolescents 1-18 years: 600 IU daily 1, 4
• Preterm infants on parenteral nutrition: 200-1,000 IU daily (or 80-400 IU/kg/day) 2, 1

Formulation Selection

Cholecalciferol (vitamin D3) is preferred over ergocalciferol (vitamin D2) due to higher bioefficacy, though long-term comparative trials in children are lacking 2, 1

Critical Monitoring Parameters

• Recheck 25(OH)D levels after 12 weeks of treatment to confirm normalization 1
• Once normalized, monitor every 6-12 months, particularly during winter months when sun exposure is limited 1
• For children on long-term parenteral nutrition, monitor periodically and provide additional supplementation if 25(OH)D falls below 50 nmol/L 2, 1

Baseline and Follow-up Laboratory Assessment

At presentation with severe deficiency, evaluate for metabolic bone disease:

• Serum calcium 1
• Serum phosphorus 1
• Alkaline phosphatase 1
• Parathyroid hormone (PTH) 1
• Assess for clinical signs of rickets (bowing, rachitic rosary, growth failure) 1, 3

Safety Thresholds - Upper Tolerable Limits

Age-specific maximum daily doses to prevent toxicity:

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

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

Common Pitfalls to Avoid

• Do NOT use calcitriol, alfacalcidol, or other active vitamin D analogs (doxercalciferol, paricalcitol) to treat nutritional 25(OH)D deficiency—these are reserved for specific conditions like CKD-mineral bone disorder 2, 1
• Ensure adherence to the treatment regimen, as inconsistent supplementation leads to treatment failure 1
• Avoid excessive supplementation beyond recommended upper limits, though toxicity is rare at guideline-recommended doses 1
• Ensure adequate dietary calcium intake during treatment, as vitamin D improves calcium absorption 1
• Do not discontinue supplementation after 1 year of age—many families stop prematurely, increasing deficiency risk 5

Special Populations Requiring Modified Approach

Children with Chronic Kidney Disease (CKD)

• Optimal dosing for CKD stages 3-5 is not established 2
• Higher or more frequent supplementation may be needed 1
• Monitor calcium and phosphorus closely to avoid hypercalcemia 2

Children on Parenteral Nutrition

• Administer vitamins with lipid emulsion whenever possible to increase stability 2
• Provide additional supplementation if 25(OH)D <50 nmol/L 2, 1
• Consider oral supplementation during weaning from parenteral nutrition 2, 1