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Rios-Leyvraz M, Thacher TD, Dabas A, Elsedfy HH, Baroncelli GI, Cashman KD. 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. Eur J Nutr 2024; 63:673-695. [PMID: 38280944 PMCID: PMC10948504 DOI: 10.1007/s00394-023-03299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/28/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE The objective of this systematic review was to determine a minimum serum 25-hydroxyvitamin D (25OHD) threshold based on the risk of having rickets in young children. This work was commissioned by the WHO and FAO within the framework of the update of the vitamin D requirements for children 0-3 years old. METHODS A systematic search of Embase was conducted to identify studies involving children below 4 years of age with serum 25OHD levels and radiologically confirmed rickets, without any restriction related to the geographical location or language. Study-level and individual participant data (IPD)-level random effects multi-level meta-analyses were conducted. The odds, sensitivity and specificity for rickets at different serum 25OHD thresholds were calculated for all children as well as for children with adequate calcium intakes only. RESULTS A total of 120 studies with 5412 participants were included. At the study-level, children with rickets had a mean serum 25OHD of 23 nmol/L (95% CI 19-27). At the IPD level, children with rickets had a median and mean serum 25OHD of 23 and 29 nmol/L, respectively. More than half (55%) of the children with rickets had serum 25OHD below 25 nmol/L, 62% below 30 nmol/L, and 79% below 40 nmol/L. Analysis of odds, sensitivities and specificities for nutritional rickets at different serum 25OHD thresholds suggested a minimal risk threshold of around 28 nmol/L for children with adequate calcium intakes and 40 nmol/L for children with low calcium intakes. CONCLUSION This systematic review and IPD meta-analysis suggests that from a public health perspective and to inform the development of dietary requirements for vitamin D, a minimum serum 25OHD threshold of around 28 nmol/L and above would represent a low risk of nutritional rickets for the majority of children with an adequate calcium intake.
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Affiliation(s)
- Magali Rios-Leyvraz
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland.
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aashima Dabas
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | | | - Giampiero I Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Kevin D Cashman
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, and Department of Medicine, University College Cork, Cork, Ireland
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Pérez A, Ruz M, García P, Jiménez P, Valencia P, Ramírez C, Pinto M, Nuñez SM, Park JW, Almonacid S. Nutritional Properties of Fish Bones: Potential Applications in the Food Industry. FOOD REVIEWS INTERNATIONAL 2023. [DOI: 10.1080/87559129.2022.2153136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Alvaro Pérez
- Department of Nutrition, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Manuel Ruz
- Department of Nutrition, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Paula García
- Department of Nutrition, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Paula Jiménez
- Department of Nutrition, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Pedro Valencia
- Departamento de Ingeniería Quimica y Ambiental, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
| | - Cristian Ramírez
- Departamento de Ingeniería Quimica y Ambiental, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
| | - Marlene Pinto
- Departamento de Ingeniería Quimica y Ambiental, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
| | - Suleivys M. Nuñez
- Departamento de Ingeniería Quimica y Ambiental, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
| | - Jae W. Park
- Department of Food Science & Technology, Oregon State University Seafood Research and Education Center, Astoria, OR, USA
| | - Sergio Almonacid
- Departamento de Ingeniería Quimica y Ambiental, Universidad Técnica Federico Santa Maria, Valparaíso, Chile
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Petrikova I, Bhattacharjee R, Fraser PD. The 'Nigerian Diet' and Its Evolution: Review of the Existing Literature and Household Survey Data. Foods 2023; 12:foods12030443. [PMID: 36765972 PMCID: PMC9914143 DOI: 10.3390/foods12030443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/26/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
Natural and social science studies have commonly referenced a 'typical' or 'habitual' Nigerian diet, without defining what such a diet entails. Our study, based on a systematic review of the existing literature and an analysis of household-level survey data, describes the general outline of a common Nigerian diet and how it varies based on spatial, demographic, and socio-economic characteristics. We further try to establish whether Nigeria has embarked on a dietary transition common in most modern economies, marked by a greater consumption of processed foods, fats, and sugar at the expense of traditional whole cereals and pulses. We conclude that while a traditional Nigerian diet is still relatively healthy from an international perspective, it has indeed been transitioning, with an increasing inclusion of high-energy, high-fat, and high-sugar processed foods and a related growing incidence of overweight, obesity, and diet-related non-communicable diseases.
