Vitamin D deficiency and insufficiency in 0-18 year old children guideline

Vitamin D deficiency and insufficiency in 0-18 year

old children guideline

Lead Author: Dr Kalpesh Dixit, Consultant Paediatrician

Additional author(s) Alison Fryer, Clinical Tutor and PANDA pharmacist

Division/ Department:: Medical Child Health

Applies to: Salford Royal Care Organisation

Approving Committee: Medicines Management Committee

Date approved: 18/02/2021

Review date: February 2026

Contents Contents

Section Page

Document summary sheet 2

1 Overview ₃

2 Scope & Associated Documents 3

3 _{Background 3}

4 What is new in this version? ₃

5 Policy 3

5.1 _{Risk factors for vitamin D deficiency 3}

5.2 Symptoms and signs 4

5.3 History and examination ₄

5.4 _{Serum levels and definitions 5}

5.5 Treatment guidelines 6

5.6 Follow up advice 8

5.7 _{Preparations available for treating vitamin D deficiency 9} 5.8 Important calcium information in relation to vitamin D 9

6 Roles and responsibilities 12

7 _{Monitoring document effectiveness 12}

8 Abbreviations and definitions ₁₂

9 References 13

10 _{Document Control Information 14}

11 Equality Impact Assessment (EqIA) tool 15

12 Appendices 17

Group arrangements:

Document Summary Sheet

Vitamin D deficiency and insufficiency in 0-18 year old children guidelines,

version 2

• Vitamin D deficiency and insufficiency are very common in the United Kingdom given not only geographical settings but also for a multitude of other reasons. Local studies show a significant proportion of healthy adolescents to be Vitamin D deficient ( ref- ADC

2006.91(7), 569-72)

• Natural dietary sources provide a very small contribution to the body stores of vitamin D • Vitamin D is important for skeletal, cardiac muscle function. Vitamin D receptor is also

expressed in the brain, bowels, prostate and immune system.

• Dietary calcium intake is very important as children with low calcium intake are more likely to have musculoskeletal signs of Vitamin D deficiency and abnormal bone biochemistry.

• Large doses of multi-vitamin preparations (using two or more over the counter

preparations at the same time) can produce hypervitaminosis D and hypervitaminosis A with its ensuing risks and side effects.

• This guideline focuses on assessment and management not only in at risk children but also gives a guidance on the maintenance treatment, products available, calcium intake calculations and general lifestyle advice pertaining to Vitamin D. Dosage regimen vary in different age groups- this is to avoid wastage and utilise appropriate strength

formulations.

• An E-learning training package (power point presentation) is available for personal and professional development for all healthcare professionals involved in the assessment and management of children with vitamin D deficiency or insufficiency

(www.salfordlearning.nhs.uk)

Group arrangements:

1.

Overview

This policy covers the investigation and management of vitamin D deficiency and insufficiency in children up to 18 years of age.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2.

Scope

The scope of this document is to provide a simple, yet consistent guideline that can be used by all professionals.

It is relevant for all healthcare professionals involved in the assessment and management of children (up to 18 years of age) with Vitamin D deficiency or insufficiency. This includes health visitors, school health advisors and specialist nurses who provide advice on use of multivitamin drops.

3.

Background

Vitamin D insufficiency and deficiency are very common in the United Kingdom. Vitamin D has a role in a variety of systemic functions and its deficiency is linked to multiple conditions. At

present there are differing opinions on how best to manage Vitamin D insufficiency and

deficiency and there is no unified guideline available. This guideline is hence written with expert opinion obtained from local expert teams and that provided by the Royal College of Paediatrics and Child Health.

4.

What is new in this version?

Policy reviewed and updated with respect to the strength of preparations with no changes to the content. This version has been endorsed also by the specialist Team at Royal Manchester Childrens Hospital as they provide local expertise in relation to management.

Only change is update to amount of vitamin D contained within “healthy start” vitamins and re-formatted to new policy template.

5.

Policy

5.1 Risk factors for vitamin D deficiency

All of these factors pose a risk for development of Vitamin D deficiency/insufficiency. Factors causing inadequate light exposure- causing reduced production of Vitamin D

• Northern latitude above 50 degrees north(north of Brighton, Southampton—whole of UK) • Occlusive garments worn regularly

• Habitual sunscreen use

Factors with poor dietary intake: • Vegetarian or vegan diet

• Prolonged breast fed baby even if mother has sufficient Vitamin D

• Malabsorption states- coeliac disease, cystic fibrosis (CF), Crohns disease, cholestatic jaundice, liver and kidney diseases

• Low calcium intake in diets Factors posing a metabolic risk:

• Obesity

• All infants and children under 5 years • Adolescents

• Pregnant and breast feeding women, teenagers, twin and multiple pregnancies, young women.

