Policies, Procedures, Guidelines and Protocols Document Details

Transcription

1 Title Policies, Procedures, Guidelines and Protocols Document Details Trust Ref No Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approved by (Committee/Director) Approval Date 19/10/17 Initial Equality Impact Screening Full Equality Impact Assessment Guideline for the Prevention, Diagnosis and Management of Vitamin D Deficiency in childhood Identification and evidence based Prevention of Vitamin D Deficiency in childhood Community Health Professionals Dr C J Allsop, Associate Specialist Approval process Clinical Policies Group Y N Lead Director Executive Director of Nursing and Operations. Category Sub Category Clinical Review date 19/10/2020 Who the policy will be distributed to Method Required by CQC Required by NHSLA Other No Date Amendment Distribution Community Paediatricians, School Nurses, Community Children s Nurses, Health Visitors. Electronically via managers / Datix, available to all staff via Trust Website and key clinicians Document Links Amendments History 1 September 2017 New Policy published

2 Contents 1 Introduction..2 2 Definition/Glossary.2 3 Duties Body of Guideline Purpose Sources of Vitamin D Mode of action Groups at Risk Clinical features of Vitamin D deficiency Assessment for Vitamin D deficiency Blood test investigations Blood levels of Vitamin D and Bone Biochemistry Management Long term Treatment of relatives Prevention Adverse effects Availability lifestyle.8 6 Consultation Dissemination and Implementation Monitoring Compliance References 9 10 Associated documents...9 Datix Ref: Page 1 Oct 2017

3 1 Introduction Vitamin D is essential for the absorption and utilisation of calcium in the body needed for healthy bones. Vitamin D deficiency impairs the absorption of dietary calcium and phosphorus, which can impair growth, give rise to bony deformity (including rickets), muscle weakness at any age and severe vitamin D deficiency may cause hypocalcaemia seizures. 2 Definitions / Glossary TB UVA UVB Tuberculosis Ultraviolet A Ultraviolet B 3 Duties 3.1 Chief Executive The chief executive has ultimate accountability for the strategic and operational management of the Trust, including ensuring there are effective and appropriate processes in place for the medical management of Vitamin D in childhood and availability of Vitamin D supplementation through the Governments Healthy Start Scheme. 3.2 Director of Nursing and Medical Director The Director of Nursing and Medical Director have responsibility for ensuring the children with Vitamin D Deficiency and Insufficiency and groups at risk of developing these conditions are offered appropriate medical management and support patient safety at all times. 3.3 Service Managers Service managers are responsible for the day to day operational management and coordination of the medical management of children with Vitamin D Deficiency and Insufficiency and groups at risk of developing these conditions in line with the clinical guidelines. 3.4 All Clinical Staff Clinical staffs are key essential members of the Multi-disciplinary team in ensuring that children with Vitamin D Deficiency and Insufficiency and groups at risk of developing these conditions are managed appropriately as per national/local guidelines. All clinical staff are required to comply with this guideline and to report any adverse care related issues to their line manager and to complete a Datix incident report in line with the Trust s incident reporting policy. 4 Guideline for the Prevention, Diagnosis and management of Vitamin D deficiency in childhood 4.1 Purpose To prevent Vitamin D deficiency in all groups of children and know how to treat should we diagnose it. Datix Ref: Page 2 Oct 2017