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Affiliation(s)
- Ivica Petrikova
- Department of Politics, International Relations and Philosophy, Royal Holloway University of London, Egham TW20 0EX, UK
- Correspondence:
| | | | - Paul D. Fraser
- Department of Biological Sciences, Royal Holloway University of London, Egham TW20 0EX, UK
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Das RR, Singh M, Naik SS. Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Cochrane Database Syst Rev 2023; 1:CD011597. [PMID: 36633175 PMCID: PMC9835443 DOI: 10.1002/14651858.cd011597.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases children's risk of developing pneumonia. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. This is an update of a Cochrane Review first published in 2018. OBJECTIVES To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trial registries on 28 December 2021. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared vitamin D supplementation with placebo in children (aged one month to five years) hospitalised with acute community-acquired pneumonia, as defined by the World Health Organization (WHO) acute respiratory infection guidelines. For this update, we reappraised eligible trials according to research integrity criteria, excluding RCTs published from April 2018 that were not prospectively registered in a trials registry according to WHO or Clinical Trials Registry - India (CTRI) guidelines (it was not mandatory to register clinical trials in India before April 2018). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with number of participants in each group. We used standard methodological procedures expected by Cochrane. MAIN RESULTS In this update, we included three new trials involving 468 children, bringing the total number of trials to seven, with 1601 children (631 with pneumonia and 970 with severe or very severe pneumonia). We categorised three previously included studies and three new studies as 'awaiting classification' based on the research integrity screen. Five trials used a single bolus dose of vitamin D (300,000 IU in one trial and 100,000 IU in four trials) at the onset of illness or within 24 hours of hospital admission; one used a daily dose of oral vitamin D (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used variable doses (on day 1, 20,000 IU in children younger than six months, 50,000 IU in children aged six to 12 months, and 100,000 IU in children aged 13 to 59 months; followed by 10,000 IU/day for four days or until discharge). Three trials performed microbiological diagnosis of pneumonia, radiological diagnosis of pneumonia, or both. Vitamin D probably has little or no effect on the time to resolution of acute illness (mean difference (MD) -1.28 hours, 95% confidence interval (CI) -5.47 to 2.91; 5 trials, 1188 children; moderate-certainty evidence). We do not know if vitamin D has an effect on the duration of hospitalisation (MD 4.96 hours, 95% CI -8.28 to 18.21; 5 trials, 1023 children; very low-certainty evidence). We do not know if vitamin D has an effect on mortality rate (risk ratio (RR) 0.69, 95% CI 0.44 to 1.07; 3 trials, 584 children; low-certainty evidence). The trials reported no major adverse events. According to GRADE criteria, the evidence was of very low-to-moderate certainty for all outcomes, owing to serious trial limitations, inconsistency, indirectness, and imprecision. Three trials received funding: one from the New Zealand Aid Corporation, one from an institutional grant, and one from multigovernment organisations (Bangladesh, Sweden, and UK). The remaining four trials were unfunded. AUTHORS' CONCLUSIONS Based on the available evidence, we are uncertain whether vitamin D supplementation has important effects on outcomes of acute pneumonia when used as an adjunct to antibiotics. The trials reported no major adverse events. Uncertainty in the evidence is due to imprecision, risk of bias, inconsistency, and indirectness.
