9.6 Vitamins

General Notes
  • The use of vitamins as general “pick–me–ups” is of unproven value and, in the case of preparations containing vitamin A or D, may be harmful if the prescribed dose is exceeded.
  • Mega–vitamin therapy with water–soluble vitamins, such as ascorbic acid and pyridoxine, is unscientific and can be harmful.
  • There are certain patient groups who require various vitamin supplementation including several metabolic and liver disorders.
  • High risk groups for Vitamin D defiiciency are:
    • Northern UK abode
    • Poor or ‘faddy’ eaters
    • Restricted diet without meat or dairy products or exclusion diets
    • Ethnic groups who have restricted diet for cultural or religious reasons
    • Dark skin
  • Primary source of vitamin D is from sunlight, the amount of ultraviolet exposure depends on many factors not just time spent outdoors: skin pigmentation, latitude, season, air pollution and body mass. Much of the UK, but all of Scotland, is at a latitude such that there is no UV light of the appropriate wavelength during the winter months for adequate vitamin D production.
  • Vitamin D supplementation is recommended for everyone in the UK particularly during the winter months (October-March).  Scottish Government Vitamin D recommendation for new parents March 2017.
  • Babies who are formula fed and having at least 500ml/day do not require vitamin D supplements as the formula milk will provide the required amount of vitamin D.
  • Breastfed babies from birth up to one year of age should receive a vitamin D supplement beginning within the first two weeks of birth. Healthy Start vitamins drops are recommended. Some children age less than 4 years may be eligible for free vitamin supplements.
  • More information on Healthy Start is available here (for intranet users only): http://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A-Z/InfantFeeding/Pages/Vitamin%20supplementation.aspx
  • From October 2018 a new vitamin preparation containing the recommended dose of 8.5 -10 micrograms vitamin D will be available.
  •  
9.6.1 Vitamin A

First Choice:
vitamin A oral solution [unlicensed preparation]
Formulations/Dose
  • vitamin A oral solution 10,000 units/mL[unlicensed preparation]
    • Neonate, 5,000 units daily
    • 1 month – 1 year, 5,000 units daily, adjusted according to levels.
    • 1 – 18 years, 10,000 units daily, adjusted according to levels.
Prescribing Notes
  • Oral solution should be given with or after food.
9.6.2 Vitamin B group
Prescribing Notes
  • Vitamin B deficiency, other than B12, is rare. See section 9.1.2(a).
  • Pyridoxine (vitamin B6) deficiency may occur during isoniazid treatment.
  • Oral vitamin B12 is only prescribable to treat or prevent Vitamin B12 deficiency in a vegan patient or patient who has a proven deficiency of dietary origin. Prescriptions should be endorsed “SLS”.
9.6.3 Vitamin C
Prescribing Notes
  • Ascorbic acid is used in certain metabolic disorders.
9.6.4 Vitamin D

Vitamin D deficiency
Preparation chosen according to childs age and ability to take the medication
First Choice:
colecalciferol
Short gut/chronic renal or cholestatic liver disease
First Choice:
alfacalcidol
Formulations/Dose
  • colecalciferol (InVitaD3®) oral solution 25,000units; oral drops 2400units/mL
  • colecalciferol capsules/tablets 800 units (equivalent to 20 micrograms), capsules 3200units (equivalent to 80micrograms), capsules 20,000units (equivalent to 500micrograms)
  • alfacalcidol capsules 250 nanograms, 500 nanograms, 1microgram; oral drops 2micrograms/ml (1 drop = 100 nanograms); injection 2micrograms/ml
    (a) Hypophosphataemic rickets
    • 1 month – 12 years, by mouth or intravenous injection, initially 25–50nanogram/kg once daily, adjusted according to biochemical response (max 1 microgram).
    • 12 – 18 years, 1 microgram daily, adjusted as necessary. 
    (b) Neonatal hypocalcaemia
    • Birth–1 month, by mouth or intravenous injection, initially 50–100nanogram/kg once daily, adjusted according to biochemical response (up to 2 micrograms/kg).
    (c) Prophylaxis of vitamin D deficiency in renal patients/Cholestatic liver disease
    • 1 month – 12 years, by mouth or intravenous injection, 15-30nanogram/kg daily (max 500 nanograms).
    • 12 – 18 years, by mouth or intravenous injection, 250-500nanograms once daily adjusted as necessary.
Prescribing Notes
  • Patients with severe renal and liver impairment requiring vitamin D therapy should be prescribed alfacalcidol.  Alfacalcidol is not appropriate for standard vitamin D deficiency.
  • Alfacalcidol is also used in different doses for hypoparathyroidism and pseudohypoparathyroidism; see section 6.2.3.
  • Standard combination preparations of vitamins A and D may not be sufficient for cystic fibrosis patients. For patients requiring additional vitamin D supplementation, colecalciferol 800unit tablets can be used; the tablets can be crushed for those patients who cannot swallow whole tablets. CF patients with renal and liver impairment should receive a trial of daily alfacalcidol.
  • Various products are available for children requiring vitamin D treatment and/or supplementation and should be chosen according to the child's age and ability to take medicines.   For further information see Investigation and management of children and adolescents with vitamin D deficiency guideline produced by University Hospitals Division Children's Services.

  • InVitaD3® is presented as single dose oral ampoules, the contents of the ampoule should be emptied directly into the mouth and swallowed, or emptied on to a spoon and taken orally.  It can also be mixed with a small amount of childrens's foods, yoghurt or milk.  It should not be mixed into a bottle of milk or a whole container of food in case the child does not consume the whole portion.

