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Child health Preventative medicine Endocrine and metabolic Musculoskeletal

Vitamin D deficiency in children

Last revised in January 2022

Vitamin D is a fat soluble vitamin that regulates calcium and phosphate homeostasis and is therefore vital for musculoskeletal health.

Vitamin D deficiency in children: Summary

  • Vitamin D is a fat-soluble vitamin that regulates calcium and phosphate homeostasis and is therefore vital for musculoskeletal health.
  • Vitamin D circulates in the blood as both vitamin D3 (colecalciferol) and vitamin D2 (ergocalciferol).
    • In the UK, 80–90% of vitamin D is derived from skin exposure to ultraviolet B radiation from sunlight, with the remaining 10–20% being derived from dietary sources.
  • Recommended vitamin D thresholds in the UK in respect to bone health are:
    • An increased risk of vitamin D deficiency at serum 25-hydroxyvitamin D (25[OH]D) levels less than 25 nmol/L.
    • Vitamin D levels may be inadequate (or insufficient) in some people when serum 25(OH)D is 25–50 nmol/L.
    • Vitamin D levels are sufficient for most people when serum 25(OH)D is greater than 50 nmol/L.
  • Risk factors for vitamin D deficiency include children:
    • Who have low or no exposure to the sun.
    • Who have darker skin pigmentation.
    • Who are exclusively breastfed babies from birth.
    • Who are infants over 6 months of age taking less than 500 mL of formula milk a day.
    • With a malabsorption disorder, severe liver or end-stage chronic kidney disease.
    • Taking certain drugs.
    • Who are pregnant or breastfeeding.
    • With obesity.
  • Complications of vitamin D deficiency include increased risk of:
    • Rickets — may present with progressive leg deformity, painful wrist or costochondral swelling, craniotabes, and impaired growth.
    • Osteomalacia — may present with bone pain, muscle pain and weakness; waddling gait.
    • Hypocalcaemia — may present with irritability, tetany, or seizures.
  • Assessment for vitamin D deficiency (by checking serum 25[OH]D levels) should be arranged if a child has:
    • Musculoskeletal symptoms that may be attributable to vitamin D deficiency, such as suspected rickets or osteomalacia.
    • Abnormal serum bone profile or X-ray findings.
    • Suspected bone disease such as osteomalacia that may be improved with vitamin D treatment.
    • Known bone disease such as osteoporosis, where correction of vitamin D deficiency is needed prior to specific treatment.
  • Management of a child with vitamin D deficiency includes:
    • Seeking specialist advice or arranging referral if there are clinical features of rickets or hypocalcaemia; a condition predisposing to hypercalcaemia; a malabsorption disorder; renal stone disease; severe kidney or liver disease; or pregnancy.
    • Providing advice on sources of information and support.
    • Advising on safe sunlight exposure and dietary sources of vitamin D.
    • Prescribing a fixed loading dose followed by maintenance dose vitamin D for treatment of vitamin D deficiency.
    • Prescribing maintenance dose vitamin D for treatment of vitamin D insufficiency.
    • Assessing dietary calcium intake and the need for supplementation.
    • Arranging follow up to reassess serum vitamin D levels and bone profile.
  • Advice for the prevention of vitamin D deficiency includes:
    • Information on safe sunlight exposure and dietary sources of vitamin D.
    • Vitamin D supplement drops for children from birth to 4 years of age.
    • Considering vitamin D supplements for all other children, including those at high risk of deficiency.

Have I got the right topic?

From age 1 month to 18 years.

This CKS topic covers the diagnosis and management of children and young people with vitamin D deficiency and inadequate (or insufficient) vitamin D levels caused by inadequate sunlight exposure or nutritional deficiency. It also covers the prevention of vitamin D deficiency in children and young people.

This CKS topic does not cover the management or prevention of vitamin D deficiency in adults.

There are separate CKS topics on Antenatal care - uncomplicated pregnancy, Hypercalcaemia, and Vitamin D deficiency in adults.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

 

January 2022 — minor update. Broken link  replaced for advice on vitamin D preparations for people on a halal or kosher diet. 

Previous changes

April 2021 — reviewed. A literature search was conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations have been updated in line with current evidence in the literature. The recommended dose for vitamin D supplementation for prevention of vitamin D deficiency has been amended in line with the Royal Osteoporosis Society (ROS) publication Vitamin D and bone health: a practical clinical guideline for patient management in children and young people.

December 2020  — minor update. The vitamin D level threshold below which musculoskeletal complications may occur has been updated in line with the UK Scientific Advisory Committee on Nutrition (SACN). A previously cited US Institute of Medicine (IOM) reference has been removed.

December 2016 — minor update. Ergocalciferol 1.25 mg (50,000 IU) capsules have been added to the section on product availability (ABPI, 2016). Desunin® (colecalciferol) 100 micrograms (4,000 IU) tablets have been added to the section on product availability in line with the British National Formulary (BNF, 2016).

August to November 2016 — new topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

  • SPS (2021) Choosing a calcium and vitamin D preparation for vegetarians or vegans. Specialist Pharmacy Service. www.sps.nhs.uk [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 April 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 April 2021.

New policies

No new national policies or guidelines since 1 April 2021.

New safety alerts

No new safety alerts since 1 April 2021.

Changes in product availability

  • New product: Colextra-D3 (Colecalciferol) 20,000 IU Soft Capsules. Colextra-D3 is licensed for the prevention and treatment of vitamin D deficiency in adults and adolescents with an identified risk. It may be used as an adjunct to specific therapy for osteoporosis in patients with vitamin D deficiency or at risk of vitamin D insufficiency. See more here.
  • SPC for Fultium-D3 (colecalciferol) updated with license extension to include use as prophylaxis of vitamin D deficiency in adults and adolescents over 12 years with an identified risk, at a dose of 1-2 capsules weekly, dependent upon the patient’s risk factors (e.g. dietary intake, light exposure, skin tone). See more here. 

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Be aware when to assess for vitamin D deficiency and insufficiency in children and young people.
  • Provide advice on management of vitamin D deficiency and insufficiency in children and young people.
  • Arrange referral to an appropriate specialist if indicated.
  • Provide advice on the prevention of vitamin D deficiency in children and young people.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Vitamin D is a fat-soluble vitamin that regulates calcium and phosphate homeostasis, and is vital to allow for the rapid growth of infants and young children, and for healthy skeletal development throughout childhood [SACN, 2016] [ROS, 2018].
    • It promotes the absorption of calcium and phosphorus from the bowel and enables mineralization of newly formed osteoid tissue in bones, as well as having a role in neuromuscular function.
  • Vitamin D circulates in the blood as both vitamin D3 (colecalciferol) and vitamin D2 (ergocalciferol) [SACN, 2016] [ROS, 2018]. 
    • Vitamin D3 is synthesized in the skin from 7-dehydrocholesterol (7-DHC — a form of cholesterol naturally found in the skin) by the action of sunlight containing ultraviolet B (UVB) radiation (or by artificial UVB light).
    • Both vitamin D3 and D2 can be obtained from natural foods (limited source), fortified foods, and food supplements.
  • Dietary and skin-derived vitamin D are biologically inactive and require enzymatic conversion to the active metabolite 1,25-hydroxyvitamin D (1,25[OH]2D) [SACN, 2016].
    • Vitamin D is converted in the liver to 25-hydroxyvitamin D (25[OH]D), the main circulating metabolite. This is then converted to 1,25(OH)2D in the kidneys and other tissues. The production of 1,25(OH)2D is regulated by the action of parathyroid hormone (PTH) on the kidneys.
  • Recommended vitamin D thresholds in the UK in respect to bone health are [SACN, 2016]:
    • An increased risk of vitamin D deficiency occurs at serum 25[OH]D levels less than 25 nmol/L.
    • Vitamin D levels may be inadequate (or insufficient) in some people when serum 25(OH)D is between 25–50 nmol/L.
    • Vitamin D levels are sufficient for most people when serum 25(OH)D is greater than 50 nmol/L.

What causes it?

In the UK, 80–90% of vitamin D is derived from skin exposure to ultraviolet B (UVB) radiation from sunlight, with the remaining 10–20% being derived from dietary sources [ROS, 2018].

