VITAMIN D DEFICIENCY IN CHILDREN: CLINICAL MANIFESTATIONS, DIAGNOSTIC DIFFICULTIES, AND CURRENT MANAGEMENT – A LITERATURE REVIEW
DOI:
https://doi.org/10.31435/ijitss.2(50).2026.5448Keywords:
Vitamin D Deficiency, Children, Nutritional Rickets, Supplementation, Hypocalcemia, Pediatric ReviewAbstract
Background: Vitamin D deficiency remains an important pediatric health problem because it can lead to nutritional rickets, impaired bone mineralization, delayed growth, muscle weakness, and severe hypocalcemic complications, especially in infants and other high-risk groups. Despite being preventable, it continues to present diagnostic and therapeutic challenges in everyday pediatric practice.
Objective: This review summarizes current evidence on the epidemiology, risk factors, clinical manifestations, diagnostic difficulties, treatment, and prevention of vitamin D deficiency in children.
Methods: A structured search of PubMed/MEDLINE and the Cochrane Library was conducted on March 28, 2026. Priority was given to pediatric guidelines, consensus statements, systematic reviews, meta-analyses, randomized trials, and observational studies.
Results: Available evidence shows that low circulating vitamin D levels are common worldwide, whereas overt rickets and hypocalcemic presentations are concentrated in identifiable vulnerable populations. Diagnostic difficulties arise from inconsistent biochemical thresholds, assay variability, and the need to distinguish nutritional rickets from genetic or renal disorders. Current management relies on risk-based assessment, appropriate vitamin D replacement, adequate calcium intake, and monitoring for adverse effects, while prevention centers on infant supplementation and public health measures that improve adherence.
Conclusions: Pediatric vitamin D deficiency is largely preventable, but improved diagnostic harmonization, laboratory standardization, and stronger implementation of prevention programs remain necessary to reduce avoidable morbidity.
References
Aglipay, M., Birken, C. S., Parkin, P. C., Loeb, M. B., Thorpe, K., Chen, Y., Laupacis, A., Mamdani, M., & Maguire, J. L. (2017). Effect of high-dose vs standard-dose wintertime vitamin D supplementation on viral upper respiratory tract infections in young healthy children: A randomized clinical trial. JAMA, 318(3), 245–254. https://doi.org/10.1001/jama.2017.8708
Aldana Sierra, M. C., & Christian, C. W. (2021). Vitamin D, rickets and child abuse: Controversies and evidence. Pediatric Radiology, 51(6), 1014–1022. https://doi.org/10.1007/s00247-020-04893-w
A systematic review and meta-analysis of circulating 25-hydroxyvitamin D concentration and vitamin D status worldwide. (2023). The Lancet Diabetes & Endocrinology, 11(7), 497–507. https://doi.org/10.1016/S2213-8587(23)00156-0
Basatemur, E., & Sutcliffe, A. (2015). Incidence of hypocalcemic seizures due to vitamin D deficiency in children in the United Kingdom and Ireland. The Journal of Clinical Endocrinology & Metabolism, 100(1), E91–E95. https://doi.org/10.1210/jc.2014-2773
Binkley, N., & Carter, G. D. (2017). Toward clarity in clinical vitamin D status assessment: 25(OH)D assay standardization. Endocrinology and Metabolism Clinics of North America, 46(4), 885–899. https://doi.org/10.1016/j.ecl.2017.07.012
Bouillon, R., Manousaki, D., Rosen, C., Trajanoska, K., Rivadeneira, F., & Richards, J. B. (2022). The health effects of vitamin D supplementation: Evidence from human studies. Nature Reviews Endocrinology, 18(2), 96–110. https://doi.org/10.1038/s41574-021-00593-z
Brustad, N., Yousef, S., Stokholm, J., Bønnelykke, K., Bisgaard, H., & Chawes, B. L. (2022). Safety of high-dose vitamin D supplementation among children aged 0 to 6 years: A systematic review and meta-analysis. JAMA Network Open, 5(4), e227410. https://doi.org/10.1001/jamanetworkopen.2022.7410