• Drugs like anticonvulsants, rifampicin and glucocorticoids.

5.2 Symptoms and signs

Infants Seizures, tetany, cardiomyopathy, poorly healing fractures Children Aches and pains, myopathy causing delayed walking,

rickets with bowed legs, poorly healing fractures, knock knees, poor growth, and muscle weakness.

Adolescents Aches and pains, muscle weakness and bone changes of rickets or osteomalacia, poorly healing fractures.

5.3 History and examination

• In very young children history suggestive of developmental delay, poor head growth, cardiac failure or fractures

• History suggestive of active rickets- irritability, swollen wrists and ankles, sweating, poor mobility and lethargy, abnormal head shape, persistently open anterior fontanelle. • In older children history suggestive of vague aches and pains, often back or heel pains. • Previous history of fractures.

• Appropriate dietetic history

• Antenatal use of multivitamin preparations by pregnant mother, history of ethnicity and cultural practices

• Consumption of multivitamins- if so name and dosage of the same

• History suggestive of poor mobility or moderate or severe disability.

All system examination with particular note of open anterior fontanelle, head shape, laxity of ligaments, pot belly, metaphyseal widening and/or fractures if any. Note development and head circumference.

Investigations/ Vitamin D Testing

Routine testing is not indicated. Suggested screening (inclusive of bone profile and PTH along with Vitamin D levels) is as follows:

Patient health Category

Risk Factors Action

Healthy & asymptomatic

None No investigations needed. Lifestyle advice. Healthy &

asymptomatic

Yes Lifestyle Advice

Long term preventative strategies (Over The Counter preparations)

Symptomatic Yes Consider Vitamin D deficiency

Investigate and treat, advise long term over the counter supplements

5.4 Serum levels and definitions

Total Serum Vit D levels (D2 + D3) (nmol/L)

Recommendation

< 30 Deficiency– High dose Vit D supplementation required 30-50 Insufficiency– Vitamin D supplementation required according

to guideline or on advice of Endocrine specialist team.

50-150 Adequate-supplementation usually not required except in high risk groups or on Specialist advice.

>150 Emerging evidence to potential adverse effects.

5.5 Treatment guideline

Quick reference guide

If a patient is diagnosed as vitamin D deficient, please also screen family members No Yes Yes No Yes

< 6 months 6 months – 12 years >12 years Colecalciferol liquid 3000 units daily for 8 weeks Vitamin D Thorens oral solution (25,000 units/2.5mls) – 10mls (100,000 units) to be given daily for 2 days

Plenachol 20,000 IU/capsule – 4 capsules (80,000 units) to be given daily for 2 days

Remember 1 microgram of Vit D= 40 I.U. Thus 5 micrograms of Vit D= 200 IU 10 micrograms of Vit D= 400 IU 25 micrograms of Vit D=1000 IU

Does the child have risk factors or symptoms?

No Investigations required, lifestyle advice

Does your child have signs and symptoms

Arrange investigations U&E, Ca, Profile, LFT’s, Vitamin D levels, Full blood count (for iron deficiency), Ferritin, PTH.

Risk factors only

Lifestyle advice and supplementation

All children 6 months – 5 years of age should take a daily supplement

Children consuming 500mls formula milk don’t need Vitamin D supplementation

Exclusively and partially breast fed infants need

supplementation 340-400 IU soon after birth even if mothers have sufficient Vitamin D.

Recommended Vitamin D supplement dose

• Newborn – 1 month: 400 – 400 IU daily • 1 month – 18 years: 400 – 1000 IU daily

• In Salford, Healthy Start vitamins are given free of

charge to all children under the age of 5, these contain 400 IU of Vitamin D.

• Ensure appropriate calcium intake in diet. • If children > age of 5 need maintenance doses,

products purchased over the counter like ABIDEC drops or Dalivit Drops or chewable vitamins or

Thorens Vitamin D drops (10,000 units /ml) 2 drops can be used to provide 400 IU of Vitamin D.

