Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011:  http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf.  Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.

The Paediatric Pearls newsletters are checked every month by my consultant colleagues.  We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area.  Some of the comments I have received back from my colleagues concerning this guideline include:

• A cut off of 80nmol/l is too high as the lower limit of normal.  Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
• The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time.  The advantage of this is that no monitoring of calcium levels is required.
• Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it.  There is a shortage of it at the moment and it is expensive.  It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l).  This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
• “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets. 
• Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/.  They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
• We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol.  There is also a risk of cardiomyopathy in this group.
• The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient.  We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then. 

I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out.  Do leave comments below.

This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site.  Please note that the doses here are not the same as the BNFc.  There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.