Charoenngam, N., Ayoub, D., & Holick, M. F. (2022). Nutritional rickets and vitamin D deficiency: Consequences and strategies for treatment and prevention. Expert Review of Endocrinology & Metabolism, 17(4), 351–364. https://doi.org/10.1080/17446651.2022.2099374
Chibuzor, M. T., Graham-Kalio, D., Osaji, J. O., & Meremikwu, M. M. (2020). Vitamin D, calcium or a combination of vitamin D and calcium for the treatment of nutritional rickets in children. Cochrane Database of Systematic Reviews, 2020(4), CD012581. https://doi.org/10.1002/14651858.CD012581.pub2
Corsello, A., Spolidoro, G. C. I., Milani, G. P., & Agostoni, C. (2023). Vitamin D in pediatric age: Current evidence, recommendations, and misunderstandings. Frontiers in Medicine, 10, 1107855. https://doi.org/10.3389/fmed.2023.1107855
Crowe, F. L., Mughal, M. Z., Maroof, Z., Berry, J., Kaleem, M., Abburu, S., Walraven, G., Masher, M. I., Chandramohan, D., & Manaseki-Holland, S. (2021). Vitamin D for growth and rickets in stunted children: A randomized trial. Pediatrics, 147(1), e20200815. https://doi.org/10.1542/peds.2020-0815
Cui, A., Zhang, T., Xiao, P., Fan, Z., Wang, H., & Zhuang, Y. (2023). Global and regional prevalence of vitamin D deficiency in population-based studies from 2000 to 2022: A pooled analysis of 7.9 million participants. Frontiers in Nutrition, 10, 1070808. https://doi.org/10.3389/fnut.2023.1070808
Demay, M. B., Pittas, A. G., Bikle, D. D., Diab, D. L., Kiely, M. E., Lazaretti-Castro, M., Lips, P., Manson, J. E., Mithal, A., Murad, M. H., Rosen, C., Wei, N., Zacharin, M. R., & Bilezikian, J. P. (2024). Vitamin D for the prevention of disease: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 109(8), 1907–1947. https://doi.org/10.1210/clinem/dgae290
Embleton, N. D., Moltu, S. J., Lapillonne, A., van den Akker, C. H. P., Carnielli, V. P., Fusch, C., Gerasimidis, K., van Goudoever, J. B., Haiden, N., Iacobelli, S., et al. (2023). Enteral nutrition in preterm infants (2022): A position paper from the ESPGHAN Committee on Nutrition and invited experts. Journal of Pediatric Gastroenterology and Nutrition, 76(2), 248–268. https://doi.org/10.1097/MPG.0000000000003642
Fischer, P. R., & Almasri, N. I. (2022). Nutritional rickets—Vitamin D and beyond. Journal of Steroid Biochemistry and Molecular Biology, 219, 106070. https://doi.org/10.1016/j.jsbmb.2022.106070
Fischer, P. R., Johnson, C. R., Leopold, K. N., & Thacher, T. D. (2023). Treatment of vitamin D deficiency in children. Expert Review of Endocrinology & Metabolism, 18(6), 489–502. https://doi.org/10.1080/17446651.2023.2270053
Herrmann, M., Farrell, C.-J. L., Pusceddu, I., Fabregat-Cabello, N., & Cavalier, E. (2017). Assessment of vitamin D status—A changing landscape. Clinical Chemistry and Laboratory Medicine, 55(1), 3–26. https://doi.org/10.1515/cclm-2016-0264
Jolliffe, D. A., Camargo, C. A., Sluyter, J. D., Aglipay, M., Aloia, J. F., Ganmaa, D., Bergman, P., Bischoff-Ferrari, H. A., Borzutzky, A., Damsgaard, C. T., et al. (2021). Vitamin D supplementation to prevent acute respiratory infections: A systematic review and meta-analysis of aggregate data from randomized controlled trials. The Lancet Diabetes & Endocrinology, 9(5), 276–292. https://doi.org/10.1016/S2213-8587(21)00051-6
Julies, P., Lynn, R. M., Pall, K., Leoni, M., Calder, A., Gates, A., Judge, M., Addison, G. M., Ramnarayan, P., Arundel, P., & Mughal, M. Z. (2020). Nutritional rickets under 16 years: UK surveillance results. Archives of Disease in Childhood, 105(6), 587–592. https://doi.org/10.1136/archdischild-2019-317934
Lerch, C., & Meissner, T. (2007). Interventions for the prevention of nutritional rickets in term-born children. Cochrane Database of Systematic Reviews, 2007(4), CD006164. https://doi.org/10.1002/14651858.CD006164.pub2
Martineau, A. R., Jolliffe, D. A., Hooper, R. L., Greenberg, L., Aloia, J. F., Bergman, P., Dubnov-Raz, G., Esposito, S., Ganmaa, D., Ginde, A. A., et al. (2017). Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ, 356, i6583. https://doi.org/10.1136/bmj.i6583