4 4.2 Sources of Vitamin D Sun exposure is the main source of vitamin D, however it is also found in some foods naturally and by fortification. Vitamin D can only be made in the skin by exposure to sunlight when the sun is high in the sky; therefore in most of England from November to February Vitamin D cannot be made from sunshine. Vitamin D is found in only a small number of foods naturally including oily fish and eggs. All formula milks are fortified and foods fortified with a small amount of Vitamin D include margarine and some breakfast cereals. 4.3 Vitamin D, Mode of action There are two types of Vitamin D: Ergocalciferol (Vitamin D2) a plant product, and Colecalciferol (Vitamin D3) which is a fish or mammal product. They are regarded as interchangeable. Whether ingested orally or made in the skin through sun exposure, Vitamin D is converted to 25 hydroxy Vitamin D in the liver and then on to 1.25-dihydroxy Vitamin D in the kidney. It is this which has potent metabolic effects. 4.4 Groups at risk of Vitamin D deficiency Certain groups of people are particularly at risk of developing Vitamin D deficiency. (Table 1). The patient will need to be assessed as to whether they fall into a risk group. Although sunshine is the usual source of Vitamin D, diet is the source of Calcium. It is particularly important to prevent Vitamin D deficiency in children with limited Calcium intake. Table 1 Groups of people particularly at risk of developing Vitamin D deficiency Increased Need Reduced Sun Exposure Limited Diet/absorption Pregnant and breastfeeding women Infants Twin and Multiple Pregnancies Adolescents Obesity Drugs: anti epileptics (see below), anti TB drugs Northern Latitude, especially above 50 degrees latitude (eg UK) Asian and African people dark skin needs more sunshine to make Vitamin D Wearing concealing clothing Immobility, for example in patients or those with conditions such as cerebral palsy Excessive use of sun block- most block UVB more than UVA Vegetarians and vegans Prolonged breastfeeding even if the mother has sufficient Vitamin D Exclusion diets for example milk allergy Malabsorption Liver disease Renal disease Datix Ref: Page 3 Oct 2017

5 Vitamin D and epilepsy: The association between Vitamin D deficiency and epilepsy has been known for several years. Offerman et al, in 1979, showed that 72% of children with epilepsy compared to 50% of healthy control had low Vitamin D levels (<15 ng/ml). The reasons for Vitamin D deficiency in this population are multifold. Children with intractable epilepsies often consume a poor diet which is low in Vitamin D. Epileptic children are also likely to have other co-morbid neurodisabilites such as cerebral palsy. This may reduce mobility. This impacts negatively on adequate bone deposition. Many antiepileptic drugs including carbamezepine, phenytoin, and phenobarbitone induce the Cytochrome P450 system, which would increase Vitamin D metabolism in liver. This results in reduction in 25 hydroxy Vitamin D levels, increase in PTH and an abnormal bone turnover. Oxcarbazepine, a less potent enzyme inducer has also been found to affect Vitamin D levels Gabapentin and Topiramate have been shown to reduce bone mineral density. Non enzyme inducing AEDs have also been found to affect bone health by various mechanisms including direct effect on bone cells, resistance to PTH hormone, inhibition of calcitonin secretion and impaired calcium absorption. Valproate, lamotrigine and the ketogenic diet have all shown to effect bone health and lower Vitamin D levels. Polypharmacy with these medications increases the risk of Vitamin D deficiency multifold. EPEN Clinical guidelines: Vitamin D Supplementation in children with epilepsy 6 Authors: A Rajesh, B Mukhtyar Peer review and authorization in EPEN meeting date: Feb 2015 Next review date: Feb ) Offer to parents (and young adult patients) prescription of supplemental Vitamin D 400 units for ALL children with epilepsy who are on antiepileptic treatment. 2) In children with epilepsy and one or more other risk factors for poor bone health, have a low threshold for checking Vitamin D levels prior to starting AEDs along with blood Calcium, phosphate and magnesium levels. Continue to monitor annual Vitamin D levels while children are on AEDs. 4.5 Clinical features in children with Vitamin D deficiency The patient will need to be assessed for clinical features of Vitamin D deficiency which are varied as outlined in Table 2 Table 2 Clinical Features in children of Vitamin D deficiency Babies and Infants Infants and Children Children and Adolescents Seizures, tetany and cardiomyopathy Aches and pains, myopathy causing delayed walking, rickets with bowed legs, swellings at the end of long bones, knock knees, poor growth and muscle weakness Aches and pains, muscle weakness, bone changes of rickets or osteomalacia Datix Ref: Page 4 Oct 2017

