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Vitamin Deficiency

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  • Vitamin B12 deficiency exists in around 20% of the general population ≥60 years of age. Treat symptomatic or severe deficiency with an intramuscular (IM) injection of cyanocobalamin 1,000 ¼g/day 3 times a week for 2 weeks. If there are neurologic symptoms then give the same dose of cyanocobalamin every other day for 3 weeks or unitl symptoms have resolved. To prevent recurrence or treat mild deficiency, use a regimen of oral B12 1,000 ¼g/day or an IM injection of B12 1,000 ¼g every month (6). Low-dose oral therapy with 50 to 150 ¼g/day may be considered for mild cases (1). High-dose (1,000 to 2,000 ¼g/day) oral treatment is as effective as monthly IM injections, but use caution in patients with malabsorption or compliance issues (1,6)[C].
  • >40% of elderly in United States are vitamin D deficient. Deficiency is defined as a serum 25-OH vitamin D level of <20 ng/mL. Treatment of vitamin D deficiency is 50,000 IU of oral ergocalciferol weekly for 8 weeks (3,10,13)[B].

Pediatric Considerations

  • Vitamin K deficiency bleeding (9) Neonates may exhibit signs of vitamin K deficiency because they require 1 week of life to establish intestinal flora which manufactures vitamin K. Condition peaks 2 to 10 days after birth: bleeding from the umbilical stump and/or circumcision site, generalized bruising, and GI hemorrhage Infrequent in developed countries due to routine injection of newborns with vitamin K (1 mg)
  • Vitamin D deficiency: Vitamin D supplementation (400 IU/day) is recommended in all exclusively breastfed infants starting in the first few days of life (5)[A].
  • All nonbreastfed infants and older children drinking <1,000 mL/day of vitamin D-fortified formula or milk should receive a vitamin D of 400 IU/day (5).
  • Adolescents may receive a vitamin D supplement of 400 IU/day (5).
  • Morbidly obese and minority children are at increased risk for vitamin D deficiency (14).
  • In children age >6 months in developing countries, vitamin A supplementation has been shown to decrease mortality (7)[B].
  • Vitamin deficiency associated with developmental delay.

Pregnancy Considerations

All pregnant women and women of childbearing age considering pregnancy are strongly encouraged to take a multivitamin containing at least 0.4 mg folic acid daily to prevent neural tube defects (4)[A].

ONGOING CARE

DIET

Vitamins are best utilized by the body from food intake. Supplements should be used where it is not feasible to ingest the recommended amount of a particular vitamin.

PATIENT EDUCATION

  • In healthy adults, multivitamins have no value in a patient with an adequate diet and may increase risk of some cancers.
  • Drug " drug interactions may occur between vitamins and some medications. Patients should report all supplements along with medications to their health care provider.
  • Risk of vitamin toxicity occurs most commonly with the fat-soluble vitamins (A, D, E, K).

PROGNOSIS

Most vitamin deficiencies are fully reversible if treated without undue delay.

COMPLICATIONS

  • Vitamin toxicities
  • Liver failure (vitamins A, D, E, K)
  • Desquamation of skin (vitamin A)
  • Neuropathy (vitamin B6)
  • Kidney stones (vitamin C, vitamin D)
  • Hypercoagulability (vitamin K)
  • Pseudohyperparathyroidism (vitamin D)
  • Masking of pernicious anemia (folic acid)

REFERENCES

11 Hunt A, Harrington D, Robinson S. Vitamin B12 deficiency. BMJ. 2014;349:g5226.22 Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: recommendation statement. Am Fam Physician. 2015;91(1):52D " 52F.33 LeBlanc ES, Zakher B, Daeges M, et al. Screening for vitamin D deficiency: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;162(2):109 " 122.44 Wolff T, Witkop CT, Miller T, et al. Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(9):632 " 639.55 Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding, et al. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142 " 1152.66 Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149 " 160.77 World Health Organization. Guideline: Vitamin A Supplementation in Infants and Children 6 " 59 Months of Age. Geneva, Switzerland: World Health Organization; 2011.88 Lauer B, Spector N. Vitamins. Pediatr Rev. 2012;33(8):339 " 351.99 Schulte R, Jordan LC, Morad A, et al. Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth. Pediatr Neurol. 2014;50(6):564 " 568.1010 Tack J, Deloose E. Complications of bariatric surgery: dumping syndrome, reflux and vitamin deficiencies. Best Pract Res Clin Gastroenterol. 2014;28(4):741 " 749.1111 U.S. Preventive Services Task Force. Screening for osteoporosis: recommendation statement. Am Fam Physician. 2011;83(10):1197 " 1200.1212 Pournaras DJ, le Roux CW. After bariatric surgery, what vitamins should be measured and what supplements should be given? Clin Endocrinol. 2009;71(3):322 " 325.1313 Forrest KY, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011;31(1):48 " 54.1414 Turer CB, Lin H, Flores G. Prevalence of vitamin D deficiency among overweight and obese US children. Pediatrics. 2013;131(1):e152 " e161.

CODES

ICD10

  • E56.9 Vitamin deficiency, unspecified
  • E56.0 Deficiency of vitamin E
  • E55.9 Vitamin D deficiency, unspecified
  • E50.9 Vitamin A deficiency, unspecified
  • E53.9 Vitamin B deficiency, unspecified
  • E56.8 Deficiency of other vitamins
  • E53.1 Pyridoxine deficiency
  • E56.1 Deficiency of vitamin K
  • E53.0 Riboflavin deficiency
  • E53.8 Deficiency of other specified B group vitamins

ICD9

  • 269.2 Unspecified vitamin deficiency
  • 269.1 Deficiency of other vitamins
  • 268.9 Unspecified vitamin D deficiency
  • 264.9 Unspecified vitamin A deficiency
  • 266.1 Vitamin B6 deficiency
  • 269.0 Deficiency of vitamin K
  • 266.9 Unspecified vitamin B deficiency
  • 266.2 Other B-complex deficiencies

SNOMED

  • 85670002 Vitamin deficiency (disorder)
  • 54137008 Vitamin E deficiency (disorder)
  • 34713006 Vitamin D deficiency (disorder)
  • 72000004 Vitamin A deficiency (disorder)
  • 52675005 Vitamin K deficiency (disorder)
  • 190634004 Cobalamin deficiency (disorder)
  • 386080007 Vitamin B6 deficiency (disorder)
  • 47903000 Vitamin B deficiency (disorder)

CLINICAL PEARLS

  • Obtain a thorough dietary history.
  • Specifically ask patients about supplement use.
  • Vitamin D supplementation is recommended in community-dwelling adults aged 65 years or older who are at increased risk for falls (3). All women planning or capable of pregnancy should take a daily supplement containing 0.4 to 0.8 mg of folic acid (4). All infants and children, including adolescents, should have a minimum daily intake of 400 IU of vitamin D beginning soon after birth (5).