What is the recommended treatment for a pediatric patient presenting with scurvy?

Scurvy Presentation and Treatment in Children

For pediatric patients with scurvy, initiate oral vitamin C at 15-25 mg/kg/day for infants up to 12 months or 80 mg/day for older children, with treatment continuing for at least one month until clinical symptoms resolve. 1, 2

Clinical Presentation

Scurvy in children typically presents with characteristic musculoskeletal and mucocutaneous manifestations that should prompt immediate clinical diagnosis:

Musculoskeletal Findings

• Limping or inability to walk (96% of cases) - the most common presenting symptom 3
• Tenderness and pain in lower limbs (86% of cases), often leading to pseudoparalysis 3
• Swelling of lower limbs with reluctance to bear weight 4, 5

Mucocutaneous Bleeding

• Bleeding gums and gingival swelling (36% of cases) 3
• Petechiae and ecchymoses - purpuric rash patterns 4
• Perifollicular hemorrhages 1

Radiographic Features

• Osteopenia with increased sclerosis of zones of provisional calcification 6
• Dense epiphyseal rings (Wimberger sign) 6
• Extensive calcification of subperiosteal and soft tissue hemorrhages 6
• Metaphyseal irregularity and thickening - distinct from the classic metaphyseal lesions (CMLs) of abuse 6
• Epiphyseal separation in severe cases 3

High-Risk Populations

Dietary Risk Factors

• Children fed exclusively with ultra-heat temperature (UHT) milk without vitamin supplementation (89% of cases in one series) 3
• Autistic children with restricted diets and oral aversion 4, 7
• Infants given only well-cooked foods with minimal or no fresh fruits and vegetables 3, 5
• Children with developmental delays leading to selective eating patterns 7

The American Academy of Pediatrics notes that while formula and human milk contain adequate vitamin C, exclusive cow milk feeding without supplementation places older infants at risk 6

Diagnostic Approach

Do not delay treatment while awaiting laboratory confirmation if clinical features are present - diagnosis should be made clinically based on characteristic symptoms 1

When to Order Laboratory Testing

• Plasma vitamin C measurement is the preferred test when laboratory confirmation is needed 1
• Testing should only be ordered for suspected scurvy or chronic low intake, not during acute inflammation 1
• Plasma levels are unreliable when CRP >10 mg/L, and normal values are not detected if CRP >40 mg/L 1, 8

Treatment Protocol

Initial Therapy - Age-Based Dosing

For infants up to 12 months:

• 15-25 mg/kg/day of oral vitamin C 1, 2

For children over 12 months:

• 80 mg/day of oral vitamin C 1, 2

Alternative regimen for older children:

• 100 mg three times daily (300 mg/day total) for at least one month 1
• Or 250 mg twice daily for 3 weeks for clinical scurvy 1

Route of Administration

• Oral administration is standard for uncomplicated deficiency 1
• Parenteral (IM, IV, or subcutaneous) routes should be used when malabsorption is suspected or oral intake is impossible 1, 9

Duration of Treatment

• Continue for minimum of one month for symptomatic deficiency 1
• Treatment should continue until clinical symptoms resolve and adequate dietary intake is established 8

Expected Response

• Clinical improvement occurs within 48 hours to one week after starting vitamin C supplementation 3, 10, 5
• Response is typically dramatic and rapid 3, 10

Maintenance After Repletion

Standard Maintenance

• Healthy children require 75-90 mg/day achievable through diet 1

High-Risk Populations

• Children with chronic restrictive diets require 200-500 mg/day indefinitely 1, 8
• Post-bariatric surgery patients require 200-500 mg/day long-term 8

Safety Considerations and Contraindications

Absolute Contraindications to High-Dose Vitamin C

• Hemochromatosis or iron overload conditions 2, 8
• G6PD deficiency 2, 8
• History of oxalate kidney stones 2, 8
• Severe renal dysfunction without dialysis support 2, 8

Special Monitoring in Pediatrics

• Pediatric patients under 2 years are at higher risk of oxalate nephropathy due to age-related decreased glomerular filtration 9
• Children with kidney disease (CKD stages 1-4) should not exceed 100 mg/day to prevent oxalate accumulation 2
• Never exceed 10 times the dietary reference intake without proven severe deficiency 2

Critical Pitfalls to Avoid

Diagnostic Pitfalls

• Scurvy is frequently misdiagnosed (86% of cases in one series were initially misdiagnosed) 3
• Do not overlook simple diet history - this avoids costly diagnostic workup and hospitalization 4
• Distinguish from child abuse - scurvy's metaphyseal changes occur closer to the diaphysis with florid rachitic changes, unlike the juxtaphyseal CMLs of abuse 6

Treatment Pitfalls

• Do not measure vitamin C levels in acutely ill or inflamed patients - results will be falsely low and misleading 1, 8
• Ensure proper storage of vitamin C solutions - they degrade rapidly at room temperature and should be stored at 2-8°C 2
• Address underlying dietary restrictions - treatment must include dietary counseling to prevent recurrence 5