Failure to thrive
A 13-month-old girl is anemic and not gaining enough weight. How would you proceed with her care?
When follow-up and multiple dosing are impractical—because the family finds repeated clinic visits too difficult, or because the child will not comply with the regimen—you can use stosstherapy.7 This is a bolus of cholecalciferol (D3) or ergocalciferol (D2), 150,000 to 600,000 IU, given as a single dose or divided over several days. For example, you would give 300,000 IU over 1 to 7 days in children 1 to 12 months of age. With this therapy, onset of action is less than a day and maximal effects are seen in 4 weeks. Some preparations contain propylene glycol, which is limited in food additives to <25 mg/kg of body weight because of potential toxicity.
When supplementation doesn’t work. Vitamin D is not effective in treatment of familial hypophosphatemic rickets, Type II vitamin D-dependent rickets, or disorders of phosphate metabolism.
Monitoring therapeutic success
When possible, treatment should be monitored by checking serum calcium and alkaline phosphatase at 1 month, and calcium, magnesium, phosphate, alkaline phosphatase, calcidiol, parathyroid hormone, and wrist x-ray at 3 months from initiation of treatment, to ensure that they are normalizing.
Preventing rickets
In the developed world, public health efforts to prevent rickets have been largely successful. Rickets was prevalent worldwide in the early decades of the 20th century, but after milk began to be routinely fortified with vitamin D in the 1920s, cases of nutritional rickets almost disappeared in industrialized nations.
In 1963, the American Academy of Pediatrics (AAP) began recommending vitamin D supplementation to prevent rickets. Although the recommendation remains controversial because of concerns about the possibility of hypervitaminosis and the resultant hypercalcemia and hypercalciuria, there has been renewed emphasis on this recommendation in light of a rise in the number of cases of rickets in the United States in recent years.8-14 Current AAP recommendations for vitamin D supplementation are daily supplementation of 400 IU vitamin D for the following groups:3
- Breastfed infants, beginning with the first few days of life and continued until they are weaned to at least 1000 mL per day of vitamin D-fortified formula or milk.
- Nonbreastfed infants who are ingesting less than 1000 mL per day of vitamin D-fortified formula or milk. Most commercial baby formulas contain 400 IU/L, which means that an intake of 500 mL of formula per day provides 200 IU.15 Additionally, special milk supplemented with vitamin D3 up to 200 IU per 250 mL has recently become available in Europe.16
- Children and adolescents who do not get regular sunlight exposure, do not ingest at least 32 ounces per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 400 IU of vitamin D.
Others have suggested a bolus dosing 150,000 IU each autumn for those in northern climates.17
Most over-the-counter vitamin formulations now contain D3 (cholecalciferol), as recent studies show this form is more potent than D2 (ergocalciferol).18 Calcium supplements are available in combination with vitamin D. Calcitriol, the most active form of vitamin D, is available only by prescription. Because it does not require activation in the kidneys, it is the drug of choice for renally impaired patients.
Q: How would you treat this child?
Bad taste is a big hurdle
The child in this case was prescribed 150,000 U oral cholecalciferol. She spit it out at the clinic, and the dose was sent home for her parents to administer. She was also started on a multivitamin (Poly-Vi-Sol). On the return visit a few days later, the parents reported that she only took three-quarters of the vitamin D dose, spitting out the remainder.
When that didn’t work…
The child was then admitted to the hospital for administration of vitamin D and to allow for dietary and social work evaluations of factors contributing to her malnutrition.
Social services evaluation ruled out an economic etiology for the child’s failure to thrive. The family was able to afford a nutritionally adequate diet for the child. They were enrolled in Medicaid and WIC. Willful neglect was not an issue: A very loving and appropriate relationship was evident between the child and her parents. Child care was shared equally by the young parents, but they simply didn’t know what foods were appropriate for a child of her age.
Turning things around
The hospital dietician observed one of the child’s meals. The child ate some of everything on the plate: mashed potatoes and gravy, chicken strips, vegetables, bananas, yogurt, and milk. She was willing to try a variety of foods, and ate most of them. Both the physician and the dietician spent a lot of time with the parents reviewing feeding techniques and healthy food choices. Language was a problem, solved for the most part with the assistance of a dial-up language translation service to ensure clear understanding of the instructions. The health care professionals prepared a list of healthy foods to buy at the grocery store, with pictures illustrating healthy food items. In addition, appropriate exposure to sunlight was explained and encouraged.