Vitamin D deficiency < 30nmol/l (12ng/ml) – see preparations available page 9

Lifestyle advice and treat (see box below)

*Low calcium levels – Calcium Sandoz 2mmol/kg in 4 divided doses orally* Admit if calcium level <1.85

Insufficiency / maintenance *Ensure adequate Calcium intake

Vit D levels 30 – 50nmol/L (12 – 30ng/ml)

Lifestyle advice plus:

• Vitamin D supplementation 400 IU daily

• Low calcium levels – calcium Sandoz 2mmol/kg in 4

divided doses

• ADMIT IF CALCIUM LEVEL <1.85

Important information:

1. Abidec contains peanut oil hence it is recommended these be avoided in children with peanut allergy.

2. Do not double the dose of multivitamins to give 400 units of Vitamin D as this would increasetoxicity of other vitamins.

In children unable to consume oral dose, one off IM dose of 150,000 units can be given (Stock item at PGW)

NEVER PRESCRIBE ALPHA CALCIDIOL FOR NUTRITIONAL VIT D DEFICIENCY (USE ONLY AFTER ADVICE FROM

See appendix for information on IM dose. Treatment of Vitamin D insufficiency :

Note routine testing of Vitamin D levels is not necessary- see section on Testing on page 5. Upon identification of Vitamin D insufficiency:

1. Explain importance of Vitamin D 2. Offer lifestyle advice

3. Advise patients/parents to take over the counter Multi-Vitamin preparations.

4. Suggested maintenance dose of Vitamin D is 400-1000 IU per day(RCPCH guidance) 5. This would not be routinely prescribed and would be purchased over the counter. Please note:

1. RCPCH (Royal college of Paediatrics and Child Health) advises doses of 400-1000 IU as maintenance for all children above the age of 1. There are preparations (as tablets) available in superstores which give 1000 IU for purchase over the counter. Products like Gummy bears give 300 IU of Vit D per/Gummy bear and are available on the internet. Chewable tablets containing 1000 units per tablet can be consumed 3-4 times a week to give an average of 400-570 units per day of Vitamin D.

2. Unfortunately most preparations available over the counter contain 5 micrograms (200 I.U) of Vitamin D and this is labelled as 100% Recommended Daily Allowance on the product. This is incorrect and at present there is no way of avoiding it

3. Chewable Tablets (containing Vitamin A & D) contain 5 mcg or 200 IU of Vitamin D and this is insufficient for maintenance therapy. Do not double the dose as it increases the risk of vitamin A toxicity.

4. Healthy Start vitamins are available for all children under the age of 5 in Salford and can be obtained from their health visitor at the health centres (Lanceburn, Irlam, Eccles, Swinton, Walkden and Higher Broughton)

Treatment of Vitamin D deficiency:

• The treatment guideline has been written as above from the expert advice received from the metabolic medicine team at Royal Manchester Children’s Hospital.

• The doses suggested in the guideline are to reflect products licenced and available taking care to avoid wastage of medications. Also to improve compliance, the loading dose is given over two days aiming for as close to 150,000 IU as suggested by expert advice. Doses of Thorens solution come in packs of 4 vials of 25,000 IU each; hence in order to avoid wastage, the guideline recommends giving 200,000 IU.

Thus doses can be given as below:

Child less than 6 months: colecalciferol liquid: 3,000 units daily for 8 weeks.

Child 6 months to 12 years: Thorens vitamin D oral solution, 10 ml (4 vials) daily for two days. For children above 12 years: Plenachol capsules (20,000 IU), 4 capsules daily for 2 days.

• Recheck calcium levels after 1 week if low calcium level at presentation.

• Consider rechecking Vitamin D levels after 3 months and follow guidance Page 6.

• Post normalisation of Vitamin D levels, advise to take over the counter preparations until growth complete (age 18 years). Advise the patients that these need to be purchased over the counter and are not prescribed.

Retesting:

· 3 months after initiation of treatment- Ca, Vit D levels (consider), LFT, PTH (if rickets). · Adjusted serum calcium should be checked 1 week after completing the loading regimen

or after starting vitamin D supplementation if low calcium at presentation. If Vit D levels > 50 nmol/litre- start maintenance treatment

If Vit D levels < 30 nmol/litre- repeat course of treatment

If levels 30- 50 nmols/litre- use clinical judgment for treatment/ maintenance therapy.

If levels low after repeat course- consider non-compliance and refer specialist endocrine team at RMCH.