  • The amount of vitamin D synthesized in the skin can be affected by environmental factors [NICE, 2016] [SACN, 2016]:
    • Season, time of day, and weather conditions — solar UV levels are highest in the UK spring and summer months (between late March/early April and September), and around midday (between 11 am and 3 pm), and are reduced by cloud cover. As a result, sunlight-induced vitamin D synthesis is only effective between these months in the UK.
    • Latitude — at latitudes above 37º N such as in the UK, sunlight containing UVB radiation is limited in the winter months.
  • The amount of vitamin D synthesized in the skin can be affected by individual factors [NICE, 2016] [SACN, 2016]:
    • Age — lower serum 25-hydroxyvitamin D (25[OH]D) concentrations have been reported in older people compared with younger people. This is possibly because the amount of 7-dehydrocholesterol (7-DHC) present in the skin decreases with increasing age.
    • Skin colour — melanin pigment absorbs a proportion of the UVB radiation needed for skin synthesis of vitamin D. People with dark skin may therefore need more sunlight exposure to produce the same amount of vitamin D as people with lighter skin pigmentation.
    • Clothing cover — clothes that cover the entire body and face reduce skin exposure to sunlight.
    • Sunscreen use — although it has been theorized that sunscreen use can significantly reduce vitamin D production, the Scientific Advisory Committee on Nutrition (SACN) notes that the majority of people do not apply sunscreen at the recommended concentration, and do not apply it to all exposed areas of the skin. It states that normal usage of sunscreens does not generally prevent vitamin D synthesis [SACN, 2016].
  • In the winter months in the UK, vitamin D has to be obtained from body stores (from UVB exposure in the summer months) and dietary sources [SACN, 2016].
    • There are few naturally rich food sources of vitamin D, and most contain vitamin D3. Sources include egg yolk, oily fish (such as salmon, mackerel, herring, and sardines), wild mushrooms, red meat, fat, liver, and kidney.
    • Vitamin D-fortified foods include most margarines and fat spreads, some dried or evaporated milks and breakfast cereals, and formula milk for infants and toddlers.
    • Vitamin D3 supplements are synthesized by UVB irradiation of 7-DHC from sheep wool, and vitamin D2 by UVB irradiation of ergosterol from fungi.
  • Specific medical conditions may impair the absorption of vitamin D.
    • Intestinal malabsorption syndromes (such as coeliac disease, cystic fibrosis, and Crohn's disease), or following weight loss surgery, impair the absorption of dietary vitamin D, leading to decreased bioavailability [Holick, 2017; Aoun, 2020].
    • Obesity (body mass index above the 98th centile for age and sex) is associated with lower vitamin D levels, possibly due to vitamin D being a fat-soluble vitamin that is sequestered in adipose tissue, leading to reduced bioavailability [Vanlint, 2013; Holick, 2017].
    • Severe liver failure is associated with fat malabsorption [Aoun, 2020].
  • Specific medical conditions may impair the activation of vitamin D [Holick, 2017] [Aoun, 2020].
    • End-stage chronic kidney disease (CKD) impairs the production of sufficient 1,25-dihydroxyvitamin D (1,25[OH]2D). In addition, nephrotic syndrome can cause urinary loss of vitamin D.
    • Severe liver disease may affect the production of 25-hydroxyvitamin D (25[OH]D).
    • Inherited enzyme disorders are rare and include mutation of renal 25-hydroxyvitamin D 1 alpha-hydroxylase (which causes vitamin D-deficiency rickets).
  • Some drugs increase the risk of vitamin D deficiency. 
    • Drugs that reduce fat absorption (for example orlistat) can lead to a decreased bioavailability of vitamin D [Preston, 2015].
    • Antiepileptic drugs (especially carbamazepine, phenobarbital, and phenytoin), colestyramine, rifampicin, corticosteroids, thiazide diuretics, digoxin, calcium-channel blockers, antacids, and highly active antiretroviral treatment (HAART) can actively destroy vitamin D by activating the catabolism of both 25(OH)D and 1,25(OH)2D. See the section on Drug interactions in Prescribing information for more information [Aoun, 2020].

What are the risk factors?

The entire population of the UK are at risk of having a low vitamin D status [NICE, 2020].

How common is it?

The prevalence of vitamin D deficiency varies in the literature depending on the definitions of deficiency and insufficiency, the study population characteristics and geographical location, and laboratory assays used.

  • The UK National Diet and Nutrition Survey is designed to assess the diet, nutrient intake, and nutritional status of the general population aged 1.5 years and over living in private households. This reported low vitamin D status, as indicated by serum 25-hydroxyvitamin D (25[OH]D) concentrations below 25 nmol/L, in people of all reported age/sex groups [PHE, 2017].
    • Over the year as a whole, combined results from a 4-year rolling programme (2008/2009 – 2011/2012) showed 7.5% of children aged 1.5–3 years, 14% of children aged 4–10 years, and 22% of children aged 11–18 years had a serum 25(OH)D concentration below 25 nmol/L.
    • When subdivided by season, in the winter months of January to March this increased to 40% of children aged 11–18 years, compared with 13.4% in the summer months of July to September for the same age group.
  • A Scottish retrospective paediatric survey of hospital cases of symptomatic vitamin D deficiency reported an annual incidence of 23 cases per year over a 6-year period (2002–2008), with a clear annual trend of increasing cases. The median age at presentation was 24 months, and there was a classical clinical presentation of rickets in about two-thirds of cases [Ahmed, 2011].
    • The authors note that these figures may be underestimates as rickets may be under-diagnosed, or non-skeletal complications, such as hypocalcaemic seizures or cardiomyopathy, may not be attributed to vitamin D deficiency.
  • A primary care database cohort study (n = 711,788) of children 0–17 years in England found the incidence rate of vitamin D deficiency increased from 3.14 per 100,000 person-years in 2000 to 261 per 100,000 person-years in 2014 [Basatemur, 2017].
    • Overall, a 15-fold increase in diagnosis of vitamin D deficiency was noted, after taking account of changes in demographic characteristics.
    • Children who were older (more than 10 years of age), of non-white ethnicity, and more socially deprived were independently associated with higher rates of diagnosis.
  • A subsequent UK prospective paediatric survey of secondary care cases of nutritional rickets reported an annual incidence of 0.48 cases per 100,000 children under 16 years over a 2-year period (2015–2017) [Julies, 2020].
    • Boys were more commonly affected than girls, and the majority of affected children were of Afro-Caribbean or South Asian ethnicity.

What is the prognosis of vitamin D deficiency?

  • Management of vitamin D deficiency and correction of modifiable risk factors should [SACN, 2016; NICE, 2020]:
    • Restore vitamin D levels.
    • Reduce the risk of, or improve the symptoms of complications of vitamin D deficiency.
  • Following treatment for vitamin D deficiency or insufficiency, lifestyle changes and vitamin D supplementation are likely to be needed long term to maintain optimum vitamin D levels [SACN, 2016].

What are the complications of vitamin D deficiency?

The risk of musculoskeletal complications of vitamin D deficiency is increased at plasma 25-hydroxyvitamin D (25[OH]D) concentrations below 25 nmol/L [SACN, 2016].

  • Rickets and impaired growth 
    • Prolonged vitamin D deficiency during periods of bone growth in children may lead to a failure or delay of endochondral calcification at the growth plates of the long bones, which results in the bone disorder rickets and an accumulation of excess unmineralized osteoid (bone matrix) in all bones [Munns, 2016; SACN, 2016].
    • Rickets most commonly affects infants and young children, but may also occur during the pubertal growth spurt and adolescence, which is a critical developmental period for bone health and skeletal development, where there is rapid growth [SACN, 2016].
    • Rickets may present with progressive leg deformity (bowing or genu valgum ['knock knees']); painful wrist swelling; swelling of the costochondral junctions ('rachitic rosary'); craniotabes (skull softening with frontal bossing and delayed fontanelle closure); and delayed tooth eruption and enamel hypoplasia [Julies, 2020].
    • Skeletal deformity may be associated with bone pain or tenderness, and muscle weakness [SACN, 2016]; children with radiologically confirmed rickets are at increased risk of fractures [Munns, 2016].
    • Vitamin D deficiency is the most common cause of rickets; it may also be caused by calcium and phosphorus deficiency [Munns, 2016; SACN, 2016].
    • Insufficient vitamin D may also affect bone mineral density and lead to children and adolescents not achieving their full potential at peak bone mass [SACN, 2016].
  • Osteomalacia and muscle weakness
    • Prolonged severe vitamin D deficiency results in the bony skeleton becoming the body's main source of calcium, with osteoclasts breaking down bone to increase serum calcium levels. The low mineral-to-bone matrix ratio in bone may result in osteomalacia, characterized by replacement of resorbed bone with unmineralized osteoid [SACN, 2016].
    • Osteomalacia may present with persistent bone pain, muscle pain, and proximal muscle weakness causing difficulty climbing stairs or rising from a chair, delayed walking, or waddling gait [SACN, 2016; Julies, 2020].
    • CKS notes there is debate in the literature regarding the potential benefits of vitamin D supplementation, with some commentators noting a lack of consistent evidence that vitamin D supplementation improves musculoskeletal outcomes such as bone density, fracture prevention, and muscle strength [Bolland, 2016].
  • Hypocalcaemia
    • Symptomatic hypocalcaemia may present with irritability, tetany, or seizures and tends to present in infancy (most common) or adolescence (due to the higher metabolic demand for calcium during periods of rapid bone growth) [Pearce, 2010].
    • A 2-year prospective national surveillance study of UK and Republic of Ireland paediatricians found an overall annual incidence of hypocalcaemic seizures of 3.49 per million children aged 0–15 years [Basatemur, 2015].
  • Dilated cardiomyopathy
    • This is a potentially serious but very rare complication of vitamin D deficiency and hypocalcaemia in infants, which may be associated with life-threatening heart failure [Maiya, 2008; Ahmed, 2011; Munns, 2016; Julies, 2020].
  • Note: there is debate in the literature regarding the role of vitamin D in non-musculoskeletal disorders such as autoimmune disease, cancer, mental health problems, and cardiovascular disease, with a lack of high-quality evidence on the benefits of vitamin D supplementation for these outcomes [Bolland, 2016]. A Scientific Advisory Committee on Nutrition (SACN) evidence review found insufficient evidence for non-musculoskeletal health outcomes to inform the setting of Dietary Reference Values (DRVs) for vitamin D [SACN, 2016].

