Approach

Vitamin D deficiency is frequently underdiagnosed in children and adults, primarily because patients do not typically present with overt clinical signs and symptoms until the deficiency is severe and prolonged. In growing children, vitamin D deficiency will reduce bone mineral deposition (resulting in the skeletal manifestations of rickets), developmental delay, and delayed growth.[88]​ In adults, vitamin D deficiency causes a defect in mineralisation of the collagen matrix such that they present with signs and symptoms of osteomalacia (bone pain and tenderness, proximal muscle weakness reported as difficulty rising from a sitting position).[88]​​​

The hallmark for diagnosing vitamin D deficiency is the measurement of serum 25-hydroxyvitamin D.[3][7]​​​​​ Although several inherited or acquired disorders of vitamin D metabolism do not result in a serum 25-hydroxyvitamin D level of <50 nanomoles/L (<20 nanograms/mL), they are still considered causes of vitamin D deficiency and usually present in the same manner, often with more severe skeletal deformities and metabolic bone disease.[3]​​[9]​​

History

Establish risk factors for vitamin D deficiency when taking a history.

Groups at high risk for vitamin D deficiency include:[3][15]​​[26]​​[74][76][89]​​​[90][91]​​​

  • Neonates who receive breast milk as their sole nutrition with no vitamin D supplementation

  • Children and adults with darker and black skin

  • Patients with malabsorption syndromes (coeliac disease, cystic fibrosis, short bowel syndrome, inflammatory bowel disease, Whipple's disease), including those who have undergone gastric bypass surgery

  • Children and adults who are institutionalised, exposed to minimal sunlight, who always wear sun protection before going outdoors, or who live in cold climates

  • Adult >50 years of age (have reduced synthetic capacity to make vitamin D in their skin)

  • People with obesity (BMI >30 kg/m² (requirement of 2-3 times more vitamin D than the general population to satisfy vitamin D requirements)

  • People who take certain prescription or non-prescription drugs including glucocorticoids, anticonvulsants antiretroviral therapy (ART), rifampicin, or St. John's wort

Children who do not receive at least 600 IU/day of vitamin D from diet and supplements, and adults who do not receive at least 1500-2000 IU/day of vitamin D from diet and supplements, may be vitamin D-deficient or -insufficient (see Primary prevention).[17][85][86]​​​​

In mild or early disease, patients may be completely asymptomatic. Decreased growth and delayed achievement of motor milestones are common childhood presentations of rickets. In adults with severe or prolonged vitamin D deficiency, symptoms of osteomalacia typically include throbbing, aching bone discomfort that can be localised or generalised.[88]​ In addition, easy fatiguability and malaise are common symptoms.​ Patients may also report difficulty in rising from a sitting position (due to proximal muscle weakness), and a waddling gait. Patients with oncogenic osteomalacia usually present with non-specific symptoms of muscle weakness and aching bone pain.[8]​

Physical examination

Children

  • Rickets occurs as a consequence of poor global mineralisation of the skeleton, and is characterised by delayed growth, bone pain, and bone deformities.[9]​ These abnormalities usually manifest between 6 months and 2 years of age. Type of deformity depends on the biomechanical situation of the extremities at the time when the structural weakness develops. Bone deformities of the forearms and posterior bowing of the distal tibia can occur in infants (due to muscle tension), whereas exaggerated physiological bowing of the legs (genu varum) is a finding in toddlers who have started walking (due to gravity pushing on the lower limbs). Older children may have valgus or windswept (valgus deformity of one leg and varus deformity of the other) deformities of the legs.​​​ Other bony deformities that may occur include knob-like projections along the ribcage (rachitic rosary), frontal bossing, and widening of the ends of the long bones, especially the wrists. Muscle traction on the softened ribcage is responsible for chest deformation leading to pectus carinatum, thoracic asymmetry, and a widening of the thoracic base. Tooth development is impaired, with delayed eruption and early dental caries. Head sweating may be evident due to increased neuromuscular activity. Infants or young children may seem irritable as a result of associated bone pain. Features of hypocalcaemia may be present as a result of inherited disorders of vitamin D metabolism or chronic untreated vitamin D deficiency. These include muscle cramps, muscle weakness, carpal pedal spasm, numbness, paraesthesias, tetany, and seizures.[88] ​​See  Rickets.[Figure caption and citation for the preceding image starts]: Inward or outward bowing of the legs is a typical sign of classic ricketsCDC [Citation ends].com.bmj.content.model.Caption@547c12af

Adults

  • In adults with vitamin D deficiency, the growth plates are closed and there is enough mineral in the skeleton to prevent the gross skeletal deformities that are seen in children. Physical examination may reveal localised or generalised bony tenderness. Pressing with thumb or forefinger on the sternum, radius, and anterior tibia and eliciting wincing bone pain is a classic sign of periosteal bone discomfort associated with osteomalacia.[3][7]​ Pain in the hips may result in a waddling gait, and proximal muscle weakness is often seen; this is diagnosed by watching the patient get up from a sitting position with difficulty.

