LAUSR

Vitamin D deficiency in children is associated with decreased bone mineralisation, deformational rickets and, in severe cases, hypocalcaemic seizure, motor delay and cardiomyopathy. Infant vitamin D status at birth is a reflection of maternal stores, and deficiency less than 50 nmol/L occurs in a striking 11% of all infants in Australia, and in 72% of infants whose mothers have dark skin. Breastfed infants are at higher risk of deficiency, as, despite its benefits, breastmilk contains insufficient vitamin D for infant requirements. Most Australian formulas contain vitamin D supplementation. Australian position statements recommend routine oral vitamin D supplementation in all breastfed infants who are at high risk of deficiency (e.g. where the mother has known vitamin D deficiency, is dark-skinned or is veiled). Of note, international guidelines in the UK and USA are more interventional and recommend routine oral vitamin D supplementation in any breastfed infant. Over a 6-month period we have seen four vitamin D-deficient breastfed infants who had not received prophylactic vitamin D, despite being previously known to be at high risk. They presented with complications, including rickets and hypocalcaemic seizures. The mothers in each case had known vitamin D deficiency during pregnancy, with two of the mothers also having dark skin. The infants were born at different hospitals, suggesting a systemic problem of failure to commence prophylactic supplementation in accordance with national guidelines. We reviewed the protocols of 11 maternal-neonatal units for the prevention of infant vitamin D deficiency. All recommended empiric treatment of breastfed, high-risk group infants for 12 months. The suggested treatment is generally 400 IU cholecalciferol daily. Less commonly Stoss therapy with 50 000 IU cholecalciferol followed by 400 IU daily after 3 months is recommended, although we have seen drug errors associated with the use of the Stoss protocol in neonates. Unfortunately, there was major inconsistency across the protocols in process for identification of infants requiring preventive vitamin D treatment, and of who is responsible for arranging treatment. Protocols variously suggested a note in the parentheld child health record, or a note to the general practitioner, and in some cases, responsibility was placed solely on the parents to identify and follow up their own infant’s supplementation. Without assessment of whether every newborn is in the highrisk group requiring routine vitamin D supplementation, some children will continue to suffer serious complications following missed treatment. A standardised method for risk assessment is required, and we propose a checkbox is added to the child health record for routine consideration at the birth and early maternal child health visits. This would ensure vitamin D is provided to all infants considered at risk.