Diagnosis

When should I suspect or test for vitamin D deficiency?

Do not routinely test for vitamin D deficiency in children and young people who are asymptomatic.

  • Check the vitamin D level by measuring serum 25-hydroxyvitamin D (25[OH]D) if a person has:
    • Musculoskeletal symptoms that may be attributable to vitamin D deficiency, such as:
    • Abnormal bone profile results that suggest vitamin D deficiency. See the section on Additional investigations for more information.
    • Radiological features of osteopenia, rickets, or pathological fracture.
    • A chronic medical condition that may increase the risk of vitamin D deficiency.
    • Suspected bone disease that may be improved with vitamin D treatment, such as osteomalacia.
    • Known bone disease, where correction of vitamin D deficiency is needed prior to specific treatment, such as:
      • Osteogenesis imperfecta.
      • Idiopathic juvenile osteoporosis or osteoporosis secondary to other causes.

Basis for recommendation

The recommendations on when to suspect and test for vitamin D deficiency are largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Vitamin D: supplement use in specific population groups [NICE, 2020], the Royal Osteoporosis Society (ROS) publications Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], an international publication Global consensus recommendations on prevention and management of nutritional rickets [Munns, 2016], and expert opinion in review articles on vitamin D deficiency in adults [LeFevre, 2018; Aoun, 2020].

Not testing asymptomatic people

  • The recommendation not to routinely test asymptomatic people supported by consensus opinion in an international publication, which states that in healthy children, routine vitamin D screening is not recommended [Munns, 2016].
  • This approach is also extrapolated from expert opinion in review articles on vitamin D deficiency in adults, which note insufficient evidence to recommend screening the general population for vitamin D deficiency, as treating asymptomatic people with identified vitamin D deficiency has not been shown to improve health outcomes [LeFevre, 2018; Aoun, 2020].

Who to test

  • The recommendations on who to assess for vitamin D deficiency or vitamin D status are largely based on the ROS publications [ROS, 2018] and the NICE public health guideline [NICE, 2020].
    • The ROS guideline for adults notes that although the symptoms of vitamin D deficiency are vague and it can be difficult to determine whether a low serum vitamin D level is causal or a surrogate marker (for example of poor nutrition or a lack of outdoor activity), it is reasonable to test people suspected of having symptoms caused by osteomalacia.
    • The ROS guideline for children recommends checking vitamin D levels in children and young people with unexplained persistent bone pain, an abnormal bone profile, and/or abnormal radiological findings, as well as children who have a relevant chronic medical condition.
    • The ROS guideline for adults found good evidence that correcting vitamin D deficiency is essential in osteomalacia and may be beneficial in the management of osteoporosis. It also recommends that people receiving potent antiresorptive osteoporosis treatments are not vitamin D deficient before starting treatment, to reduce the risk of developing hypocalcaemia.

How to test

  • The recommendation to check serum 25-hydroxyvitamin D (25[OH]D) is based on the fact this is the best clinical indicator of vitamin D status. It reflects both skin synthesis and dietary sources of vitamin D, has a fairly long half-life of 21–30 days, and is not subject to tight homeostatic control. As a result, it gives an indication of vitamin D availability over recent weeks [SACN, 2016; ROS, 2018].
    • In contrast, the active circulating metabolite serum 1,25(OH)2D concentration is a poor indicator of vitamin D status because it has a short half-life (4–15 hours); it is homeostatically regulated; the plasma concentrations are not directly regulated by vitamin D intake (but by other factors, such as plasma parathyroid hormone [PTH] levels); and even in the presence of severe vitamin D deficiency, plasma concentrations may be normal or even elevated [SACN, 2016; ROS, 2018].

What additional investigations should I arrange?

If vitamin D deficiency or insufficiency is diagnosed following blood testing, consider arranging additional investigations:

  • To assess for a disorder of bone mineralization, such as rickets or osteomalacia, depending on clinical judgement:
    • Bone profile (may be low calcium, low phosphate, and raised alkaline phosphatase).
    • Parathyroid hormone (PTH) level (may be raised).
    • X-ray of a long bone, if a diagnosis of rickets is suspected.
    • X-ray of the affected area, if a diagnosis of osteomalacia is suspected.
  • To assess for an underlying cause or alternative condition that may be causing symptoms, depending on clinical judgement:

Basis for recommendation

The recommendations on additional investigations to consider are based on an international publication Global consensus recommendations on prevention and management of nutritional rickets [Munns, 2016], an epidemiological study of vitamin D deficiency in children [Ahmed, 2011], an epidemiological study of nutritional rickets in children [Julies, 2020], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Aoun, 2020] and vitamin D supplementation [Bolland, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.

  • Vitamin D deficiency is usually accompanied by normal serum levels of calcium and phosphorus, high-normal or elevated levels of parathyroid hormone (PTH), and normal to elevated levels of total alkaline phosphatase. People with severe and longstanding vitamin D deficiency may occasionally present with overt hypocalcaemia and/or hypophosphataemia [Pearce, 2010; Aoun, 2020].
  • Bloods may suggest a disorder of bone mineralization such as osteomalacia or rickets, suggested by low serum calcium and phosphate, increased serum PTH, and increased serum markers of osteoblast activity, such as alkaline phosphatase [Julies, 2020; Bolland, 2021].
  • Expert opinion in a review article recommends considering arranging X-rays if there is uncertainty about a diagnosis of rickets, such as atypical clinical features or biochemistry results, focal pain, or asymmetric deformity [Pearce, 2010].
    • Radiological features of rickets include stippling, irregularity, or cupping of the epiphyses or widening, splaying, or sclerosis of the metaphyses (of any long bone) [Ahmed, 2011; Julies, 2020].
  • The recommendation to consider arranging an X-ray if osteomalacia is suspected, is extrapolated from the ROS guideline.
    • Radiological features of osteomalacia include signs of bone mineralization defects, particularly after completion of growth [Munns, 2016].
  • Expert opinion in a review article notes that iron deficiency anaemia frequently coexists with rickets, and secondary causes of vitamin D deficiency should be sought, such as coeliac disease or cystic fibrosis causing malabsorption [Pearce, 2010].

What else might it be?

  • Conditions that may present similarly to vitamin D deficiency with bone pain and/or muscle weakness include:
    • Malignancy
    • Bone fracture — pain, swelling, or bruising over a bone, bone deformity.
    • Osteomyelitis — severe pain, systemic symptoms, and functional impairment; soft tissue swelling and bony tenderness.
    • Hyperparathyroidism — presents with symptoms of hypercalcaemia such as bone pain, muscle weakness, nausea, anorexia, renal stones, cardiac arrhythmias, depression, and cognitive impairment. See the CKS topic on Hypercalcaemia for more information.
    • Thyroid disease — may present with fatigue and muscle weakness. See the CKS topics on Hyperthyroidism and Hypothyroidism for more information.
    • Juvenile idiopathic arthritis — pain, swelling, heat (synovitis), and stiffness typically in the joints; may be associated with general malaise.
    • Connective tissue disease — such as juvenile dermatomyositis (autoimmune condition that may present with skin rash and progressive muscle weakness; may be associated with systemic symptoms) or systemic lupus erythematosus (may cause polyarticular arthritis and systemic symptoms).
    • Muscular dystrophies — cause progressive degeneration and muscle weakness.

Basis for recommendation

The information on differential diagnosis is based on the National Institute for Health and Care Excellence (NICE) clinical guidelines Hyperparathyroidism (primary): diagnosis, assessment and initial management [NICE, 2019] and Suspected cancer: recognition and referral [NICE, 2021], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Aoun, 2020]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Management

Scenario: Management of vitamin D deficiency or insufficiency

From age 1 month to 18 years.

When should I advise treatment of vitamin D deficiency of insufficiency?

If a child or young person has been tested for vitamin D deficiency:

  • If there is sufficient vitamin D, advise to maintain adequate vitamin D levels through safe sunlight exposure, diet, and vitamin D supplements, if needed. See the sections on Prevention and Lifestyle advice for more information.
  • If there is confirmed vitamin D deficiency, advise on the need for treatment. See the section on How to treat for more information.
  • If there may be inadequate or insufficient vitamin D, advise on the need for maintenance vitamin D supplementation. See the section on How to treat for more information.

Basis for recommendation

The recommendation on when to treat vitamin D deficiency or insufficiency is largely based on the Royal Osteoporosis Society (ROS) publication Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], and expert opinion in a review article on vitamin D deficiency in adults [Aoun, 2020].

