When should I consider referring a child with rickets to a specialist for further evaluation and management?

Consider referring a child with rickets to a specialist (paediatrician) for further evaluation and management if the child has clinical features of rickets or hypocalcaemia. This includes signs such as bone deformities, delayed growth, or symptoms related to low calcium levels. Referral is also indicated if the child has a medical condition that predisposes to hypercalcaemia (e.g., granulomatous disease, metastatic bone disease, lymphomas, primary hyperparathyroidism), gastrointestinal or malabsorption disorders affecting vitamin D status, active or history of renal stones, severe liver disease, or end-stage chronic kidney disease, as these conditions require specialist supervision and treatment adjustments. Specialist advice should be sought before starting vitamin D treatment in these cases to avoid complications such as vitamin D toxicity or the need for activated vitamin D metabolites.

In summary, refer any child with clinical rickets, hypocalcaemia, or complex underlying conditions affecting vitamin D metabolism or calcium homeostasis to a paediatric specialist.

For children without these features, treatment and monitoring can often be managed in primary care with appropriate vitamin D and calcium supplementation and lifestyle advice.

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