5.6 Follow up advice

• Arrange follow up in Paediatric clinic

Post treatment of Vitamin D deficient or insufficient children, do advise patients/parents to continue long term supplements until completion of growth or unless lifestyle changes (diet, sun exposure) are assured

Indications for referral to specialist endocrine team:

• Atypical biochemistry- persistent hypophosphataemia, elevate creatinine • Failure to reduce alkaline phosphatase within 3 months

• Chronic illness

• Infant under 1 month with calcium level of <2.1 mmol/litre at diagnosis as risk of seizures. Request GP to check Vit D status of mother and treatment based on guidance

5.7 Preparations available for treating vitamin D deficiency

SUMMARY TABLE OF PREPARATIONS AVAILABLE FOR DIFFERENT GROUPS: Thorens

Vitamin D solution

Plenachol Intramuscular Vitamin D *

Available as: 25,000 units/2.5 mls 20,000 IU, 40,000 IU capsules 300,000 units/ml Available from

Thorens Auden Mckenzie (Pharma Division)Ltd

Stock item at PGW and SRFT pharmacy

Licensed in UK

✓ ✓ for over 12 year olds Yes

Suitable for vegetarians ✓ ✓ Suitable for vegans Kosher approved ✓ ✓ Halal approved ✓ ✓ Peanut free ✓ ✓ Soya free ✓ ✓ Available as Liquid ✓

*While intramuscular administration results in 100% adherence, there are important factors to consider before usage, including an unpredictable bioavailability, slower onset of repletion and the additional administration burden in comparison to oral preparations. Parenteral vitamin D is therefore not the first-line recommendation within the treatment guidance, primarily due to significant inter-individual variability in absorption. It can however be considered in children where compliance is an issue. Pendleton Gateway outpatient department has a stock of this item for use.

5.8 Important calcium information in relation to vitamin D

Calcium intake Recommended daily dietary calcium intake (mg/day of elemental calcium) <1yr —— 550

Calcium containing foods:

Food/ Drink Quantity Approximate Calcium content Milk 1ml= 1 mg approx 200 mls (small glass) 250 ml (large glass) 200 mg 250 mg

Cottage cheese 125 g portion 100 mg Hard cheese 30 g portion 200 mg

Yoghurt 150 g pot 200 mg

Bread/ Toast 1 slice 50 mg

Rice pudding/ Custard

100 g portion 100 mg

Cooked Broccoli 100g portion 50 mg Milk chocolate 100g portion 200 mg

Worked example:

4 year old child eats on average 1 slice of bread in the morning and drinks 1 small glass of milk per day.

This child’s daily recommended calcium intake is 450mg/day. This child consumes 250mg of calcium/day

To correct her dietary deficit, the child should either • Eat/drink more calcium containing foods • Take ½ Calcichew tablet once a day

Note:

1. All doses are in a 24 hour period

2. Give doses over 10 ml in two divided doses

3. Consider the sucrose content of Calcium Sandoz (1.5gms/5mls) in children.

Age Intake (mg) Daily

Preparation <1 year 1-<3 years 3-<7 years 7-<11 years 11+ years

Up to 50mg Calcium Sandoz Calcichew 25ml (12.5ml BD) 15ml (7.5ml BD) or 3/4 tablet 20ml (10ml BD) or 1 tablet 25ml (12.5ml BD) or 1 tablet 2 tablets 151-100mg Calcium Sandoz Calcichew 20ml (10ml BD) 12.5ml (6.25ml BD) or 1/2 tablet 17.5ml (8.75ml BD) or 3/4 tablet 25ml (12.5ml BD) or 1 tablet 2 tablets 101-150mg Calcium Sandoz Calcichew 17.5ml (8.75ml BD) 10ml or 1/2 tablet 15ml (7.5ml BD) or 3/4 tablet 20ml (10ml BD) or 1 tablet 2 tablets 151-200mg Calcium Sandoz Calcichew 15ml (7.5ml BD) 7.5ml or 1/4 tablet 12.5ml (6.25ml BD) or 1/2 tablet 17.5ml (8.75ml BD) or 3/4 tablet 2 tablets 201-250mg Calcium Sandoz Calcichew 12.5ml (6.25ml BD) 5ml or 1/4 tablet 10ml or 1/2 tablet 15ml (7.5ml BD) or 3/4 tablet 1 & 1/2 tablets 251-300mg Calcium Sandoz Calcichew 10ml 2.5ml 7.5ml or 1/4 tablet 12.5ml (6.25ml BD) or 1/2 tablet 1 & 1/2 tablets 301-350mg Calcium Sandoz Calcichew 7.5ml 5ml or 1/4 tablet 10ml or 1/2 tablet 1 & 1/2 tablets 351-400mg Calcium Sandoz Calcichew 5ml 2.5ml 7.5ml or 1/4 tablet 1 tablet 401-450mg Calcium Sandoz Calcichew 2.5 - 5ml 5ml or 1/4 tablet 1 tablet 451-500mg Calcium Sandoz Calcichew 2.5ml 2.5ml 1 tablet 501-600mg Calcium Sandoz Calcichew 1 tablet 601-900mg Calcium Sandoz Calcichew 1/2 a tablet