  • The recommendation on lifestyle advice and vitamin D supplementation if there is sufficient vitamin D is based on the ROS publication [ROS, 2018].
    • The recommendation to assess for an alternative diagnosis if there are ongoing symptoms is extrapolated from the ROS guideline, which notes that persistent symptoms following adequate treatment for vitamin D deficiency are unlikely to be related to ongoing deficiency. In addition, it is extrapolated from expert opinion in a review article [Aoun, 2020]. It is also pragmatic, based on what CKS considers to be good clinical practice.

How should I treat vitamin D deficiency or insufficiency?

If a child or young person needs treatment for vitamin D deficiency:

  • Seek specialist advice or arrange referral before starting vitamin D treatment if a child:
    • Has clinical features of rickets — arrange referral to a paediatrician.
    • Has hypocalcaemia — seek specialist advice or arrange referral to a paediatrician, depending on clinical judgement.
    • Has a medical condition that predisposes to hypercalcaemia, such as granulomatous disease (sarcoidosis, tuberculosis), metastatic bone disease, some lymphomas, or primary hyperparathyroidism, as there is an increased risk of vitamin D toxicity. See the CKS topic on Hypercalcaemia for more information.
    • Has a gastrointestinal or malabsorption disorder resulting in an inability to maintain adequate vitamin D status, as intensive high-dose replacement or maintenance treatment may be needed under specialist supervision.
    • Has active renal stones or a history of renal stones, due to the risk of vitamin D toxicity causing hypercalciuria and renal stone disease. See the CKS topic on Renal or ureteric colic - acute for more information.
    • Has severe liver disease or end-stage chronic kidney disease (CKD), as specialist treatment with activated vitamin D metabolites may be needed. See the CKS topic on Chronic kidney disease for more information.
    • Is pregnant.
  • Advise that oral vitamin D3 is the vitamin D preparation of choice for the treatment of vitamin D deficiency, and vitamin D2 is an alternative option in some clinical situations.
  • If rapid correction of vitamin D deficiency is needed, for example in children with symptoms, prescribe a fixed loading dose for 8–12 weeks, followed by regular maintenance vitamin D therapy 1 month after loading.
    • See the section on Loading dose regimens in Prescribing information for more detailed information.
    • Advise on the need for long-term maintenance vitamin D supplements, unless there is a significant lifestyle change to improve vitamin D status.
      • For children aged 1 month to 18 years, a vitamin D supplement containing 400–600 international units (IU) daily.
    • Note: vitamin D may be prescribed for people with osteoporosis or a chronic condition or surgery that results in deficiency or malabsorption. Advise parents/carers that for other people, maintenance therapy should be bought over the counter.
  • If correction of vitamin D insufficiency is needed:
    • Advise on the need for long-term maintenance vitamin D supplements, without the use of loading doses, unless there is a significant lifestyle change to improve vitamin D status.
      • For children aged 1 month to 18 years, a vitamin D supplement containing 400–600 IU daily.
    • Note: vitamin D may be prescribed for people with osteoporosis or a chronic condition or surgery that results in deficiency or malabsorption. Advise parents/carers that for other people, maintenance therapy should be bought over the counter.
    • Note: routine monitoring of serum 25-hydroxyvitamin D (25[OH]D) levels is not needed for children on maintenance treatment.
  • Assess the child or young person's need for calcium supplementation.
    • Assess the child's dietary calcium intake.
      • Consider using an online calcium calculator, such as the UK Centre for Genomic and Experimental Medicine (CGEM) calcium calculator.
    • Advise that the recommended daily calcium intake for children to prevent rickets is:
      • Birth to 6 months: 200 mg a day.
      • 6–12 months: 260 mg a day.
      • Over 12 months: more than 500 mg a day.
    • If the child has an inadequate calcium intake, advise parents/carers to increase dietary calcium intake.
    • If the child is unable or unwilling to increase dietary calcium intake, consider the need for calcium supplements.
      • Seek specialist advice if there is any uncertainty regarding which calcium preparation to recommend. See the section on Available preparations in Prescribing information for more information.
      • The ROS leaflet Calcium includes a factsheet on calcium supplements and tests that may be helpful.
      • Note: combination calcium and vitamin D preparations (such as Calcichew D3®) are not recommended for people needing high-dose vitamin D treatment, as they contain very low levels of vitamin D (200–400 IU per tablet) and may increase the risk of hypercalcaemia. See the CKS topic on Hypercalcaemia for more information.
  • Advise the child or young person to maintain adequate vitamin D levels through safe sunlight exposure and diet. See the section on Lifestyle advice for more information.
  • Arrange follow up for a child or young person with vitamin D deficiency to reassess serum 25(OH)D and bone profile levels, and to check for ongoing symptoms. See the section on Follow up for more information.

Basis for recommendation

The recommendations on treatment of vitamin D deficiency and insufficiency are based on the Royal Osteoporosis Society (ROS) publications Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], two international publications Global consensus recommendations on prevention and management of nutritional rickets [Munns, 2016] and Vitamin D supplementation guidelines [Pludowski, 2018], an epidemiological study of nutritional rickets in children [Julies, 2020], the NHS Specialist Pharmacy Service (SPS) document Dosing and monitoring for treatment of vitamin D deficiency in pregnancy [SPS, 2021], the UK Teratology Information Service (UKTIS) document Use of vitamin D in pregnancy [UKTIS, 2019], the NHS England guidance Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs [NHS England, 2018], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Amrein, 2020; Aoun, 2020].

Seeking specialist advice or arranging referral
  • The recommendation for people with a medical condition that predisposes to hypercalcaemia is extrapolated from the ROS guideline for adults, which highlights that the upper limit of vitamin D intake does not apply in these people and they may need lower doses and more frequent monitoring, as they are at increased risk of vitamin D toxicity that manifests as hypercalcaemia [ROS, 2018]. This approach is supported by an international publication [Pludowski, 2018] and expert opinion in review articles [Amrein, 2020; Aoun, 2020].
  • The recommendation for people with a gastrointestinal or malabsorption disorder resulting in an inability to maintain adequate vitamin D status is based on both ROS guidelines, as these people may require an individualized replacement or maintenance schedule under specialist supervision [ROS, 2018]. This approach is supported by consensus opinion in an international publication [Pludowski, 2018] and expert opinion in a review article [Pearce, 2010].
  • The recommendation for people with renal stone disease is extrapolated from the ROS guideline for adults [ROS, 2018].
  • The recommendation for people with severe liver disease or end-stage chronic kidney disease (CKD) is based on the ROS guideline for children and an international publication, which notes that specialist treatment with activated vitamin D metabolites may be needed (calcifediol for liver disease, and alfacalcidol or calcitriol for kidney disease) [Pludowski, 2018].
  • The recommendation for young people who are pregnant is based on the SPS publication, which notes a lack of safety or outcome data for the use of high-dose vitamin D treatment in the first trimester of pregnancy, and states that the optimal dose to correct vitamin D deficiency in pregnancy is not clear from the available evidence [SPS, 2021]. Similarly, the UKTIS document states there are insufficient data to provide recommendations on high-dose vitamin D for established vitamin D deficiency in pregnancy [UKTIS, 2019].
Advising on the most appropriate vitamin D preparation
  • The recommendation that oral vitamin D3 is the treatment of choice in vitamin D deficiency is based on the ROS guideline for children, which notes that vitamin D2 seems to have quicker biochemical clearance that vitamin D3. Similarly, the SACN publication notes that vitamin D2 and its metabolites have a lower binding affinity to vitamin binding protein than vitamin D3 and its metabolites, with inconsistent trial evidence suggesting that vitamin D3 is more effective than vitamin D2 in raising serum 25-hydroxyvitamin D concentration [SACN, 2016].
    • Intramuscular administration of vitamin D is not recommended first line due to unpredictable bioavailability and slower onset of repletion [Munns, 2016; ROS, 2018].
  • Expert opinion in a review article notes that various vitamin D metabolites exist such as cholecalciferol, calcifediol, and calcitriol, which have different efficacies, half-life, and risk of toxicity [Amrein, 2020].
Vitamin D regimen for rapid correction of vitamin D deficiency
  • The recommendations on the loading and maintenance doses for rapid correction of vitamin D deficiency are largely based on the ROS guideline for children and expert opinion in the British National Formulary (BNF) [BNF for Children, 2021].
    • The BNF also states that initial high doses of vitamin D should be reduced to lower maintenance doses after 8–12 weeks due to the significant risk of hypercalcaemia.
    • CKS notes that an international publication states that vitamin D treatment is recommended for a minimum of 12 weeks, recognizing that some children may require a longer treatment duration [Munns, 2016].
  • The recommendation on when to prescribe vitamin D or advise this to be bought over the counter is based on the NHS England guidance [NHS England, 2018].
Vitamin D regimen for correction of vitamin D insufficiency
  • The recommendations on the use of maintenance doses without the need for loading doses for the treatment of vitamin D insufficiency is largely based on the ROS guideline for children, which notes maintenance therapy should be continued 'unless there is a significant lifestyle change to improve vitamin D status'.
  • The recommendation that routine monitoring of 25-hydroxyvitamin D (25[OH]D) levels is not needed for children on maintenance therapy for vitamin D insufficiency is based on the ROS guideline, which notes this is unnecessary if the child is asymptomatic and is compliant with therapy.
  • The recommendation on when to prescribe vitamin D or advise this should be bought over the counter is based on the NHS England guidance [NHS England, 2018].
Assessing the need for calcium supplementation
  • The recommendation to consider using a calcium calculator to assess dietary calcium intake is extrapolated from the ROS guideline for adults [ROS, 2018]. The ROS guideline for children states that many children with vitamin D deficiency will also be calcium deficient, and may therefore benefit from advice on dietary calcium intake and, in some cases, calcium supplements.
  • The information on recommended daily calcium intake to prevent rickets is based on the ROS guideline.
    • CKS notes that the recommended daily calcium intakes for different age groups in the ROS guideline differs from those in an international publication, which also notes that for children over 12 months of age, dietary calcium intake of less than 300 mg per day increases the risk of rickets independent of serum 25(OH)D levels [Munns, 2016].
  • The recommendation to advise on increasing dietary calcium intake if needed to prevent nutritional rickets is based on the consensus opinion in an international publication [Munns, 2016], and an epidemiological study of nutritional rickets [Julies, 2020].
  • The recommendation to seek specialist advice about prescribing calcium preparations is pragmatic, based on what CKS considers to be good clinical practice.
  • The information on combined calcium and vitamin D preparations is extrapolated from expert opinion in a review article that notes that preparations containing vitamin D and calcium should be avoided in the long term as the calcium component is usually unnecessary, is unpalatable, and reduces concordance with treatment [Pearce, 2010].
Arranging follow up
  • This recommendation is pragmatic, based on what CKS considers to be good clinical practice.