Mayo Clinic Staff. (2025). Rickets: Symptoms & causes. Mayo Clinic. https://www.mayoclinic.org/health/rickets/DS00813
Misra, M., Pacaud, D., Petryk, A., Collett-Solberg, P. F., & Kappy, M. (2008). Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics, 122(2), 398–417. https://doi.org/10.1542/peds.2007-1894
Mittal, H., Rai, S., Shah, D., Madhu, S. V., Mehrotra, G., Malhotra, R. K., Gupta, P., & Marwaha, R. K. (2014). 300,000 IU or 600,000 IU of oral vitamin D3 for treatment of nutritional rickets: A randomized controlled trial. Indian Pediatrics, 51(4), 265–272. https://doi.org/10.1007/s13312-014-0399-7
Munns, C. F., Shaw, N., Kiely, M., Specker, B. L., Thacher, T. D., Ozono, K., Michigami, T., Tiosano, D., Mughal, M. Z., Mäkitie, O., Ramos-Abad, L., Ward, L. M., DiMeglio, L. A., Atapattu, N., Cassinelli, H., Braegger, C., Pettifor, J. M., Seth, A., Idris, H. W., . . . Högler, W. (2016). Global consensus recommendations on prevention and management of nutritional rickets. The Journal of Clinical Endocrinology & Metabolism, 101(2), 394–415. https://doi.org/10.1210/jc.2015-2175
Mondal, K., Seth, A., Marwaha, R. K., Dhanwal, D., Aneja, S., Singh, R., & Mehan, N. (2014). A randomized controlled trial on the safety and efficacy of a single intramuscular versus a staggered oral dose of 600,000 IU vitamin D in the treatment of nutritional rickets. Journal of Tropical Pediatrics, 60(3), 203–210. https://doi.org/10.1093/tropej/fmt105
NIH Office of Dietary Supplements. (2025). Vitamin D: Fact sheet for health professionals. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
Pappa, H. M., Mitchell, P. D., Jiang, H., Kassiff, S., Filip-Dhima, R., DiFabio, D., & Gordon, C. M. (2012). Treatment of vitamin D insufficiency in children and adolescents with inflammatory bowel disease: A randomized clinical trial comparing three regimens. The Journal of Clinical Endocrinology & Metabolism, 97(6), 2134–2142. https://doi.org/10.1210/jc.2011-3182
Pettifor, J. M. (2004). Nutritional rickets: Deficiency of vitamin D, calcium, or both? The American Journal of Clinical Nutrition, 80(6 Suppl.), 1725S–1729S. https://doi.org/10.1093/ajcn/80.6.1725S
Rios-Leyvraz, M., Thacher, T. D., Dabas, A., Elsedfy, H. H., Baroncelli, G. I., & Cashman, K. D. (2024). Serum 25-hydroxyvitamin D threshold and risk of rickets in young children: A systematic review and individual participant data meta-analysis to inform the development of dietary requirements for vitamin D. European Journal of Nutrition, 63(3), 673–695. https://doi.org/10.1007/s00394-023-03299-2
Rosen, C. J., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., Durazo-Arvizu, R. A., Gallagher, J. C., Gallo, R. L., Jones, G., Kovacs, C. S., et al. (2012). IOM committee members respond to Endocrine Society vitamin D guideline. The Journal of Clinical Endocrinology & Metabolism, 97(4), 1146–1152. https://doi.org/10.1210/jc.2011-2218
Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., Durazo-Arvizu, R. A., Gallagher, J. C., Gallo, R. L., Jones, G., et al. (2011). The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: What clinicians need to know. The Journal of Clinical Endocrinology & Metabolism, 96(1), 53–58. https://doi.org/10.1210/jc.2010-2704
Roth, D. E., Abrams, S. A., Aloia, J., Bergeron, G., Bourassa, M. W., Brown, K. H., Calvo, M. S., Cashman, K. D., Combs, G., De-Regil, L. M., et al. (2018). Global prevalence and disease burden of vitamin D deficiency: A roadmap for action in low- and middle-income countries. Annals of the New York Academy of Sciences, 1430(1), 44–79. https://doi.org/10.1111/nyas.13968
Sempos, C. T., & Binkley, N. (2020). 25-hydroxyvitamin D assay standardization and vitamin D guidelines paralysis. Public Health Nutrition, 23(7), 1153–1164. https://doi.org/10.1017/S1368980019005251