6 4.6 Assessment for Vitamin D Deficiency An assessment of the patient will need carried out taking into account the Risk Factors and Clinical Features of Vitamin D deficiency which will determine the management- seetable3 Table 3 Characteristics Assessment and management of Vitamin D Deficiency Management Risk factors and Clinical Features Risk Factors, suspicion of Clinical Features Risk factors, no Clinical Features No risk factors Blood tests and/or xray, treatment, lifestyle advice and long-term prevention Consider Blood tests Give lifestyle advice and prevention Give lifestyle advice 4.7 Blood test investigations. 25 hydroxy Vitamin D is the standard blood test, and is an excellent marker of body stores. This should be tested when there are risk factors and clinical features of Vitamin D deficiency. It may also be tested when there are risk factors and a suspicion of clinical features of Vitamin D deficiency. Basic blood bone biochemistry (calcium, phosphate and alkaline phosphatase) is also investigated. 4.8 Blood Levels of Vitamin D and Bone Biochemistry Vitamin D deficiency historically has been defined as a blood level of 25 hydroxyvitamind below 25 nmol/l. Vitamin D insufficiency is regarded as a blood level of 25 hydroxyvitamind between 25 and 50 nmol/l. Current practice is based on robust evidence of benefits to bone health when levels are > 50 nmol/l. The calcium, phosphate and alkaline phosphatase are often normal despite significant Vitamin D deficiency. High alkaline phosphatase implies rickets. Summary of Vitamin D blood level, Clinical Features and Treatment/Management. This is summarised in the following Table 4: Table 4 Serum 25-hydroxyvitamin D (25-OHD) concentrations, Vitamin D Status, Clinical Features, and Treatment/Management Serum 25-OHD concentration* Vitamin D status Clinical Features Treatment/Management <25 nmol/l Deficient Associated with bone abnormalities eg Rickets Treat with high-dose Colecalciferol Datix Ref: Page 5 Oct 2017

7 Serum 25-OHD concentration* Vitamin D status Clinical Features Treatment/Management nmol/l Insufficient Associated with disease risk Vitamin D supplementation and Lifestyle advice nmol/l Adequate Healthy Lifestyle advice >75 nmol/l Optimal Healthy None Table values reference NICE 2014, *to convert to μg/l divide by Management of Vitamin D Deficiency Serum 25 OH-D Deficient Consider referral to a specialist clinic for further investigations and treatment. The treatment of serum Vitamin D Deficiency is outlined in Table 5 Table 5 Treatment of Serum OH-D Deficiency Age Vitamin D dose (available as oral Colecalciferol*) and frequency Duration Up to 6 months 1,000 units 3,000 units daily 4 to 8 weeks 6 months to 12 years 6,000 units daily 4 to 8 weeks 12 to 18 years 10,000 units daily 4 to 8 weeks Table reference RCPCH *Oral Colecalciferol can be obtained from Sterling Pharmaceuticals Ltd, 288 Upper Balsall Heath Road, Moseley, Birmingham, B12 9DR ( ) Review of the patient in 4 weeks with repeat blood Vitamin D test. Serum 25 OH-D Insufficiency Consider referral to a specialist clinic ( Dr Nick Shaw Birmingham Children s hospital) if there are clinical features otherwise advice over the counter supplements, lifestyle advice and follow up. 5.1 Long Term Management After treatment, children who were deficient or insufficient should continue with standard maintenance prevention dose supplementation (Table 5) until completion of growth unless lifestyle changes (diet/sun exposure) are assured. Dosing regimens vary and clinical evidence is weak in this area. 5.2 Treatment of Relatives If a patient is diagnosed with Vitamin D deficiency the family should be screened and treated by their general practitioner. At least screening by history taking should take place, and prevention advice given. Investigation of other family members by blood testing may be Datix Ref: Page 6 Oct 2017