What lifestyle advice should I give a child with vitamin D deficiency or insufficiency?

Following treatment for vitamin D deficiency or insufficiency, provide lifestyle advice to optimize long-term levels of vitamin D.

  • Provide advice on sources of information and support, such as:
  • Provide advice on safe sun exposure to help skin synthesis of vitamin D, such as:
    • Infants aged under 6 months should be kept out of direct strong sunlight.
    • Most people can make sufficient vitamin D by going out for short periods in strong sunlight, and leaving only areas of skin that are often exposed uncovered (such as the forearms, hands, or lower legs).
    • Longer periods of sun exposure may be needed for people with dark pigmented skin.
    • Prolonged exposure to strong sunlight (for example leading to burning or tanning) is unlikely to provide additional benefit, and should be avoided.
    • Use of sunbeds is ineffective for vitamin D synthesis, is potentially harmful, and should be avoided.
      • The British Association of Dermatologists' Sunscreen Fact Sheet provides useful information on sunscreens and sun safety tips.
      • The Meteorological Office 'UV index' forecast indicates how strong the sun's ultraviolet (UV) rays are and when there may be an increased risk of skin burning in different parts of the UK.
  • Provide advice on dietary sources of vitamin D.
    • Advise that it is difficult to obtain sufficient vitamin D from food sources alone. The British Dietetic Association (BDA) Vitamin D: food fact sheet may be helpful.
    • Advise the person to continue long-term maintenance vitamin D supplementation to prevent recurrent vitamin D deficiency and to maintain bone health. See the section on How to treat for more information.
  • Provide advice on dietary intake of calcium.
    • The British Dietetic Association (BDA) Calcium: food fact sheet may be helpful.
    • The Royal Osteoporosis Society (ROS) Calcium-rich food chooser may be helpful.
    • If dietary calcium intake is inadequate, advise the child or young person to take calcium supplementation, if needed. See the section on How to treat for more information.

Basis for recommendation

The recommendations on lifestyle advice are largely based on the National Institute for Health and Care Excellence (NICE) guideline Sunlight exposure: risks and benefits [NICE, 2016], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], the British Association of Dermatologists (BAD) consensus statement on vitamin D [BAD, 2010], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Aoun, 2020].

Advising on safe sun exposure
  • The recommendation about infants aged under 6 months is based on the NICE guideline [NICE, 2016].
  • The information that short periods of sun exposure on often-exposed skin is usually sufficient is based on the NICE guideline [NICE, 2016].
    • It notes that skin not usually exposed to sunlight such as the back, abdomen, and shoulders is particularly prone to sunburn which increases the risk of developing skin cancer.
  • The SACN publication notes that recommendations on the exact amount of sunlight exposure needed for vitamin D skin synthesis are not possible [SACN, 2016]. This is supported by the BAD consensus statement [BAD, 2010].
    • Quantifying the amount of sunlight exposure that would be required during the summer to maintain a serum 25-hydroxyvitamin D greater than 25 nmol/L in 97.5% of the UK population during the following winter is not possible, due to the number and complexity of environmental and individual factors that affect endogenous vitamin D production, storage, and use [SACN, 2016].
  • The information that longer sun exposure may be needed for people with darker skin pigmentation is based on the NICE guideline [NICE, 2016] and expert opinion in a review article [Aoun, 2020].
  • The information that prolonged sun exposure is unlikely to provide additional benefit is based on the NICE guideline, which also notes that excessive ultraviolet (UV) exposure increases the risk of sunburn and developing skin cancer [NICE, 2016]. This is supported by the BAD consensus statement, which notes that after prolonged UV exposure, vitamin D is converted into inert substances in the skin [BAD, 2010].
  • The information that use of sunbeds is ineffective and potentially harmful is based on the BAD consensus statement, which notes that any vitamin D increases due to UVB exposure through sunbeds plateau rapidly and are outweighed by the risks, which include exposure to UVA which increases the risk of skin cancer and UVA does not contribute to vitamin D production [BAD, 2010].
  • The information on the Meteorological Office 'UV index' forecast is included in the NICE guideline [NICE, 2016].

How should I follow up a child with vitamin D deficiency?

If a child or young person has completed treatment with a fixed loading regimen for vitamin D deficiency:

  • Check the serum 25-hydroxyvitamin D (25[OH]D) level and bone profile after the last loading dose.
    • If the serum 25(OH)D level is above 50 nmol/L and the bone profile is normal, advise on the use of long-term lower dose maintenance treatment with vitamin D, unless there is a significant lifestyle change to improve vitamin D status. See the section on How to treat for more information.
    • If the serum 25(OH)D level is below 50 nmol/L and/or the bone profile is abnormal, assess adherence to treatment and arrange referral to an appropriate specialist for investigation of an underlying cause, depending on clinical judgement.
    • If hypercalcaemia is detected, advise to stop supplementation with vitamin D (and calcium, if taking) and arrange ongoing investigation and management. See the CKS topic on Hypercalcaemia for more information.
      • People with increased sensitivity to vitamin D therapy, such as those with chronic kidney disease (CKD), sarcoidosis, tuberculosis, or hyperparathyroidism may need lower subsequent dosing. Seek specialist advice if there is any uncertainty.
    • If hypocalcaemia is detected, arrange hospital admission if the child has symptoms, or seek specialist advice from a paediatrician or paediatric endocrinologist regarding further investigation and management, if the child is asymptomatic.
  • Advise parents/carers to maintain adequate vitamin D levels through safe sunlight exposure and diet. See the section on Lifestyle advice for more information.
  • If the person has ongoing symptoms despite adequate treatment with vitamin D, consider an alternative diagnosis and manage appropriately.

Basis for recommendation

The recommendations on follow up are based on the Royal Osteoporosis Society (ROS) publications Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], two international publications Vitamin D supplementation guidelines [Pludowski, 2018] and Global consensus recommendations on prevention and management of nutritional rickets [Munns, 2016], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Aoun, 2020].

Checking serum 25-hydroxyvitamin D levels and bone profile
  • The recommendation to check serum 25-hydroxyvitamin D (25[OH]D) levels and bone profile at the end of high-dose treatment for vitamin D deficiency is based on both ROS guideline [ROS, 2018], and consensus opinion in an international publication [Pludowski, 2018].
    • The ROS guideline for adults states that adjusted serum calcium levels should be checked to detect people who remain deficient after loading, who become deficient during maintenance therapy, and those with unmasked previously undiagnosed primary hyperparathyroidism [ROS, 2018].
    • The international publication states that a follow-up 25(OH)D level should not be arranged before 8–12 weeks after the beginning of treatment.
  • The recommendations to assess adherence to vitamin D therapy and arrange further investigation if there has been an inadequate response to treatment or abnormal bone profile are based on expert opinion in a review article [Pearce, 2010].
    • Expert opinion in a review article notes that people with severe malabsorption or poor compliance with oral therapy may need treatment with intramuscular vitamin D [Pearce, 2010].
  • The recommendation to stop vitamin D supplements if hypercalcaemia is detected and to arrange further investigation is based on the SACN publication [SACN, 2016] and an international guideline [Munns, 2016], and is also extrapolated from the ROS guideline for adults [ROS, 2018].
    • Excess vitamin D intake and vitamin D toxicity may result in hypercalcaemia, caused by increased intestinal calcium absorption and mobilization of calcium from the bone. Hypercalcaemia and hypercalciuria can result in soft tissue calcification, diffuse demineralization of bones, and irreversible renal and cardiovascular toxicity [Munns, 2016; SACN, 2016].
    • The recommendation to seek specialist advice if there is uncertainty on management is pragmatic, based on what CKS considers to be good clinical practice.
Considering an alternative diagnosis
  • This recommendation is pragmatic, based on what CKS considers to be good clinical practice.

