Vitamin D guidance at last!

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:  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  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.

3 thoughts on “Vitamin D guidance at last!

  1. I had another child with fairly severe rickets in clinic the other day; widened wrists, knees and ankles, bow legs and didn’t walk till they were 2. This child’s mother is white; it is not just people with darker skins who cover up for cultural reasons who are affected. There is comprehensive patient information on rickets at The same website has some nice general information on vitamin D deficiency as well which patients may appreciate.

  2. Dear Julia,

    I am the commercial manager at Kora Healthcare and we now have a liquid formulation of vitamin D3 only 0.2 mL/5µg (200 IU) readily available in the UK. In the coming weeks we aim to improve supply of this product to 100% of all retail pharmacy outlets within the UK. I would be interested to discuss this with you. Please feel free to email me on or Kind Regards, Mark

  3. My colleague, Dr John Ho, who is involved in research projects on vitamin D, comments that:

    Patients on high dose vit D treatment because of symptomatic hypocalcemia (e.g. hypocalcemic tetany) should have their vit D levels and calcium checked weekly to fortnightly. The dosage recommended in the Paeds BNF is considered as high dose. The turnover time for vit D analyisis is 2-3 weeks. Once hypercalcemia has been corrected, the high dose therapy can be reduced to a low dose regime to avoid hypervitaminosis D and frequent monitoring. Hypervitaminosis D can lead to hypercalciuria, nephrocalcinosis nad hypercalcaemia. If a patient has hypervitaminosis of D, nephrocalcinosis will occur. The time frame for nephrocalcinosis to develop is uncertain.

    Younger patients seems to be prone to nephrocalcinosis (e.g. neonates). Patients particularly at risk are those on diuretic treatment (e.g. cardiac failure and low vit d), sarcoid, steroid treatment. A renal US should be considered in anyone with iatrogenic ‘high’ vit D levels to exclude nephrocalcinosis. Nephrocalcinosis is asymptomatic but could lead to renal problems in the future.

    The Royal London Hospital vitamin D guideline advcoates lower doses of vitamin D. See

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.