Sosa-Henríquez, M., Torregrosa-Suau, Ó., Tejada-Romero, M. J., Cancelo-Hidalgo, M. J., Tarazona-Santabalbina, F. J., Etxebarria-Foronda, I., Díaz-Guerra, G. M., & Valdés-Llorca, C. (2025). Rethinking vitamin D deficiency: Controversies and practical guidance for clinical management. Nutrients, 17(22), 3573. https://doi.org/10.3390/nu17223573
StatPearls Publishing. (2023). Vitamin D deficiency. In StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK532266/
Tan, J. K. G., Kearns, P., Martin, A. C., & Siafarikas, A. (2015). Randomized controlled trial of daily versus stoss vitamin D therapy in Aboriginal children. Journal of Paediatrics and Child Health, 51(6), 626–631. https://doi.org/10.1111/jpc.12781
Tan, M. L., Abrams, S. A., & Osborn, D. A. (2020). Vitamin D supplementation for term breastfed infants to prevent vitamin D deficiency and improve bone health. Cochrane Database of Systematic Reviews, 2020(12), CD013046. https://doi.org/10.1002/14651858.CD013046.pub2
Thacher, T. D., Fischer, P. R., Isichei, C. O., & Pettifor, J. M. (2006). Early response to vitamin D2 in children with calcium deficiency rickets. The Journal of Pediatrics, 149(6), 840–844. https://doi.org/10.1016/j.jpeds.2006.08.070
Thandrayen, K., & Pettifor, J. M. (2010). Maternal vitamin D status: Implications for the development of infantile nutritional rickets. Endocrinology and Metabolism Clinics of North America, 39(2), 303–320. https://doi.org/10.1016/j.ecl.2010.02.006
Uday, S., Fratzl-Zelman, N., Roschger, P., Klaushofer, K., Chik, M., Ahmed, S. F., & Högler, W. (2018). Cardiac, bone and growth plate manifestations in hypocalcemic infants: Revealing the hidden body of the vitamin D deficiency iceberg. BMC Pediatrics, 18(1), 183. https://doi.org/10.1186/s12887-018-1159-y
Uday, S., & Högler, W. (2017). Nutritional rickets and osteomalacia in the twenty-first century: Revised concepts, public health, and prevention strategies. Current Osteoporosis Reports, 15(4), 293–302. https://doi.org/10.1007/s11914-017-0383-y
Uday, S., & Högler, W. (2020). Nutritional rickets and osteomalacia: A practical approach to management. Indian Journal of Medical Research, 152(4), 356–367. https://doi.org/10.4103/ijmr.IJMR_1961_19
Uday, S., Kongjonaj, A., Aguiar, M., Tulchinsky, T., & Högler, W. (2017). Variations in infant and childhood vitamin D supplementation programmes across Europe and factors influencing adherence. Endocrine Connections, 6(8), 667–675. https://doi.org/10.1530/EC-17-0193
Wadia, M., Weston, P., Chivers, P., Roy, A., & Danchin, M. (2018). Randomized controlled trial comparing daily versus depot vitamin D3 therapy in 0–16-year-old newly settled refugees in Western Australia over a period of 40 weeks. Nutrients, 10(3), 348. https://doi.org/10.3390/nu10030348
Ward, L. M., Gaboury, I., Ladhani, M., & Zlotkin, S. (2007). Vitamin D-deficiency rickets among children in Canada. CMAJ, 177(2), 161–166. https://doi.org/10.1503/cmaj.061377
Winzenberg, T. M., Powell, S., Shaw, K. A., & Jones, G. (2010). Vitamin D supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews, 2010(10), CD006944. https://doi.org/10.1002/14651858.CD006944.pub2
Wu, F., El-Hajj Fuleihan, G., Cai, G., Jorde, R., Vanderschueren, D., Brandi, M.-L., Dawson-Hughes, B., Lips, P., Rizzoli, R., Tikkinen, K. A. O., et al. (2023). Vitamin D supplementation for improving bone density in vitamin D-deficient children and adolescents: Systematic review and individual participant data meta-analysis of randomized controlled trials. The American Journal of Clinical Nutrition, 118(3), 498–506. https://doi.org/10.1016/j.ajcnut.2023.05.028
World Health Organization. (2019). Nutritional rickets: A review of disease burden, causes, diagnosis, prevention and treatment. https://www.who.int/publications/i/item/9789241516587
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Amin Abdulgater, Urszula Przewoźna, Gabriela Stępień, Wiktoria Urowska, Jędrzej Łysiak, Laura Szalewska, Paulina Osuch-Tomaszewska, Magdalena Kossmann, Izabela Kazubek-Fuksiewicz, Julia Burtowicz
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
How to Cite