Scenario: Prevention of vitamin D deficiency

From age 1 month to 18 years.

How can I prevent vitamin D deficiency in children and young people?

Provide parents/carers of children in the UK with advice about the prevention of vitamin D deficiency.

  • Advise on ways to maintain adequate vitamin D levels through safe sunlight exposure and diet. See the section on Lifestyle advice for more information.
  • Advise on the need for daily vitamin D supplement drops for children from birth to 4 years of age, depending on their age.
    • For children aged 0–1 year (including exclusively and partially breastfed infants, from birth), a vitamin D supplement containing 8.5–10 micrograms (340–400 international units [IU]) daily.
    • For children aged 1–4 years, a vitamin D supplement containing 10 micrograms (400 IU) daily.
      • Note: children who have more than 500 mL of infant formula a day do not need any additional vitamin D, as formula milk is already fortified.
    • Children and young people eligible for the NHS Healthy Start scheme can obtain free vitamin drops (containing 7.5 micrograms/300 IU of vitamin D3, 233 micrograms of vitamin A, and 20 mg of vitamin C). The NHS information on the Healthy Start scheme provides advice on eligibility and how to apply.
    • Advise parents/carers that for other children, vitamin supplement preparations can be bought over the counter.
  • Consider the need for daily vitamin D supplementation for all other children including those at high risk of vitamin D deficiency, particularly if they are unable to maintain adequate vitamin D levels through safe sunlight exposure and diet. See the section on Lifestyle advice for more information.
    • For children aged 1 month to 18 years, a vitamin D supplement containing 400–600 international units (IU) daily.
  • Advise that routine monitoring of serum 25-hydroxyvitamin D (25[OH]D) levels is not needed.
  • Assess the child or young person's need for calcium supplementation.
    • Assess the child's dietary calcium intake.
      • Consider using an online calcium calculator, such as the UK Centre for Genomic and Experimental Medicine (CGEM) calcium calculator.
    • Advise that the recommended daily calcium intake for children to prevent rickets is:
      • Birth to 6 months: 200 mg a day.
      • 6–12 months: 260 mg a day.
      • Over 12 months: more than 500 mg a day.
    • If the child has an inadequate calcium intake, advise parents/carers to increase dietary calcium intake.
    • If the child is unable or unwilling to increase dietary calcium intake, consider the need for calcium supplements.
      • Seek specialist advice if there is any uncertainty regarding which calcium preparation to recommend. See the section on Available preparations in Prescribing information for more information.
      • The ROS leaflet Calcium includes a factsheet on calcium supplements and tests that may be helpful.

Basis for recommendation

The recommendations on prevention of vitamin D deficiency are based on the National Institute for Health and Care Excellence (NICE) public health guideline Vitamin D: supplement use in specific population groups [NICE, 2020], the Royal Osteoporosis Society (ROS) publications Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], the Public Health England (PHE) statements PHE publishes new advice on vitamin D [PHE, 2016] and Vitamin D supplementation during winter: PHE and NICE statement [PHE, 2020], the international publication Global consensus recommendations on prevention and management of nutritional rickets [Munns, 2016], the NHS England guidance Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs [NHS England, 2018], an epidemiological study of nutritional rickets in children [Julies, 2020], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Amrein, 2020].

Vitamin D supplementation for all children less than 4 years
  • The recommendation for children to take daily vitamin D supplementation is based on the NICE public health guideline [NICE, 2020], the PHE statement [PHE, 2016], and the SACN publication [SACN, 2016].
    • The NICE guideline analyzed the evidence for increasing vitamin D supplementation and recommends that supplements are made widely available for specific at-risk population groups including infants and children aged under 4 years, to promote skeletal growth and bone health.
      • The NICE public health guideline states that breastfed infants may need vitamin D drops from 1 month of age if the mother has not taken vitamin D supplements throughout pregnancy.
    • The SACN analysis found data were insufficient to set reference nutrient intakes (RNIs) for infants and children younger than 4 years of age, so it recommends a precautionary ‘safe intake’ of vitamin D in the range of 340–400 international units (IU; 8.5–10 micrograms) daily for children aged 0–1 years (including exclusively breastfed and partially breastfed infants, from birth), and 400 IU (10 micrograms) for children aged 1–4 years [SACN, 2016].
      • CKS notes that an international publication states that 400 IU (10 micrograms) of daily vitamin D supplementation is adequate to prevent rickets and is recommended for all infants from birth to 12 months of age, independent of their mode of feeding [Munns, 2016].
    • The information that children who have more than 500 mL of infant formula a day do not need any additional vitamin D is based on the ROS guideline, the NICE public health guideline, and the PHE statement.
  • The recommendation to promote the NHS Healthy Start scheme for eligible people is based on the NICE guideline, which highlights this UK-wide government scheme that provides a 'nutritional safety net' for pregnant women and families on benefits and tax credits [NICE, 2020].
  • The information that vitamin D supplements are available to buy over the counter is based on the NHS England guidance [NHS England, 2018].
 Vitamin D supplementation for all other children
  • The recommendations for all other children including those at high risk of vitamin D deficiency are based on the SACN publication [SACN, 2016], the NICE public health guideline [NICE, 2020], and the PHE statement [PHE, 2016].
    • The SACN publication recommends a daily RNI of 10 micrograms or 400 IU for the UK population aged 4 years and above. This is the average amount needed (from natural food sources, fortified foods including formula milk for infants and toddlers, or supplements) by 97.5% of the population to maintain a serum 25-hydroxyvitamin D (25[OH]D) concentration at or above 25 nmol/L, when ultraviolet (UV)-B radiation exposure is minimal. It refers to average intake over a period of time (such as a week) and takes account of day-to-day variations in vitamin D intake. As a precaution, it is recommended that the RNI is applicable throughout the year to protect population groups and unidentified people in the UK with a serum 25(OH)D concentration less than 25 nmol/L in the summer. An increment to the RNI was not considered necessary for people at increased risk of vitamin D deficiency, because the recommendation for the RNI to be applicable throughout the year takes account of people with minimal sunshine exposure, including those most at risk.
    • The SACN publication highlights that although achievement of the proposed RNI would lead to an increase in mean/median vitamin D intakes of the UK population, it is unlikely that this would lead to vitamin D intakes at the upper end of the distribution reaching levels that might pose a risk of adverse effects.
    • The ROS guideline also recommends considering vitamin D supplementation for children at risk of vitamin D deficiency. The recommended dose of vitamin D supplementation for this group has been extrapolated from the recommended dose for children with vitamin D insufficiency, as the guideline also mentions that children at risk of deficiency should be considered for primary prevention. CKS notes that the ROS recommended vitamin D supplement dose of 400–600 IU is different from the SACN recommended dose of 400 IU for all children aged 4 years and above.
    • The NICE public health guideline recommends that vitamin D supplements are made widely available for specific at-risk population groups, to promote skeletal growth and bone health.
Assessing the need for calcium supplementation
  • The recommendation to consider using a calcium calculator to assess dietary calcium intake is extrapolated from the ROS guideline for adults [ROS, 2018].
  • The recommendation to advise on increasing dietary calcium intake if needed to prevent nutritional rickets is based on consensus opinion in an international publication [Munns, 2016], and an epidemiological study of nutritional rickets [Julies, 2020]. It is also extrapolated from expert opinion in a review article, which notes that combined supplement preparations containing vitamin D and calcium should be avoided in the long term as the calcium component is usually unnecessary, is unpalatable, and reduces concordance with treatment [Pearce, 2010].
  • The recommendation to consider seeking specialist advice if calcium supplements are needed is pragmatic, based on what CKS considers to be good clinical practice.

What lifestyle advice should I give to reduce the risk of vitamin D deficiency?

Provide parents/carers with lifestyle advice for the prevention of vitamin D deficiency in children and young people.

