1. PLI cases Paul Arundel

2. Case 1 A 2 year old child is brought to see you by his father. He has markedly bowed legs with swelling of his wrists, knees and ankles. What additional information would you like from the history and examination? What is the likely diagnosis? What would you do next?

3. Case 2 A 14 year old girl is brought to your clinic by her mother. She has been complaining of “aching legs” for a number of months and does not want to do PE at school. What additional information would you like from the history and examination? What is the likely diagnosis? What would you do next?

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5. Symptoms or signs strongly suggestive of rickets or other bone disease? Refer to or discuss with physicians at SCH, as appropriate Measure bone profile and 25-hydroxyvitamin D Pregnancy and Lactation Vitamin D 400 iu (10 mcg) daily advised for all Healthy start vitamins free for eligible women from Children’s centres OTC supplement from Children’s centre or community pharmacy Only measure vitamin D if clinically indicated (investigate and treat as in non- pregnant state) see linklink Pregnancy and Lactation Vitamin D 400 iu (10 mcg) daily advised for all Healthy start vitamins free for eligible women from Children’s centres OTC supplement from Children’s centre or community pharmacy Only measure vitamin D if clinically indicated (investigate and treat as in non- pregnant state) see linklink Draft - Summary management algorithm – For children who present with suspected vitamin D deficiency Refer to “Guidelines for management of children with suspected vitamin D deficiency in primary care setting” for background and detailsGuidelines for management of children with suspected vitamin D deficiency in primary care setting Date – October 2013 Produced by – Heidi Taylor (MMT, WSY&BSCU) and Paul Arundel (Consultant in paediatric MBD at SCH) Yes Low calcium and/or markedly raised alkaline phosphatase (i.e.2x upper limit of normal range for age)? i)? No 25-hydroxyvitamin D ≤25nmol/L No Yes Treat for vitamin D deficiency; 1 month - 2 years – 3000iu daily for 4-8 wks 2-11 years – 6000iu daily for 8 wks 12 years and over – 10,000iu daily for 8 wks Prescribe orally as Pro D3* 2,000iu/ml liquid or Pro D3* 10,000iu capsules (>12 years). Pro D3 is a nutritional supplement. Consider calcium intake and need for supplementation. Repeat bone profile and vitamin D level 2-3 months after commencement of treatment. Consider ongoing supplementation with daily low dose vitamin D e.g. multivitamin preparation. Treat for vitamin D deficiency; 1 month - 2 years – 3000iu daily for 4-8 wks 2-11 years – 6000iu daily for 8 wks 12 years and over – 10,000iu daily for 8 wks Prescribe orally as Pro D3* 2,000iu/ml liquid or Pro D3* 10,000iu capsules (>12 years). Pro D3 is a nutritional supplement. Consider calcium intake and need for supplementation. Repeat bone profile and vitamin D level 2-3 months after commencement of treatment. Consider ongoing supplementation with daily low dose vitamin D e.g. multivitamin preparation. 25-hydroxyvitamin D 25nmol/L? No General advice should be given and vitamin D supplementation provided at a dose of 200-400iu/day (dose dependent on age/product). Healthy Start* (see link for nearest stockist) Dalivit* (Do not exceed stated dose, contains 5000iu/drop vitamin A) Abidec Neo-D* drops (nutritional supplement) General advice should be given and vitamin D supplementation provided at a dose of 200-400iu/day (dose dependent on age/product). Healthy Start* (see link for nearest stockist) Dalivit* (Do not exceed stated dose, contains 5000iu/drop vitamin A) Abidec Neo-D* drops (nutritional supplement) Yes *Gelatin and peanut oil free Offer reassurance and counsel about importance of adequate safe sun exposure and calcium and vitamin D dietary intake. Department of Health Advice The DH recommends daily vitamin D supplementation (280-340iu/daily) in all children between 6 months and 5 years (unless they are receiving over 500ml formula milk daily). Breast fed babies may need to take drops from one month if the mother didn’t take supplements during pregnancy or is know to be deficient. See Healthy Start website for nearest centre.Healthy Start website Offer reassurance and counsel about importance of adequate safe sun exposure and calcium and vitamin D dietary intake. Department of Health Advice The DH recommends daily vitamin D supplementation (280-340iu/daily) in all children between 6 months and 5 years (unless they are receiving over 500ml formula milk daily). Breast fed babies may need to take drops from one month if the mother didn’t take supplements during pregnancy or is know to be deficient. See Healthy Start website for nearest centre.Healthy Start website Yes