Children with severe hypocalcemia and low Vit D presenting with

seizures

1. Give Oral Calcium– 2 mmol/kg/day (4 doses) 2. Once calcium >1.85 can go home 3. Recheck Calcium in 2 days 4. Refer Endocrinology for CARDIOMYOPATHY screen

Recommended calcium supplementation in accordance with calculated calcium intake -

6.

Roles & responsibilities

Practitioners involved with assessment and treatment of children should read the guidance and offer products available within the trust as outlined above to ensure consistency of therapy regimens.

7.

Monitoring document effectiveness

Monitoring of prescribing within the PANDA unit of vitamin D supplements.

8.

Abbreviations and definitions

Ca – calcium IM – intramuscular IU – international units LFTs – liver function tests PGW – Pendleton Gateway PTH – parathyroid hormone

RCPCH – Royal College of Paediatrics and Child Health U&E – urea and electrolytes

Definitions

Rickets: a disorder due to Vitamin D deficiency occurring in children pre- epiphyseal closure causing delayed growth and development and presence of weak, soft bones likely to cause fractures. This condition is called osteomalacia if it occurs in later life.

Tetany: a sustained state of painful muscle contraction seen in many conditions including Vitamin D deficiency.

9.

References

1. Royal College of Paediatrics and Child Health : guide for vitamin D in childhood– October 2013

2. Vitamin D prescribing guidelines in Children- CMFT July 2013

3. Vitamin D treatment guideline for Primary Care—Rotheram NHS trust.

4. Sun exposure & life style advice: Greater Manchester Medicines Management Group 5. Vitamin D and the Sun Consensus Statement 2010–

www.bad.org.uk//site/1221/default.aspx

6. Www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups 7. Www.healthystart.nhs.uk

8. https://www.salfordlearning.nhs.uk – E-learning package

9. www.gmmmg.nhs.uk - Greater Manchester Medicine management group guideline May 2015 - changes to Vit D assay.

10. www.nos.org.uk -- National Osteoporosis Society

Practical guideline for Vitamin D and bone health for adults. 11. Rapid assessment of dietary calcium intake.

Nordblad M, Graham F, Mughal MZ, Padidela R. Arch Dis Child. 2016 Jul;101(7):634-6. doi:10.1136/archdischild-2015-308905. Epub 2015 Dec 10. PMID: 26662924

10.

Document Control Information

Must be fully completed by the Author prior to submission for approval

Name of lead author: Dr Kalpesh Dixit

Job Title: Consultant Paediatrician

Contact number: 0161 206 0266

Email address: kalpesh.dixit@srft.nhs.uk

Consultation: List persons/groups included in consultation. N.B Include Pharmacy/PADAT/D&T/MMG for

documents containing drugs.

Indicate whether feedback used (FU), not used (FNU) or not-received (NR)

Name of person or group Role / Department / Service / Committee / Corporate Service

Date Response:

FU / FNU / NR

Dr Richard Cooper Medicines Management Committee 18/02/2021 FU

EqIA sign off: See Appendix 11

Name: (Insert named lead from EDI Team) Date:

J McMahon 24/06/2021

Communication plan:

Available via the intranet and highlighted to PANDA clinical teams via teams update Part 2

Must be fully completed by the Author following committee approval. Failure to complete fully will potentially delay publication of the document.

Submit to Document Control/Policy Support for publication.

Approval date: Method of document approval:

18/02/2021 Formal Committee decision

Yes

Chairperson’s approval Yes

Name of Approving Committee

Medicines Management Committee

Chairperson Name/Role Dr Richard Cooper

Amendments approval:

Name of approver, version number and date. Do not amend above details.

Part 3

Must be fully completed by the Author prior to publication

Keywords & phrases: Vitamin D, children, colecalciferol.

Document review arrangements

11.

Equality Impact Assessment (EqIA) tool

• The below tool must be completed at the start of any new or existing policy, procedure, or guideline development or review. N.B. For ease, all documents will be referred to as ‘Policy*’. The EqIA should be used to inform the design of the new policy and reviewed right up until the policy is approved and not completed simply as an audit of the final Policy itself.