  • Provide advice on sources of information and support, such as:
  • Provide advice on safe sun exposure to help skin synthesis of vitamin D, such as:
    • Infants aged under 6 months should be kept out of direct strong sunlight.
    • Most people can make sufficient vitamin D by going out for short periods in strong sunlight, and leaving only areas of skin that are often exposed uncovered (such as the forearms, hands, or lower legs).
    • Longer periods of sun exposure may be needed for people with dark pigmented skin.
    • Prolonged exposure to strong sunlight (for example leading to burning or tanning) is unlikely to provide additional benefit, and should be avoided.
    • Use of sunbeds is ineffective for vitamin D synthesis, is potentially harmful, and should be avoided.
      • The British Association of Dermatologists' Sunscreen Fact Sheet provides useful information on sunscreens and sun safety tips.
      • The Meteorological Office 'UV index' forecast indicates how strong the sun's ultraviolet (UV) rays are and when there may be an increased risk of skin burning in different parts of the UK.
  • Provide advice on dietary sources of vitamin D.
    • Advise that it is difficult to obtain sufficient vitamin D from food sources alone. The British Dietetic Association (BDA) Vitamin D: food fact sheet may be helpful.
    • Advise on the use of vitamin D supplements to prevent vitamin D deficiency and to maintain bone health. See the section on Prevention for more information.

Basis for recommendation

The recommendations on lifestyle advice are largely based on the National Institute for Health and Care Excellence (NICE) guideline Sunlight exposure: risks and benefits [NICE, 2016], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health [SACN, 2016], the British Association of Dermatologists (BAD) consensus statement on vitamin D [BAD, 2010], and expert opinion in review articles on vitamin D deficiency [Pearce, 2010; Aoun, 2020].

Advising on safe sun exposure
  • The recommendation about infants aged under 6 months is based on the NICE guideline [NICE, 2016].
  • The information that short periods of sun exposure on often-exposed skin is usually sufficient is based on the NICE guideline [NICE, 2016].
    • It notes that skin not usually exposed to sunlight such as the back, abdomen, and shoulders is particularly prone to sunburn which increases the risk of developing skin cancer.
  • The SACN publication notes that recommendations on the exact amount of sunlight exposure needed for vitamin D skin synthesis are not possible [SACN, 2016]. This is supported by the BAD consensus statement [BAD, 2010].
    • Quantifying the amount of sunlight exposure that would be required during the summer to maintain a serum 25-hydroxyvitamin D greater than 25 nmol/L in 97.5% of the UK population during the following winter is not possible, due to the number and complexity of environmental and individual factors that affect endogenous vitamin D production, storage, and use [SACN, 2016].
  • The information that longer sun exposure may be needed for people with darker skin pigmentation is based on the NICE guideline [NICE, 2016] and expert opinion in a review article [Aoun, 2020].
  • The information that prolonged sun exposure is unlikely to provide additional benefit is based on the NICE guideline, which also notes that excessive ultraviolet (UV) exposure increases the risk of sunburn and developing skin cancer [NICE, 2016]. This is supported by the BAD consensus statement, which notes that after prolonged UV exposure, vitamin D is converted into inert substances in the skin [BAD, 2010].
  • The information that use of sunbeds is ineffective and potentially harmful is based on the BAD consensus statement, which notes that any vitamin D increases due to UVB exposure through sunbeds plateau rapidly and are outweighed by the risks, which include exposure to UVA which increases the risk of skin cancer and UVA does not contribute to vitamin D production [BAD, 2010].
  • The information on the Meteorological Office 'UV index' forecast is included in the NICE guideline [NICE, 2016].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Vitamin D supplements

Available preparations

  • Vitamin D3 (colecalciferol) is the vitamin D preparation of choice for treatment of vitamin D deficiency.
    • For a list of medicinal forms of colecalciferol, see the British National Formulary (BNF) for children section on Colecalciferol.
  • Vitamin D2 (ergocalciferol) can be used in people who cannot take vitamin D3 for cultural, dietary, or religious reasons because of the animal sourcing of vitamin D, or the use of gelatine in some preparations.
    • For a list of medicinal forms of ergocalciferol, see the BNF for children section on Ergocalciferol.
  • For people with specific dietary requirements, the NHS Specialist Pharmacy Service (SPS) provides guidance on prescribing vitamin D preparations for people with:
  • For those whose diet is halal or kosher, the South West London CCG provides guidance on the [South West London CCG Local Prescribing Guideline for the Management of Vitamin D Deficiency in Adults]. 

[BNFC, 2025]

Loading dose regimens

Recommended loading dose regimens to treat vitamin D deficiency are:

  • Age 1–5 months: 3000 international units (IU) daily for 8–12 weeks.
  • Age 6 months–11 years: 6000 IU daily for 8–12 weeks.
  • Age 12–18 years: 10,000 IU daily for 8–12 weeks. A single or divided oral dose totalling 300,000 IU can be considered if there is concern about compliance with treatment.
  • Note: equivalent weekly or fortnightly dosing is likely to be effective in treating vitamin D deficiency.

[BNFC, 2025]

Contraindications and cautions

  • Do not prescribe vitamin D to people with:
  • Prescribe vitamin D with caution to:
    • People with mild-to-moderate renal impairment [BNF for Children, 2021].
    • People with a co-existing condition associated with increased sensitivity to vitamin D (such as sarcoidosis, tuberculosis, lymphoma, or primary hyperparathyroidism) — seek specialist advice [ROS, 2018; BNF for Children, 2021].
    • Pregnant women — seek specialist advice [SPS, 2021].
    • Breastfeeding women (due to the risk of infant hypercalcaemia) [BNF for Children, 2021].

Adverse effects

  • Possible adverse effects of vitamin D preparations include [BNF for Children, 2021]:
    • Vitamin D toxicity (rare) manifests mainly through hypercalcaemia and hypercalciuria, leading to soft tissue calcification, diffuse demineralization of bones, and irreversible renal and cardiovascular toxicity [SACN, 2016]. See the CKS topic on Hypercalcaemia for more information on the clinical presentation, investigation, and management.
    • Abdominal pain, headache, nausea, skin reactions (common).
    • Appetite decrease, arrhythmia, constipation, diarrhoea, hypertension, myalgia, thirst, vomiting, weight decrease (uncommon).

Drug interactions

  • Potential drug interactions associated with vitamin D include the following list. Seek specialist advice as appropriate during concurrent treatment with these drugs.
    • Antiepileptic drugs (carbamazepine, phenytoin, or barbiturates) — can increase the metabolism of vitamin D, leading to a reduction in the effects of vitamin D.
      • Higher doses of vitamin D may be needed.
    • Cardiac glycosides — excessive dosing of vitamin D can induce hypercalcaemia, which may enhance the effects of digoxin and other cardiac glycosides (leading to an increased risk of digoxin toxicity and serious arrhythmias).
      • Close monitoring (and possibly a dose reduction of vitamin D) is needed during concurrent use.
    • Corticosteroids — may increase vitamin D metabolism and elimination.
      • Higher doses of vitamin D may be needed. 
    • Ion exchange resins (such as colestyramine) or laxatives (such as paraffin oil) — may reduce the gastrointestinal absorption of vitamin D.
      • Higher doses of vitamin D may be needed.  
    • Ketoconazole, miconazole, and clotrimazole — these drugs are predicted to decrease the exposure to vitamin D.
    • Orlistat — may prevent the absorption of vitamin D, even in people also taking multivitamins.
      • Advise that vitamin D preparations should be taken at least 2 hours after taking orlistat. It may be necessary to monitor vitamin D levels, even if multivitamins are given [Preston, 2015].
    • Thiazide diuretics (such as bendroflumethiazide, indapamide, and metolozone) — may reduce the urinary excretion of calcium thereby increasing the risk of hypercalcaemia.
      • Close monitoring (and possibly a dose reduction of vitamin D) is needed during concurrent use. 

[ABPI, 2020; BNF for Children, 2021]

Calcium supplements

Available preparations

  • There are various different calcium preparations available to prescribe, which contain different quantities of elemental calcium [ROS, 2021].
    • For a list of medicinal forms of calcium carbonate, see the British National Formulary (BNF) for children section on Calcium carbonate.
  • The recommended doses for children for treatment of calcium deficiency are [BNF for Children, 2021]:
    • Age 1 month–4 years: 0.25 mmol per kg four times daily, adjusted to response.
    • Age 5–11 years: 0.2 mmol per kg four times daily, adjusted to response.
    • Age 12–17 years: 10 mmol four times daily, adjusted to response.
  • For people with specific dietary requirements, the NHS Specialist Pharmacy Service (SPS) provides guidance on prescribing calcium and vitamin D preparations for people with:

Contraindications and cautions

  • Do not prescribe calcium supplements to people with [BNF for Children, 2021]:
    • Conditions associated with hypercalcaemia and/or hypercalciuria (such as some forms of malignant disease). See the CKS topic on Hypercalcaemia for more information.
  • Prescribe calcium supplements with caution to people with [BNF for Children, 2021]:
    • A history of nephrolithiasis — seek specialist advice.
    • A co-existing condition associated with increased sensitivity to vitamin D (such as sarcoidosis, tuberculosis, lymphoma, or primary hyperparathyroidism) — seek specialist advice [ROS, 2018].
    • Renal impairment — risk of hypercalcaemia and renal stones.

