supplementation with phosphate or calcium may be
required.
Hypophosphataemicrickets occurs due to abnormal
phosphate excretion; treatment with high doses of oral
phosphate, and hydroxylated (activated) forms of vitamin D
allow bone mineralisation and optimise growth.
Nutritional deficiency of vitamin D is best treated with
colecalciferol or ergocalciferol. Preparations containing
calcium and colecalciferol are also occasionally used in
children where there is evidence of combined calcium and
vitamin D deficiency. Vitamin D deficiency caused by
intestinal malabsorptionorchronic liver diseaseusually
requires vitamin D in pharmacological doses; the
hypocalcaemia ofhypoparathyroidismoften requires higher
doses in order to achieve normocalcaemia and alfacalcidol
p. 630 is generally preferred.
Vitamin D supplementation is often given in combination
with calcium supplements for persistent hypocalcaemia in
neonates, and in chronic renal disease
Vitamin D requires hydroxylation, by the kidney and liver,
to its active form therefore the hydroxylated derivatives
alfacalcidol or calcitriol p. 631 should be prescribed if
patients withsevere liver or renal impairmentrequire vitamin
D therapy. Alfacalcidol is generally preferred in children as
there is more experience of its use and appropriate
formulations are available. Calcitriol is unlicensed for use in
children and is generally reserved for those with severe liver
disease.
Vitamin E
The daily requirement of vitamin E (tocopherol) has not
been well defined. Vitamin E supplements are given to
children with fat malabsorption such as in cysticfibrosis and
cholestatic liver disease. In children with
abetalipoproteinaemia abnormally low vitamin E
concentrations may occur in association with neuromuscular
problems; this usually responds to high doses of vitamin E.
Some neonatal units still administer a single intramuscular
dose of vitamin E at birth to preterm neonates to reduce the
risk of complications; no trials of long-term outcome have
been carried out. The intramuscular route should also be
considered in children with severe liver disease when
response to oral therapy is inadequate.
Vitamin E has been tried for various other conditions but
there is little scientific evidence of its value.
Vitamin K
Vitamin K is necessary for the production of blood clotting
factors and proteins necessary for the normal calcification of
bone.
Because vitamin K is fat soluble, children with fat
malabsorption, especially in biliary obstruction or hepatic
disease, may become deficient. For oral administration to
prevent vitamin K deficiency in malabsorption syndromes, a
water-soluble synthetic vitamin K derivative, menadiol
sodium phosphate p. 636 can be used if supplementation
with phytomenadione p.^636 by mouth has been insufficient.
Oral coumarin anticoagulants act by interfering with
vitamin K metabolism in the hepatic cells and their effects
can be antagonised by giving vitamin K; see advice on the
use of vitamin K in haemorrhage.
Multivitamins
Multivitamin supplements are used in children with vitamin
deficiencies and also in malabsorption conditions such as
cysticfibrosis or liver disease. Supplementation is not
required if nutrient enriched feeds are used; consult a
dietician for further advice.
Vitamin K
Vitamin K deficiency bleeding
Neonates are relatively deficient in vitamin K and those who
do not receive supplements of vitamin K are at risk of serious
bleeding including intracranial bleeding. The Chief Medical
Officer and the Chief Nursing Officer have recommended
that all newborn babies should receive vitamin K to prevent
vitamin K deficiency bleeding (previously termed
haemorrhagic disease of the newborn). An appropriate
regimen should be selected after discussion with parents in
the antenatal period.
Vitamin K (as phytomenadione) may be given by a single
intramuscular injection at birth; this prevents vitamin K
deficiency bleeding in virtually all babies.
Alternatively, in healthy babies who are not at particular
risk of bleeding disorders, vitamin K may be given by mouth,
and arrangements must be in place to ensure the appropriate
regimen is followed. Two doses of a colloidal (mixed micelle)
preparation of phytomenadione should be given by mouth in
thefirst week, thefirst dose being given at birth and the
second dose at 4 – 7 days. For exclusively breast-fed babies, a
third dose of colloidal phytomenadione is given by mouth at
1 month of age; the third dose is omitted in formula-fed
babies because formula feeds contain adequate vitamin K.
An alternative regimen is to give one dose of
phytomenadione by mouth at birth (using the contents of a
phytomenadione capsule) to protect from the risk of vitamin
Kdeficiency bleeding in thefirst week; for exclusively breast-
fed babies, further doses of phytomenadione are given by
mouth (using the contents of a phytomenadione capsule) at
weekly intervals for 12 weeks.VITAMINS AND TRACE ELEMENTS›
MULTIVITAMINSVitamins A and D
lINDICATIONS AND DOSE
Prevention of vitamin A and D deficiency
▶BY MOUTH
▶Child: 1 capsule daily, 1 capsule contains 4000 units
vitamin A and 400 units ( 10 micrograms) vitamin DlUNLICENSED USENot licensed in children under 6 months
of age.
lSIDE-EFFECTS
Overdose
Excessive ingestionProlonged excessive ingestion of
vitamins A and D can lead to hypervitaminosis.
lPRESCRIBING AND DISPENSING INFORMATIONThis drug
contains vitamin D; consult individual vitamin D
monographs.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Capsule
▶Vitamins a and d (Non-proprietary)
Vitamin D 400 unit, Vitamin A 4000 unitVitamins A and D
capsules BPC 1973 | 28 capsule £ 2. 81 | 28 capsuleG£ 2. 81 |
84 capsule £ 6. 75 – £ 8. 42 DT = £ 8. 42Vitamins A, B group, C and D
lINDICATIONS AND DOSE
Prevention of deficiency
▶BY MOUTH USING CAPSULES
▶Child 1–11 years: 1 capsule daily
▶Child 12–17 years: 2 capsules daily continued→BNFC 2018 – 2019 Vitamin deficiency 625
Blood and nutrition9