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Affiliation(s)
- Rashmi R Das
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sushree S Naik
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Abstract
Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology & Diabetes, Birmingham Women's & Children's NHS Foundation Trust; Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Wolfgang Högler
- Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK; Department of Paediatrics & Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Med Campus IV, Linz, Austria
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Zhao Y, Qin R, Hong H, Lv H, Ye K, Wei Y, Zheng W, Qi H, Ni Y, Zhang L, Yang G, Liu G, Wu A. Vitamin D status and its dietary and lifestyle factors in children during the first 5 years of life: A cross-sectional multicentre Jiangsu bone study. J Hum Nutr Diet 2021; 34:792-806. [PMID: 33751685 DOI: 10.1111/jhn.12883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND To explore the vitamin D status with its demographic and lifestyle factors including dietary, supplementation, and physical activity in 0-5 years old children. METHODS This was a large population-based cross-sectional multicentre study in which the children were recruited from 12 Children's Health Care Centers by a stratified cluster random-sampling method in 10 cities in Jiangsu Province, China. RESULTS A total number of 5289 children were investigated. The prevalence of vitamin D deficiency was 30.1%. The concentration of 25 hydroxyvitamin D was 64.0 (46.3-83.0) nmol mL-1 after adjustment for covariates. Children with higher risk of vitamin D deficiency were more likely to be at older age, girls, survey conducted in spring, location in southern Jiangsu province, residence in urban, outdoor activity < 2 h day-1 (all p < 0.05). Moreover, those with lower risk were more likely to be the number of parity ≥ 2 times, vitamin D supplementation from birth to 6 months, the initial time of vitamin D supplementation after birth ≤ 1 months, vitamin D and calcium supplementation in the last 3 months, and dose of vitamin D supplementation > 400 IU day-1 (all p < 0.05). Children with preferences for sweets, meat consumption > 150.0 g day-1 , milk consumption < 250 mL day-1 , time of sleeping < 10 h day-1 had higher risks of vitamin D deficiency. However, these relationships were affected by demographics. CONCLUSIONS Vitamin D status during the first five years of life was suboptimal and was associated with demographic and lifestyle determinants including milk, meat, sweets, vitamin D and calcium supplementation, sleeping and outdoor activity.
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Affiliation(s)
- Yan Zhao
- Department of Clinical Nutrition, Jiangsu Province Hospital, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Qin
- Department of Child Health Care, Jiangsu Women and Children Health Hospital, Women and Child Branch Hospital of Jiangsu Province Hospital, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hong Hong
- Department of Child Health Care, Drum Tower Maternity and Child Health Care Institute, Nanjing, China
| | - Heyu Lv
- Department of Child Health Care, Jiangning Maternity and Child Health Care Institute, Nanjing, China
| | - Kan Ye
- Department of Child Health Care, Suzhou Municipal Hospital, Suzhou, China
| | - Yarong Wei
- Department of Child Health Care, Wuxi Maternity and Child Health Care Hospital, Wuxi, China
| | - Wen Zheng
- Department of Child Health Care, Yancheng Maternity and Child Health Care Institute, Yancheng, China
| | - Hongxia Qi
- Department of Child Health Care, Xuzhou Children's Hospital, Xuzhou, China
| | - Yufei Ni
- Department of Child Health Care, Nantong Maternity and Child Health Care Hospital, Nantong, China
| | - Li Zhang
- Department of Child Health Care, Huai'an Maternity and Child Health Care Hospital, Huai'an, China
| | - Guoqiang Yang
- Department of Child Health Care, Kunshan Maternity and Child Health Care Institute, Kunshan, China
| | - Guoqin Liu
- Department of Child Health Care, Dafeng Maternity and Child Health Care Hospital, Dafeng, China
| | - Aiping Wu
- Department of Child Health Care, Xinghua Maternity and Child Health Care Hospital, Xinghua, China
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Bouillon R, Antonio L. Nutritional rickets: Historic overview and plan for worldwide eradication. J Steroid Biochem Mol Biol 2020; 198:105563. [PMID: 31809867 DOI: 10.1016/j.jsbmb.2019.105563] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/10/2019] [Accepted: 12/02/2019] [Indexed: 02/01/2023]
Abstract
Rickets was first described in great detail in the mid 17th century and was affecting a great number of children in major European cities. The disease, however, existed already in the Roman times. The etiology of this disease remained enigmatic until the 1920s when two different mechanisms, lack of exposure to sunlight and lack of a dietary factor were finally solved by the discovery of vitamin D and its dual origin. Soon thereafter, the implementation of vitamin D supplementation for all infants and small children largely eliminated nutritional rickets in Europe and North America. It took nearly a century to elucidate the complex chemistry, metabolism, mode and spectrum of activity of the vitamin D endocrine system. Nutritional rickets, whether due to simple vitamin D or calcium deficiency or both, remains widely ravaging many infants and children around the world. Asian countries and the Middle East are mainly confronted with vitamin D deficiency whereas many African and some Asian countries face calcium deficiency rickets. Immigrants and refugees or in general people with a darker skin living in moderate climate zone are also confronted with this disease. There is great consensus how this disease could be prevented or cured. In collaboration with most international professional societies, we prepare a memorandum, in line with the successful battle against iodine deficiency disorders, to convince the World Health Organization and its member states to start an implementation program to eradicate nutritional rickets by 2030.