Adverse effects

  • Possible adverse effects of calcium supplements include [BNF for Children, 2021]:
    • Constipation, diarrhoea, nausea, hypercalcaemia, hypercalciuria (uncommon).
    • Flatulence, gastrointestinal discomfort, milk-alkali syndrome, skin reactions (rare).
      • Milk-alkali syndrome may occur in calcium overdose and can cause urinary frequency, headache, loss of appetite, nausea or vomiting, tiredness or weakness, hypercalcaemia, alkalosis, and renal impairment [ABPI, 2016].

Drug interactions

  • Potential drug interactions associated with calcium supplements include the following list. Seek specialist advice as appropriate during concurrent treatment with these drugs.
    • Bisphosphonates — calcium salts reduce absorption of bisphosphonates.
      • Bisphosphonate should be taken at least 2 hours before taking calcium supplements.
    • Cardiac glycosides — calcium supplements can induce hypercalcaemia, which may enhance the effects of digoxin and other cardiac glycosides (leading to an increased risk of digitalis toxicity and serious arrhythmias).
      • Close monitoring is needed during concurrent use.
    • Systemic corticosteroids — absorption of calcium salts may be reduced by corticosteroids.
      • It may be necessary to increase the dose of the calcium supplement.
    • Thiazide diuretics — may reduce the urinary excretion of calcium thereby increasing the risk of hypercalcaemia.
      • Close monitoring (and possibly a dose reduction of calcium) is needed during concurrent use.
    • Tetracycline antibiotics — calcium supplements may reduce the absorption of tetracyclines.
      • Tetracyclines should be taken at least 2–3 hours before or after taking calcium supplements.
    • Levothyroxine — calcium salts reduce the absorption of levothyroxine.
      • Levothyroxine should be taken at least 4 hours before or after taking calcium supplements.
    • Quinolones — calcium salts may impair the absorption of quinolones (such as ciprofloxacin).
      • Quinolone antibiotics should be taken 2 hours before or after taking calcium supplements.
    • Zinc, iron, and strontium ranelate — calcium salts reduce the absorption of zinc salts, oral iron salts, and strontium ranelate.
      • These preparations should be taken 2 hours before or after taking calcium supplements.

[ABPI, 2016; BNF for Children, 2021]

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Vitamin D: supplement use in specific population groups [NICE, 2020], the NICE guideline Sunlight exposure: risks and benefits [NICE, 2016], the Royal Osteoporosis Society (ROS) publications Vitamin D and bone health: a practical clinical guideline for patient management [ROS, 2018], the UK Scientific Advisory Committee on Nutrition (SACN) publication Vitamin D and health 2016 [SACN, 2016], an international publication Vitamin D supplementation guidelines [Pludowski, 2018], the British Association of Dermatologists (BAD) consensus statement on vitamin D [BAD, 2010], the Public Health England (PHE) statement PHE publishes new advice on vitamin D [PHE, 2016], and expert opinion in review articles. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of vitamin D deficiency in children.

Search dates

September 2016 - February 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline limiting to child/children.

  • exp vitamin D deficiency/ [Diagnosis, Prevention and control, therapy]
  • Vitamin d Insufficiency.kw
  • *Vitamin D
  • Cholecalciferol
  • Ergocalciferol
  • Hypovitaminosis D, Low Vitamin D

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2016) SPC for Calcichew 500mg chewable tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk [Free Full-text]
  • ABPI (2020) SPC for Colecalciferol. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Ahmed, S.F., Franey, C., McDevitt, H. and Somerville, L. (2011) Recent trends and clinical features of childhood vitamin D deficiency presenting to a children's hospital in Glasgow. Archives of Disease in Childhood 96(7), 694-696. [Abstract]
  • Amrein, K., Scherkl, M., Hoffmann, M. and Neuwersch-Sommeregger, S. (2020) Vitamin D deficiency 2.0: an update on the current status worldwide. European Journal of Clinical Nutrition 74(11), 1498-1513. [Abstract]
  • Aoun, A., Maalouf, J., Fahed, M. and El Jabbour, F. (2020) When and how to diagnose and treat vitamin D deficiency in adults: a practical and clinical update. Journal of Dietary Supplements 17(3), 336-354. [Abstract]
  • BAD, Cancer Research UK, Diabetes UK, Multiple Sclerosis Society, National Heart Forum, National Osteoporosis Society, Primary Care Dermatology Society (2010) Consensus Vitamin D position statement. British Association of Dermatologists. http://www.bad.org.uk [Free Full-text]
  • Basatemur, E. and Sutcliffe, A. (2015) Incidence of hypocalcemic seizures due to vitamin D deficiency in children in the United Kingdom and Ireland. Journal of Clinical Endocrinology and Metabolism 100(1), E91-E95. [Abstract]
  • Basatemur, E., Horsfall, L., Marston, L. and Rait, G. (2017) Trends in the diagnosis of vitamin D deficiency. Pediatrics 139(3). [Abstract]
  • BNF (2021) British National Formulary for Children. BMJ Group and Pharmaceutical Press. https://bnfc.nice.org.uk
  • BNFC (2025) British National Formulary for Children. National Institute for Health and Care Excellence. https://bnfc.nice.org.uk
  • Bolland, M.J., Avenell, A. and Grey, A. (2016) Should adults take vitamin D supplements to prevent disease? BMJ 355. [Abstract]
  • Bolland, M.J., Avenell, A., Smith, K. and Witham, M.D. (2021) Vitamin D supplementation and testing in the UK: costly but ineffective? BMJ 372. [Abstract]
  • Holick, M.F. (2017) The vitamin D deficiency pandemic: approaches for diagnosis, treatment and prevention. Reviews in Endocrine and Metabolic Disorders 18(2), 153-165. [Abstract]
  • Joint Formulary Committee (2021) British National Formulary (online). BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk
  • Julies, P. Lynn, R.M., Pall, K. and Leoni, M. (2020) Nutritional rickets under 16 years: UK surveillance results. Archives of Disease in Childhood 105(6), 587-592. [Abstract]
  • LeFevre, M.L. LeFevre, M.N. (2018) Vitamin D screening and supplementation in community-dwelling adults: common questions and answers. American Family Physician 97(4), 254-260. [Abstract]
  • Maiya, S., Sullivan, I., Allgrove, J. and Yates, R. (2008) Hypocalcaemia and vitamin D deficiency: an important, but preventable, cause of life-threatening infant heart failure. Heart 94(5), 581-584. [Abstract]
  • Munns, C.F., Shaw, N., Kiely, M. and Specker, B.L. (2016) Global consensus recommendations on prevention and management of nutritional rickets. Journal of Clinical Endocrinology and Metabolism 101(2), 394-415. [Abstract]
  • NHS England (2018) Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs. NHS England. http://www.england.nhs.uk [Free Full-text]
  • NICE (2016) Sunlight exposure: risks and benefits. National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text]
  • NICE (2019) Hyperparathyroidism (primary): diagnosis, assessment and initial management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2020) Vitamin D: supplement use in specific population groups. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2021) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Pearce, S.H.S. and Cheetham, T.D. (2010) Diagnosis and management of vitamin D deficiency. BMJ 340, b5664.
  • PHE (2016) PHE publishes new advice on vitamin D. Public Health England. http://www.gov.uk [Free Full-text]
  • PHE (2017) National diet and nutrition survey: results from years 1, 2, 3 and 4 (combined) of the rolling programme (2008/2009-2011/2012). Executive summary. Public Health England. http://www.gov.uk [Free Full-text]
  • PHE (2020) Vitamin D supplementation during winter: PHE and NICE statement. Public Health England. http://www.gov.uk [Free Full-text]
  • Pludowski, P., Holick, M.F., Grant, W.B. and Konstantynowicz, J. (2018) Vitamin D supplementation guidelines. Journal of Steroid Biochemistry and Molecular Biology 175, 125-135. [Abstract]
  • Preston, C.L. (Eds.) (2015) Stockley's drug interactions 2015: pocket companion. London: Pharmaceutical Press.
  • ROS (2018) Vitamin D and bone health: a practical clinical guideline for patient management. Royal Osteoporosis Society. https://theros.org.uk [Free Full-text]
  • ROS (2021) Calcium. Royal Osteoporosis Society. http://theros.org.uk [Free Full-text]
  • SACN (2016) Vitamin D and health. Scientific Advisory Committee on Nutrition. www.gov.uk [Free Full-text]
  • South West London CCG (2020) Local Prescribing Guideline for the Management of Vitamin D Deficiency in Adults. https://psnc.org.uk/kingstonandrichmondlpc/wp-content/uploads/sites/107/2020/08/Attachment-2-Primary-Care-Prescribing-Guideline-for-the-Management-of-Vitamin-D-Deficiency-in-Adults.pdf [Free Full-text]
  • SPS (2021) Dosing and monitoring for treatment of vitamin D deficiency in pregnancy. NHS Specialist Pharmacy Service. http://www.sps.nhs.uk [Free Full-text]
  • UKTIS (2019) Use of vitamin D in pregnancy. UK Teratology Information Service. http://www.uktis.org [Free Full-text]
  • Vanlint, S. (2013) Vitamin D and obesity. Nutrients 5(3), 949-3. [Abstract] [Free Full-text]
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