Calcium and vitamin D supplements

First Choice:
Calcichew D3® Forte
orCalcichew D3® caplets
Second Choice:
Calfovit D3®
Adcal D3®
Formulations/Dose
  • Calcichew–D3® forte tablets (chewable) containing 500mg calcium and 400 units colecalciferol.
  • Calcichew–D3® caplets (swallowed whole) containing 500mg calcium and 400 units colecalciferol.
  • Calfovit D3® powder containing calcium phosphate 3.1g (calcium 1.2g or Ca2+ 30mmmol), colecalciferol 20micrograms (800units): for prevention of steroid-induced osteoporosis.
  • Adcal D3® tablets (chewable) calcium carbonate 1.5g (calcium 600mg or 15.1mmol), colecalciferol 10 micrograms (400 units).
Prescribing Notes
  • Calcichew–D3® Forte may be prescribed for osteoporosis.
  • Calcichew–D3® Forte may be ineffective in moderate–severe renal disease; alfacalcidol may be a suitable alternative; see above.
  • Select an appropriate preparation and dose according to the child's age, ability to take the medication and individual calcium and vitamin D requirements.

  • Compliance with calcium and vitamin D preparations is often poor due to the unpleasant taste.  This should be monitored and, if patients cannot tolerate the first choice LJF preparation, other products which contain an appropriate dose of calcium and vitamin D may be tried.

  • Calfovit D3® is a suitable second choice for patients with compliance problems or unable to chew tablets.
9.6.5 Vitamin E

First Choice:
alpha tocopheryl acetate
Formulations/Dose
  • alpha tocopheryl acetate suspension 100mg/ml; 50mg gel capsules[unlicensed preparation]
    • 1 month – 1 year, 50mg (approx 50 units) daily, adjusted according to levels.
    • 1 – 12 years, 100mg (approx 100 – 150 units) daily, adjusted according to levels.
    • 12 – 18 years, 200mg (approx 200 – 300 units) daily, adjusted according to levels.
Prescribing Notes
  • 100mg of suspension is equivalent to 100 units Vitamin E, 50mg gel capsule is equivalent to 75 units Vitamin E.
9.6.7 Multivitamin preparations
Vitamins are used for the prevention and treatment of specific deficiency states, or where the diet is known to be inadequate, vitamins may be prescribed in the NHS to prevent or treat deficiency but not as dietary supplements.

Supplementation for pre-term neonates less than 35 weeks gestation or 1.8kg at birth and high risk groups:
First Choice:
Abidec ®
Second Choice:
Dalivit ®
Supplementation for patients with cystic fibrosis with pancreatic insufficiency:
First Choices:
DEKAs Plus® liquid
orADEKplus chewable tablets
Formulations/Dose
  • Abidec® drops containing 1,333 units vitamin A, 400 units vitamin D in 0.6mL.
    • Pre-term neonates less than 35 weeks gestation or birth weight less than 1.8 kg 0.6mL daily until age 5 years
    • Neonates and infants 1 month – 1 year 0.3mL daily
    • Neonates and infants 1 month - 1 year with cystic fibrosis 0.6mL daily.
    • 1 year – 18 years 0.6mL daily.
  • Dalivit® drops containing 5,000 units vitamin A, 400 units vitamin D in 0.6mL.
    • Pre-term neonates - see prescribing notes
    • Neonates and infants 1 month - 1 year 0.3mL daily
    • Neonates and infants 1 month - 1 year with cystic fibrosis - see prescribing notes
    • 1 year – 18 years 0.6mL daily.
  • DEKAs PLUS liquid [unlicensed preparation] (1mL contains vitamin A 5751 units, vitamin D3 750 units, vitamin E 50 units, vitamin K 500 micrograms. Also contains other vitamins and trace elements)      
    • Age 0 - 1 years 1mL once daily 
    • Age 1 - 3 years 1 - 2mL once daily dose adjusted according to vitamin levels
  • ADEKplus chewable tablets[unlicensed preparation]  (one tablet contains vitamin A 2700 units, vitamin D3 1000 units, vitamin E 100mg, vitamin K 5 mg. Also contains other vitamins and trace elements)
    • from age 2 years 1-2 tablets daily
Prescribing Notes
  • NHS Lothian Neonatal Services recommend that infants less than 35 weeks gestation or 1.8kg at birth should continue a vitamin supplement containing vitamin D from the time of discharge until the age of 5 years.
  • Infants receiving breast milk fortifier do not require Abidec® or Dalivit®.
  • If Abidec® is not available neonates and infants less than 35 weeks gestation or 1.8kg at birth or with CF age 1 month to 1 year may be prescribed Dalivit® 0.6mL daily in order to deliver an equivalent dose of vitamin D.  The daily vitamin A dose in 0.6mL of Dalivit® is higher than routinely required for this age group.
  • For more information on multivitamins for premature and low birth weight infants see the NHS Neonatal Services Clinical Guidelines.
  • In Cystic fibrosis the choice of multivitamin will depend on the patient's pancreatic status. Additional vitamin D supplementation may be required in some individuals. For more information see the guideline on Vitamin Supplementation for Paediatric Cystic Fibrosis patients.
  • Children should be swapped from DEKAs Plus®  liquid to ADEKplus chewable tablets when able.