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Affiliation(s)
- Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium.
| | - Leen Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium
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Sayehmiri K, Shohani M, Kalvandi G, Najafi R, Tavan H. Biochemical parameters of rickets in Iranian children: A systematic review and meta-analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:76. [PMID: 31523262 PMCID: PMC6734666 DOI: 10.4103/jrms.jrms_354_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/19/2018] [Accepted: 05/05/2019] [Indexed: 12/13/2022]
Abstract
Background: Many causes can lead to childhood rickets. We aimed to investigate the biochemical symptoms of childhood rickets with systematic review and meta-analysis. Materials and Methods: Seven articles published from 1975 to 2018 were recruited. The literature search was performed in the Scientific Information Database, Google Scholar, PubMed, and Elsevier databases using related keywords. For meta-analysis, the results of the studies were pooled using the random-effects model. The heterogeneity between the studies was checked using Q test and I2 index. Results: The total sample population consisted of 933 children with biochemical symptoms of rickets (133 participants per article). According to our findings, the mean serum levels of PO4, Ca, and alkaline phosphatase in children with rickets were 4.18 (95% confidence interval [CI]: 3.75–4.61, I2 = 98.3%, P < 0.001), 9.23 (95% CI: 8.78–9.68, I2 = 99.6%, P < 0.001), and 1.33 (95% CI: 1.23–1.44, I2 = 95.6%, P < 0.001), respectively. Conclusion: Characterizing the biochemical symptoms of rickets in children can help to early diagnose and prevent the disease in children. Furthermore, educating parents about biochemical symptoms can lead to early diagnosis and successful treatment of rickets in children.
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Affiliation(s)
- Kourosh Sayehmiri
- Professor of Biostatistics, School of Medicine, Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Masoumeh Shohani
- Assistant Professor, PhD of Nursing, Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
| | - Gholamreza Kalvandi
- Associate Professor of Pediatrics Gastroenterology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Reza Najafi
- Assistant Professor of Pediatric Endocrinology & Metabolism, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Hamed Tavan
- Faculty of Nursing and Midwifery, Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
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Aul AJ, Fischer PR, O'Grady JS, Mara KC, Maxson JA, Meek AM, Petterson TM, Thacher TD. Population-Based Incidence of Potentially Life-Threatening Complications of Hypocalcemia and the Role of Vitamin D Deficiency. J Pediatr 2019; 211:98-104.e4. [PMID: 30954245 PMCID: PMC6661008 DOI: 10.1016/j.jpeds.2019.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the incidence of potentially life-threatening complications of hypocalcemia in infants and children in Olmsted County, Minnesota; and to determine if vitamin D deficiency contributed to these events and was, at the time of clinical presentation, considered as a possible cause. STUDY DESIGN In this population-based descriptive study, data were abstracted from the Rochester Epidemiology Project, a medical record linkage system covering 95% of patients in Olmsted County, Minnesota. Participants were children aged 0-5 years who resided in Olmsted County between January 1, 1996 and June 30, 2017, and who received diagnoses of seizures, cardiomyopathy, cardiac arrest, respiratory arrest, laryngospasm, and/or tetany. The incidence of hypocalcemia plus a potentially life-threatening complication was calculated. RESULTS Among 15 419 patients aged 0-5 years in Olmsted County during the study period, 1305 had eligible complications: 460 had serum calcium checked within 14 days of presentation and 85 had hypocalcemia. Patients were excluded when causes other than hypocalcemia likely triggered the complication, leaving 16 children whose complication was attributed to hypocalcemia. Three of these 16 patients had a serum 25-hydroxyvitamin D measurement and 2 were deficient (≤6 ng/mL [15 nmol/L]). Among children aged 0-5 years, the incidence of hypocalcemia plus a potentially life-threatening complication was 6.1 per 100 000 person-years (95% CI, 3.5-10.0). CONCLUSIONS Vitamin D deficiency is an underinvestigated cause of complications of hypocalcemia in children. Serum calcium and 25-hydroxyvitamin D should be measured in children with these complications to identify possibly life-threatening vitamin D deficiency.
