Rapid Normalization of Vitamin D in Critically Ill Children: A Phase II Dose Evaluation Randomized Controlled Trial

Background & Rationale: Documented roles for vitamin D in calcium homeostasis, cardiovascular and respiratory health, inflammation, innate immunity, and neuromuscular function have led to the hypothesis that deficiency might represent a modifiable risk factor for outcomes in critical illness. In recent years, dozens of adult studies have reported both high deficiency rates, and associations between lower vitamin D levels and organ dysfunction, health resource utilization, and mortality in the intensive care unit (ICU). More recently, similar observations have been made in critically ill pediatric populations. The cumulative body of basic science and clinical literature demonstrates that deficiency is common in critical illness and rapid normalization of vitamin D status could improve clinical outcomes and/or reduce health care costs. However, before conducting a phase III trial to determine whether restoration of vitamin D status improves outcomes in the PICU, the appropriate dosing regimen must be identified. Consequently, the investigators propose a phase II, double blind randomized controlled trial to determine a loading therapy dosing regimen that can safely and rapidly normalize vitamin D status in critically ill children.

Objectives:

Primary Objective: Determine whether a weight-based loading protocol can rapidly normalize blood vitamin D levels in critically ill children Secondary Objectives: (1) Evaluate whether a weight-based loading protocol, when compared with usual care, results in a greater occurrence of vitamin D related adverse events (hypercalcemia, hypercalciuria); and (2) determine the barriers to and feasibility of a multicenter phase III randomized control trial evaluating whether rapid vitamin D normalization improves clinical outcome and/or reduces health care spending in critically ill children.

Eligibility Criteria: The inclusion criteria for this study are: (i) Admitted to ICU, (ii) Corrected gestational age > 37 weeks to age < 18 years, (iii) Expected ICU admission in excess of 48 hours and expected access for blood work at Day 7 of hospital admission, and (iv) Blood 25(OH)D less than 50 nmol/L (regardless of prior approach to supplementation). Exclusion criteria are: (i) Significant gastrointestinal disorder preventing enteral drug administration (e.g. necrotizing enterocolitis); (ii) Hypercalcemia (excluding transient abnormalities and those related to parenteral calcium administration for hypocalcemia); (iii) Confirmed or suspected William's syndrome; (iv) Patient known to have nephrolithiasis or Nephrocalcinosis; (v) Imminent plan for withdrawal of care or transfer to another ICU; (vi) Physician refusal; (vii) Previous enrollment in the study; (viii) Patient known to have granulomatous disease (tuberculosis or sarcoidosis), (ix) Severe liver dysfunction/liver failure; (x) Patient know to have hypersensitivity or allergy to vitamin D or any of the non-medicinal ingredients of the formulation; (xi) Patient on thiazide diuretics who is also receiving regular ongoing calcium supplementation above the daily recommended intake (for reasons other than hypocalcemia); (xii) Adolescent female of child-bearing age with a positive serum pregnancy test; or (xiii) Patient on digoxin-therapy

Patients meeting inclusion criteria #1-3 and with no exclusion criteria will be approached regarding participation. If consent is given, 25OHD will be determined and those under 50 nmol/L will be randomized. Participants will be stratified by age in two categories (above 30 days of age or below/equal to 30 days of age). Randomization/allocation concealment will be performed using a web-based randomization system.