• All sections of the tool will expand as required.

• EqIAs must be sent for review prior to the policy* being sent to committee for approval. Any changes made at committee after an EqIA has been sign off must result in the EqIA being updated to reflect these changes. Policies will not be published without a completed and quality reviewed EqIA. Help and guidance available:

• Click here for the Policy*EqIA Tips for Completion QRG

• Email the Group EDI Team: eqia@pat.nhs.uk for advice or training information.

• Submission of policy* documents requiring EqIA sign off to: eqia@pat.nhs.uk. Allowing an initial four week turnaround.

• Where there is a statutory or significant risk, requests to expedite the review process can be made by exception to the Group Equality & Inclusion Programme Manager tara.hewitt@pat.nhs.uk

1. Possible Negative Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age Safety Safeguarding pathways

as per usual practice

Disability Communication barrier Support from learning

disability nurses if needed

Ethnicity Communication barrier Translators/interpreters

available as per usual practice

Gender N/A

Marriage/Civil Partnership N/A

Pregnancy/Maternity N/A

Religion & Belief Medication ingredients Vitamin D products do

not contain animal products

Sexual Orientation N/A

Trans N/A

Other Under Served Communities

(Including Carers, Low Income, Veterans)

N/A

2. Possible Opportunity for Positive Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age N/A

Disability N/A

Ethnicity N/A

Gender N/A

Marriage/Civil Partnership N/A

3. Combined Action Plan

(List all actions & mitigation below) Due Date

Lead

(Name & Job Role)

From Negative or Positive Impact?

Safeguarding pathways as per usual practice

Negative Support from learning disability nurses if

needed

Negative Translators/interpreters available as per

usual practice

Negative Vitamin D products do not contain animal

products

Negative

5. EqIA Update Log

(Detail any changes made to EqIA as policy has developed and any additional impacts included)

Date of Update Author of Update Change Made

Religion & Belief N/A

Sexual Orientation N/A

Trans N/A

Other Under Served Communities (Including Carers, Low Income, Veterans)

N/A

4. Information Consulted and Evidence Base

Protected Characteristic Name of Source Summary of Areas Covered Web link/contact info Age Disability Ethnicity Gender Marriage/Civil Partnership Pregnancy/Maternity Religion & Belief Sexual Orientation Trans

Other Under Served Communities

(Including Carers, Low Income, Veterans)

6. Have all of the negative impacts you have considered been fully mitigated or resolved? (If the answer is no please explain how these don’t constitute a breach of the Equality Act 2010 or the Human Rights Act 1998)

7. Please explain how you have considered the duties under the accessible information standard if your document relates to patients?

The policy will be available to staff in different formats, including large print, enlarged on computer screen and/or on different colour paper. This would also include all Appendices

Information for patients and parents/carers can be given in a variety of formats if required using online resources.

8. Equality Impact Assessment completed and signed off? (Insert named lead from EDI Team below). Please also add this information within Section 11.

12.

Appendices

Appendix 1

Dietary sources of Vitamin D :

 2-3 portions weekly of oily fish including anchovies, trout, salmon, mackerel, herring, pilchards and fresh tuna. Because of the concerns of heavy metal contamination in the marine food chain, it is recommended that these amounts should not be exceeded in pregnancy, or in women who may conceive

 Cod liver oil and other fish oils

 Egg Yolk

 Liver

 Shitake Mushrooms are a good source of vitamin D2

 Some breakfast cereals are supplemented

¨ Margarine and infant formula milk have statutory supplementation in the UK

Appendix 2

LIFESTYLE ADVICE:

Factors affecting production of Vitamin D in the skin depend on the season, time of day, cloud cover, smog, melanin content of the skin (dark skin) use of sun creams and protective clothing used for cultural or religious reasons. Thus many children living in the United Kingdom are unlikely to meet their daily requirements.

The time required to make Vitamin D post sun exposure is short and less than the time needed for skin to redden and burn.

The following sun exposure suggestions can be used as a rough guide as the factors that affect UV radiation exposure and research on amount of sun exposure make it difficult to provide general guidelines

For older children and adults (Caucasians) 5-15 minutes twice weekly sun exposure between 10am and 3pm to face, arms, legs or back without sunscreen.

All subsequent sun exposure must be undertaken after sunscreen application. Sunburn must be avoided whilst following this advice.