1. A daily dose of 3,000 IU vitamin D should be safe in a 4-year-old child

    The case report from Dr. Boyd and Dr. Moodambail highlights the potential for over-zealous administration of vitamin D to result in toxicity (1). However, we contend that it is very unlikely that the reported daily dose of 3,000 IU (75 micrograms) vitamin D would elevate serum 25-hydroxyvitamin D (25[OH]D) concentrations to over 2000 nmol/L in a 4-year-old child. The US Institute of Medicine specifies a safe Upper Level Intake of 3000 IU vitamin D per day for children aged 4-8 years (2), and vitamin D intoxication in children typically arises when very much larger doses of vitamin D (240,000 IU to 4,500,000 IU) are administered (3). Mutations in genes encoding enzymes in the vitamin D metabolic pathway have been associated with hypercalcaemia in individuals with relatively modest vitamin D intakes, but circulating 25(OH)D concentrations in these cases are below the thresholds associated with toxicity (4). It is therefore likely that the dose of vitamin D taken by this child was far in excess of the reported 3,000 IU per day; determination of the vitamin D content of the supplements that he was taking would be instructive.

    1. Boyd C, Moodambail A. Severe hypercalcaemia in a child secondary to use of alternative therapies. BMJ Case Reports. 2016; 2016. 2. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press; 2011. 3. Vogiatzi MG, Jacobson-Dickman E, DeBoer MD. Vitamin D supplementation and risk of toxicity in pediatrics: a review of current literature. J Clin Endocrinol Metab. 2014; 99(4): 1132-41. 4. Schlingmann KP, Kaufmann M, Weber S, Irwin A, Goos C, John U, et al. Mutations in CYP24A1 and idiopathic infantile hypercalcemia. N Engl J Med. 2011; 365(5): 410-21.

    Conflict of Interest:

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  2. Non-Disclosure of CAM usage: a case of "for every complex problem, there is a solution that is plain, simple and wrong"?

    We thank Dr. Boyd and Dr. Moodambail for their recent article in BMJ Case Reports, which describes the case of a four-year old boy with hypercalcaemia and hypervitaminosis D that was possibly attributed to the inappropriate prescribing of nutrient supplements. The case was complicated by the fact that the parent failed to disclose the use of these supplements until several days into the child's admission.

    Patient underreporting of complementary and alternative medicine (CAM) use during clinical encounters with conventional health care providers is a well-documented concern. It is estimated that 50% to 77% of people consuming CAM do not inform their medical practitioner (1-5), which is alarming. Drs. Boyd and Moodambail suggest that the issue of non- disclosure could be resolved if medical practitioners routinely gathered information about CAM use as part of the history taking process. This proposed solution is underpinned by a rather simplistic view of a complex problem.

    Myriad factors undoubtedly determine whether a patient divulges the use of CAM to a medical practitioner or other health care provider. Drs. Boyd and Moodambail allude to just one of these factors - 'opportunity' - highlighting that the health care provider should at least ask the patient if they are taking any CAM. Evidence suggests that communication is merely one of many factors impacting patient disclosure of CAM use. Yet another reason for non-disclosure are patient concerns regarding a potential negative response (such as being judged) by a medical practitioner (4). What this means is that even if the appropriate questions are posed by the medical practitioner, the patient may not divulge relevant information about CAM use because of fear.

    Given the complexity underpinning this issue, we propose a multifaceted strategy to overcome barriers associated with the disclosure of CAM use. In addition to improving communication, strategies to improve the disclosure of CAM use should draw attention to shared decision making between patient and medical practitioner (6), and to fostering positive relationships between patient and health care provider (5). Medical practitioners would also benefit from seeking relevant and unbiased information about CAM and to have a greater respect for patient decision making (7). This is especially poignant given the emergence of patient- centered and consumer-directed care, where the patient plays the role of an active and informed decision maker. The onus is not just on the medical practitioner and patient, however; CAM practitioners also need to be aware of their limitations and the potential adverse effects of their treatments, and to encourage patients to share relevant details with other health care providers such as medical professionals and pharmacists.

    Ultimately, all health care providers, conventional and complementary, should work towards ensuring that their patients receive timely, quality and safe health care. This can only be achieved if conventional and complementary health care providers: (1) communicate effectively with each other and with the patient, (2) openly and respectfully discuss each other's roles in the patient's care, and (3) acknowledge the patient's right to privacy, respect, access to all forms of health care, and their own personal belief system. By adopting a multi- faceted approach to such a complex issue, it is more likely that patients - the primary stakeholders in health care - would have the opportunity and confidence to disclose CAM usage to their health care providers.


    1. MacLennan A, Myers S, Taylor A. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Medical Journal Australia. 2006;184(1):27-31. 2. World Health Organization. WHO traditional medicine strategy 2002-2005. Geneva World Health Organization; 2002. 3. Crawford NW, Cincotta DR, Lim A, Powell CVE. A cross-sectional survey of complementary and alternative medicine use by children and adolescents attending the University Hospital of Wales. BMC Complementary and Alternative Medicine. 2006;6. 4. Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies. Complementary Therapies in Medicine. 2004;12(2-3):90-8. 5. Faith J, Thorburn S, Tippens KM. Examining CAM use disclosure using the Behavioral Model of Health Services Use. Complementary Therapies in Medicine. 2013;21(5):501-8. 6. Wallen GR, Brooks AT. To Tell or Not to Tell: Shared Decision Making, CAM Use and Disclosure Among Underserved Patients with Rheumatic Diseases. Integrative Medicine Insights. 2012;7:15-22. 7. Saxe GA, Madlensky L, Kealey S, Wu DP, Freeman KL, Pierce JP. Disclosure to physicians of CAM use by Breast cancer patients: Findings from The women's healthy eating and living study. Integrative Cancer Therapies. 2008;7(3):122-9.

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  3. Vitamin D

    I think it is irresponsible of this author not to mention that there has indeed been research linking vitamin D to Autism and it is quite reasonable for parents to consider that supplements might improve their child's symptoms. I have certainly seen in clinical practice a reduction in autistic symptoms in patients over the summer months.

    There is also evidence that low vitamin D in pregnancy might acutally increase the likelihood of autism. A Swedish study found significantly lower levels of vitamin D in chord blood in siblings who went on to develop autism compared with the siblings who did not. low-vitamin-d-birth-may-increase-autism-risk Part of the problem is that the UK guidelines suggest levels of vitamin D supplementation which have been shown by research to be too low, but there is no clear consensus as to what the levels should be, particularly in children and no access to blood tests for families. Given that an adult can produce 10,000 iu a day of vitamin D in full sun, whilst 3000iu sounds a lot, it might be other factors such as the amount of calcium which was at fault in this case. More research is urgently needed. The author should at least advocate adherence to current advice that everyone should take at least a low dose vitamin D supplement in the winter months and vulnerable groups year round. guidelines-on-vitamin-D-what-you-need-to-know.aspx

    Parents can also be blamed when their children develop rickets which is sometimes misdiagnosed as child abuse. This can be due to avoiding the sun as they are told to do and not taking supplements in pregnancy or giving children supplements through ignorance.

    This website gives some useful information for parents

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