Laboratory investigations

The diagnosis of vitamin D deficiency and insufficiency in both adults and children is made by determining the serum 25-hydroxyvitamin D concentration.[79][3]​​​ Testing is recommended for those with symptoms of deficiency, as well as for those with an established clinical indication for vitamin D testing; for example, hypocalcaemia, osteomalacia, or following a fall.[4][7][81]​ Furthermore, some clinicians also measure serum 25-hydroxyvitamin D in select people at increased risk for vitamin D deficiency.[81] See History.

A 25-hydroxyvitamin D concentration of ≤50 nanomolesl/L (≤20 nanograms/mL) is typically associated with a normal serum calcium, low-normal serum phosphorus, normal or high-normal 1,25-dihydroxyvitamin D, and a high-normal or elevated intact PTH concentration.[79][7][92][93]​​​​ A 25-hydroxyvitamin D concentration between 52 and 72 nanomoles/L (21 and 29 nanograms/mL) is typically associated with a normal concentration of serum calcium and phosphorus, a normal 1,25-dihydroxyvitamin D, and usually a normal or slightly elevated intact PTH.[7][93]

Measuring the serum concentration of 1,25-dihydroxyvitamin D is of no value in determining vitamin D status because it circulates at a concentration 1000 times lower than 25-hydroxyvitamin D, has a half-life of only 4 hours (compared with the 2-3 weeks for 25-hydroxyvitamin D), and secondary hyperparathyroidism enhances its production, which is the reason why patients who are vitamin D deficient can still maintain a normal serum concentration of 1,25-dihydroxyvitamin D. Many physicians who obtain a serum 1,25-dihydroxyvitamin D level find it normal and conclude that the patient cannot be vitamin D-deficient. However, this measurement is of great value in distinguishing the inherited or acquired disorders of vitamin D metabolism.[7][94]​​​

Children

  • A serum 25-hydroxyvitamin D concentration of <25 nanomoles/L (<10 nanograms/mL) is usually associated with overt skeletal manifestations of vitamin D-deficiency rickets.[95][96]​​​​[97][98]

  • The serum calcium can be normal or low and the serum phosphorus is usually low-normal or low.[99] The serum alkaline phosphatase and intact PTH levels are usually elevated. A child with pseudovitamin D-deficiency rickets usually has a normal 25-hydroxyvitamin D level with hypocalcaemia, hypophosphataemia, elevated alkaline phosphatase, and intact PTH levels with a low or undetectable level of 1,25-dihydroxyvitamin D. A child with vitamin D-resistant rickets has all the biochemical manifestations of pseudovitamin D-resistant rickets, with the exception that the serum 1,25-dihydroxyvitamin D is markedly elevated. Children with X-linked hypophosphataemic rickets and autosomal-dominant hypophosphataemic rickets have a normal serum 25-hydroxyvitamin D and calcium, a low level of serum phosphorus, and an inappropriately low or low-normal level of 1,25-dihydroxyvitamin D.[3][9]​​​​

Adults

  • For adults, there are no overt skeletal deformities because the growth plates are closed. Instead, vitamin D deficiency causes secondary hyperparathyroidism, with a normal or mildly elevated alkaline phosphatase, normal calcium, and low or low-normal fasting phosphorus. The hallmark of oncogenic osteomalacia is a low serum phosphorus level (usually 0.39 to 0.52 mmol/L [1.2 to 1.6 micrograms/dL]) and an inappropriately low-normal or low level of serum 1,25-dihydroxyvitamin D.[8]​ Serum calcium and intact PTH levels are usually normal, whereas 25-hydroxyvitamin D level is low or normal.

Imaging

In asymptomatic patients, plain-film radiographs are usually unnecessary, but x-rays of the knees and wrists should be performed when rickets or osteomalacia is suspected.[88]​ Widening of the epiphyseal plate, and loss of definition of the zone of provisional calcification at the epiphyseal/metaphyseal interface, are early signs of rickets. Looser's pseudofractures, which lie perpendicular to the cortical margins with the characteristic sclerotic borders, are a pathognomonic finding in osteomalacia. Classic metaphyseal lesions also known as bucket-handle fractures can be observed at the growth plates of long bones.[95][100]​​​[101][102]​​[Figure caption and citation for the preceding image starts]: X-rays of a wrist from a child with vitamin D-deficiency rickets before (left panel) and after (right panel) treatment with vitamin DFrom the collection of M.F. Holick, PhD, MD; used with permission [Citation ends].com.bmj.content.model.Caption@5ce5f8ba[Figure caption and citation for the preceding image starts]: Radiograph of the femoral shaft in a patient with osteomalacia demonstrating a 'pseudofracture' (also known as Looser's zone) on the medial aspect of the mid-femoral shaftFrom the collection of Bridget Sinnott, MD [Citation ends].com.bmj.content.model.Caption@5c3b68bb

Adults with chronic vitamin D deficiency may have low bone density, leading to osteopenia and osteoporosis. A dual-energy x-ray absorptiometry (DEXA) scan should therefore be performed to assess bone density; it also aids in tracking disease progression.

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