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Affiliation(s)
- Andrea J Aul
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Julie A Maxson
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Alicia M Meek
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Tanya M Petterson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN.
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Hanh NT, Bich PTN, Thao HTT. Acute and subchronic oral toxicity assessment of calcium hydroxyapatite-alginate in animals. VIETNAM JOURNAL OF CHEMISTRY 2019. [DOI: 10.1002/vjch.201960002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Nguyen Thi Hanh
- Institute of Chemistry, Vietnam Academy of Science and Technology; Viet Nam
| | - Phan Thi Ngoc Bich
- Institute of Chemistry, Vietnam Academy of Science and Technology; Viet Nam
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Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci 2018; 1430:44-79. [PMID: 30225965 PMCID: PMC7309365 DOI: 10.1111/nyas.13968] [Citation(s) in RCA: 286] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022]
Abstract
Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.
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Affiliation(s)
- Daniel E. Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - John Aloia
- NYU Winthrop Hospital, Mineola, New York
| | - Gilles Bergeron
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Megan W. Bourassa
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | | | - Mona S. Calvo
- Retired, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin D. Cashman
- Cork Centre for Vitamin D and Nutrition Research, University College Cork, Cork, Ireland
| | | | | | | | - Kerry S. Jones
- MRC Elsie Widdowson Laboratory, Cambridge, United Kingdom
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12
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Das RR, Singh M, Naik SS. Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Cochrane Database Syst Rev 2018; 7:CD011597. [PMID: 30024634 PMCID: PMC6513535 DOI: 10.1002/14651858.cd011597.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Children with acute pneumonia may be vitamin D deficient. Clinical trials have found that prophylactic vitamin D supplementation decreases the risk of developing pneumonia in children. Data on the therapeutic effects of vitamin D in acute childhood pneumonia are limited. OBJECTIVES To evaluate the efficacy and safety of vitamin D supplementation as an adjunct to antibiotics for the treatment of acute childhood pneumonia. SEARCH METHODS We searched CENTRAL (2017, Issue 7), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; Ovid MEDLINE Epub Ahead of Print; In-Process & Other Non-Indexed Citations; Ovid MEDLINE Daily and Ovid MEDLINE (1946 to July Week 4, 2017); and Embase (2010 to 28 July 2017). We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 28 July 2017. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) including children (aged over one month and up to five years) hospitalised with acute community-acquired pneumonia, as defined by the WHO acute respiratory infection guidelines, that compared vitamin D supplementation with control. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and extracted data. For dichotomous data, we extracted the number of participants experiencing the outcome and the total number of participants in each treatment group. For continuous data, we used the arithmetic mean and standard deviation (SD) for each treatment group together with numbers of participants in each group. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included seven RCTs conducted in low-income countries that involved 1529 children (780 with pneumonia and 749 with severe or very severe pneumonia). Four studies used a single 100,000 IU dose of vitamin D₃ at the onset of illness or within 24 hours of hospital admission; two used a daily dose of oral vitamin D₃ (1000 IU for children aged up to one year and 2000 IU for children aged over one year) for five days; and one used a daily dose of oral vitamin D₃ (50,000 IU) for two days. One study reported microbiological and radiological diagnosis of pneumonia.The effects of vitamin D on outcomes were inconclusive when compared with control: time to resolution of acute illness (hours) (mean difference (MD) -0.95, 95% confidence interval (CI) -6.14 to 4.24; 3 studies; 935 children; low-quality evidence) mortality rate (risk ratio (RR) 0.97, 95% CI 0.06 to 15.28; 1 study; 193 children; very low-quality evidence); duration of hospitalisation (MD 0.49, 95% CI -8.41 to 9.4; 4 studies; 835 children; very low-quality evidence) and time to resolution of fever (MD 1.66, 95% CI -2.44 to 5.76; 4 studies; 584 children; very low-quality evidence).No major adverse events were reported.The GRADE assessment found very low-quality evidence (due to serious study limitations, inconsistencies, indirectness, and imprecision) for all outcomes except time to resolution of acute illness.One study was funded by the New Zealand Aid Corporation; one study was funded by an institutional grant; and five studies were unfunded. AUTHORS' CONCLUSIONS We are uncertain as to whether vitamin D has an important effect on outcomes because the results were imprecise. No major adverse events were reported. We assessed the quality of the evidence as very low to low. Several trials are ongoing and may provide additional information.
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Affiliation(s)
- Rashmi R Das
- All India Institute of Medical Sciences (AIIMS)Department of PediatricsSijuaBhubaneswarOdishaIndia751019
| | - Meenu Singh
- Post Graduate Institute of Medical Education and ResearchDepartment of PediatricsSector 12ChandigarhIndia160012
| | - Sushree S Naik
- All India Institute of Medical Sciences (AIIMS)Department of Obstetrics and GynecologySijuaBhubaneswarOdishaIndia751019
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Bommersbach TJ, Fischer PR, Pettifor JM, Thacher TD. The relationship between maternal and child bone density in Nigerian children with and without nutritional rickets. Osteoporos Int 2018; 29:1313-1320. [PMID: 29487981 DOI: 10.1007/s00198-018-4422-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 02/04/2018] [Indexed: 10/17/2022]
Abstract
UNLABELLED We found a positive relationship between bone density in Nigerian children with and without rickets and that of their mothers. After treatment, children with rickets had greater bone density than children without rickets, indicating that children genetically programmed to have greater bone density may have a higher risk of rickets. INTRODUCTION To determine the relationship between bone density in children with and without rickets and that of their mothers METHODS: Using an unmatched case-control design, forearm areal bone mineral density (aBMD) was measured in 52 and 135 Nigerian children with and without rickets and their mothers, respectively. We performed multivariate linear regression analyses to assess the relationship between maternal and child aBMD Z-scores. RESULTS Forearm aBMD Z-scores in children were associated with maternal aBMD Z-scores at metaphyseal (effect estimate 0.23; 95% CI 0.08 to 0.37) and diaphyseal (effect estimate 0.16; 0.01 to 0.30) sites, after adjustment for rickets in the child, child's age and sex, height-for-age Z-score, and weight-for-age Z-score. In the adjusted model, rickets was inversely associated with child's aBMD Z-score at the diaphyseal site only (- 0.45, - 0.65 to - 0.24). The positive relationship between maternal and child aBMD Z-scores was marginally greater in children with rickets (slope 0.56, r = 0.47) than without rickets (slope 0.19, r = 0.20) at the diaphyseal site only (P = 0.06 for interaction) but not at the metaphyseal site (slopes 0.35 and 0.30, respectively, P = 0.48). After treatment with calcium for 6 months, metaphyseal aBMD Z-scores were greater in children with treated rickets (effect estimate 0.26; 95% CI 0.02 to 0.49) than in those without rickets. CONCLUSION In Nigerian children with and without rickets, forearm aBMD Z-scores were positively associated with maternal aBMD Z-scores. Active rickets in the child marginally modified the relationship at the diaphyseal site only. After treatment, children with rickets had greater metaphyseal aBMD Z-scores than children without rickets.