8 indicated. Alternatively, recommend a Vitamin D supplement to those sharing the same sun exposure and diet. 5.3 Prevention of Vitamin D Deficiency (Table 5) The British Paediatric and Bone Group s2014 recommendation is that exclusively breastfed babies receive Vitamin D supplements soon after birth. The Department of Health and the Chief Medical Officer (statement 2012) recommend a dose of 7 to 8.5 micrograms daily (approx. 300 units) for ALL children from six months to five years of age. This is the dose that the NHS Healthy Start vitamin drops provide. Table 5 Standard prevention doses of Vitamin D Age Dose and Frequency Examples of Preparations Newborn up to 1 month 300 to 400 units daily Abidec, Dalivit, Baby D drops and Healthy Start Vitamins 1 month to 18 years 400 units to 1,000 units daily Over-the-counter preparations eg Abidec, Dalivit, Boots high strength Vitamin D, Ddrops, Holland and Barrett SunviteD3, DLux oral spray, SunVitD3 and Vitabiotics tablets. Table reference RCPCH 2013, a dose of 10 micrograms (mcg) of Vitamin D = 400 Units 5.4 Adverse Effects of Vitamin D Adverse effects of Vitamin D overdose are rare but care should be taken with multivitamin preparations as vitamin A toxicity is a concern. Multivitamin preparations often contain a surprisingly low dose of vitamin D 5.5 Availability of Free vitamin D supplements Women and children from families who are eligible for the Government s Healthy Start scheme can get free vitamin supplements which include vitamin D, in the form of tablets for women and drops for children. Parents may be sent an application form in the post if they are on certain benefits or download an application form from the healthystart.nhs.uk website. There is also a help line Once they have the vouchers (sent every 2 months) their health visitor or midwife will be able to tell them where to get the vitamins. It is the statutory responsibility of Trusts to make Healthy Start vitamins available locally to women and children on the scheme. Women qualify for Healthy Start from the 10 th week of pregnancy or if they have a child under four years old, and if she or her family receive various specified allowances. All pregnant women who are under 18 qualify. NHS organisations can choose to sell the vitamins or supply them free of charge to those who are not eligible for Healthy Start. Alternatively, Vitamin D supplements are available for purchase or can be prescribed for those who are not eligible for the scheme. Datix Ref: Page 7 Oct 2017

9 5.6 Lifestyle Advice (Lifestyle Advice: Vitamin D and the Sun Consensus statement) The consensus statement represents the unified views of the British Association of Dermatologists, Cancer Research UK, Diabetes UK, the Multiple Sclerosis Society, the National Heart Forum, the National Osteoporosis Society and the Primary Care Dermatology Society. Vitamin D is essential for good bone health and for most people sunlight is the most important source of Vitamin D. The time required to make sufficient Vitamin D varies according to a number of environmental, physical and personal factors, but is typically short and less than the amount of time needed for skin to redden and burn. Enjoying the sun safely, while taking care not to burn, can help to provide the benefits of Vitamin D without unduly raising the risk of skin cancer. Vitamin D supplements and specific foods can help to maintain sufficient levels of Vitamin D, particularly in people at risk of deficiency. 6 Consultation 13 October 2015 Community Paediatricians Guidelines: Meeting Dr Angela Hulme, Dr Suzan Allen, Dr Shachi Buch, Dr Janet Butterworth,Dr Mahadeva Ganesh,, Nurse Consultant Narinder Kular, Dr Indu Mahabeer, Dr Sarah Ogilvie, Dr Samantha Postings, Dr Diane Short, Dr Abdo Tarhini. 7 Dissemination and Implementation These guidelines will be disseminated by the following methods: Managers Informed via DATIX system who then confirm they have disseminated to staff as appropriate Staff via Team Brief Published to the staff zone of the trust website 8 Monitoring Compliance Adherence to these guidelines will be monitored through DATIX reporting and intermittent audit. 9 References a. Lifestyle Advice Vitamin D and the Sun Consensus statement - British Association of Dermatologists; 2010 b. Diagnosis and management of vitamin D deficiency Pearce, Cheetham BMJ 2010;340:b5664 c. Vitamin D Advice on Supplements for At Risk Groups Welsh Government, Health, Social Services and Public Safety, The Scottish Government, Department of Health; February 2012 d. Position Statement Vitamin D Royal College of Paediatrics and Child Health; December 2012 e. Vitamin D in Children Frequently asked questions about Vitamin D in childhood Royal National Orthopaedic Hospital NHS Trust; June 2013 f. Guide For Vitamin D in Childhood - Royal College of Paediatrics and Child Health; October 2013 g. Vitamin D Deficiency and Fractures Position Statement The British Paediatric and Adolescent Bone Group; 2014 Datix Ref: Page 8 Oct 2017

10 h. Prophylaxis and treatment guidelines for calcium and vitamin D for children and young people with neuromuscular disorders in the UK Great Ormond Street Hospital; February 2014 i. Vitamin D: Increasing supplement use among at-risk groups NICE public health guidance; November 2014 j. EPEN clinical guideline February Associated Documents Shropshire Community Health NHS Trust Consent to Examination and Treatment Policy Shropshire Community Health NHS Trust Records Management Policy Vitamin D: Increasing supplement use among at-risk groups NICE public health guidance; November 2014 Datix Ref: Page 9 Oct 2017