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Patricia Casey,N Cassidy,JA Tracey
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Ir Med J. 2012 Jun;105(6):189
Sir
Since May 2010 it has been the policy of the Department of Health & Children and the Health Service Executive that all infants, from birth to 12 months, be given a daily supplement of 5 micrograms (200IU) of vitamin D3, to prevent deficiency1. Parents are advised to use a supplement containing vitamin D3 exclusively and instructed to “Give your baby the correct dose into their mouth”. Enquiries to the National Poisons Information Centre (NPIC) about accidental vitamin D overdose have increased since May 2010. The NPIC received enquiries about 8 cases of vitamin D overdose in the five months June to October 2010 inclusive, compared to five in the preceding 17 months (January 2009 to May 2010). These enquiries were exceptional in that nearly all concerned infants aged between 6 days and 9 months, whereas most enquiries to the NPIC about children involve 1-4 year olds2.
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Nine of these 13 cases were due to therapeutic error, where a parent had administered an excessive dose on a single occasion (five cases), repeatedly over periods of 2-10 days (three cases), or chronically (for 6 weeks in one case). Two infants were inadvertently given an acute overdose; in one case the solution came out of the dropper faster than the parent expected while giving the drops directly into a 17-day-old baby’s mouth, and in the other case an unsecure dropper top resulted in 5ml being given to a 6 week old infant. Two further cases involved accidental ingestion by the child. Four infants had received the European tolerable upper intake of 1000IU vitamin D3 per day1 and 6 had exceeded it. Four infants who had received excessive doses repeatedly were referred to hospital to check for hypercalcaemia. Chronic overdose with vitamin D3 can cause hypercalcaemia with nausea, vomiting, anorexia, anaemia, impaired renal function and cardiac arrhythmias. High doses of vitamin D are given to treat deficiency and hypercalcaemia has not been reported in children receiving single oral doses below 200,000IU3. However, there is no consensus in the literature about what chronic vitamin D intakes are optimal or safe, particularly for infants.
These cases of accidental vitamin D3 overdose in infants indicate that parents may have difficulty reading or understanding the dosing instructions that accompany these over- the-counter food supplements. Dosing errors might be prevented by pictograms accompanying the written instructions, as well as instruction by healthcare professionals4. Two acute overdoses happened because the drops were given directly into the baby’s mouth, as advised. While vitamin D3 has negligible acute toxicity, parents will be unaware of this fact and will seek medical advice if their young baby receives an excessive dose. Advising parents to apply the drops to the bottle teat or breast before feeding their baby, instead of giving them directly into their mouth, would prevent these types of accidents. These cases of accidental vitamin D overdose in infants signal problems with the dosing instructions and the method of administration of vitamin D3 supplements. These should be revised to prevent further accidents occurring.
P Casey, N Cassidy, JA Tracey
The National Poisons Information Centre, Beaumont Hospital, Beaumont, Dublin 9
Email: [email protected]
References
1. Health Service Executive. Vitamin D Supplementation for Infants – Information for Health Professionals. May 2010. Available from http://www.hse.ie/eng/services/healthpromotion/Vitamin_D_and_your_baby/Vitamin%20D%20Information%20for%20professionals.pdf
2. Poisons Information Centre of Ireland. Annual Report 2009. Available from http://www.poisons.ie/downloads/Annual_Report_2009.pdf
3. Cranney A, Horsley T, O’Donnell S, Weiler H et al. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep) 2007; 158: 1-235.
4. Yin HS, Dreyer BP, van Schaick L, Foltin GL, Dinglas C, Mendelsohn AL. Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med 2008; 162: 814-822.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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