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Affiliation(s)
- T J Bommersbach
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - P R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - J M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - T D Thacher
- Department of Family Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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Uday S, Högler W. Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies. Curr Osteoporos Rep 2017; 15:293-302. [PMID: 28612338 PMCID: PMC5532418 DOI: 10.1007/s11914-017-0383-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Nutritional rickets and osteomalacia are common in dark-skinned and migrant populations. Their global incidence is rising due to changing population demographics, failing prevention policies and missing implementation strategies. The calcium deprivation spectrum has hypocalcaemic (seizures, tetany and dilated cardiomyopathy) and late hypophosphataemic (rickets, osteomalacia and muscle weakness) complications. This article reviews sustainable prevention strategies and identifies areas for future research. RECENT FINDINGS The global rickets consensus recognises the equal contribution of vitamin D and dietary calcium in the causation of calcium deprivation and provides a three stage categorisation for sufficiency, insufficiency and deficiency. For rickets prevention, 400 IU daily is recommended for all infants from birth and 600 IU in pregnancy, alongside monitoring in antenatal and child health surveillance programmes. High-risk populations require lifelong supplementation and food fortification with vitamin D or calcium. Future research should identify the true prevalence of rickets and osteomalacia, their role in bone fragility and infant mortality, and best screening and public health prevention tools.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Creo AL, Thacher TD, Pettifor JM, Strand MA, Fischer PR. Nutritional rickets around the world: an update. Paediatr Int Child Health 2017; 37:84-98. [PMID: 27922335 DOI: 10.1080/20469047.2016.1248170] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.
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Affiliation(s)
- Ana L Creo
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
| | - Tom D Thacher
- b Department of Family Medicine , Mayo Clinic , Rochester , MN , USA
| | - John M Pettifor
- c Wits/SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics , University of the Witwatersrand , Johannesburg , South Africa
| | - Mark A Strand
- d Pharmacy Practice, Department of Public Health , North Dakota State University , Fargo , ND , USA
| | - Philip R Fischer
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
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16
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Hsu J, Fischer PR, Pettifor JM, Thacher TD. The relationship of maternal bone density with nutritional rickets in Nigerian children. Bone 2017; 97:216-221. [PMID: 28126634 DOI: 10.1016/j.bone.2017.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/03/2017] [Accepted: 01/21/2017] [Indexed: 01/01/2023]
Abstract
Factors that affect maternal bone mineral density may be related to the risk of nutritional rickets in their offspring. Our aim was to determine the relationship between maternal areal bone mineral density (aBMD) and rickets in Nigerian children. Using a case-control design, we measured forearm aBMD in 56 and 135 mothers of children with and without nutritional rickets, respectively. Active rickets was confirmed or excluded in all children radiographically. Using logistic regression, we assessed the association of maternal aBMD, adjusted for parity, pregnancy and lactation status, duration of most recent completed lactation, age of menarche, height, body mass index, and maternal age with nutritional rickets. The median (range) age of all mothers was 30years (17-47years), and parity was 4 (1-12). A total of 36 (19%) were pregnant and 55 (29%) were currently breast feeding. Mean (±SD) metaphyseal forearm aBMDs were 0.321±0.057 and 0.316±0.053g/cm2 in mothers of children with and without rickets, respectively (P=0.60). Diaphyseal forearm aBMDs were 0.719±0.071 and 0.715±0.072g/cm2, respectively (P=0.69). In an adjusted analysis, maternal forearm aBMD, bone mineral content and bone area at metaphyseal and diaphyseal sites were not associated with rickets in the child. In the adjusted analysis, rickets was associated with shorter duration of most recently completed lactation (aOR 0.91 for each additional month; 95% CI 0.83-0.99), older maternal age (aOR 1.07 for each additional year; 1.00-1.14), and less frequent maternal use of lead-containing eye cosmetics (aOR 0.20; 95% CI 0.05-0.64), without any difference in maternal blood lead levels. Maternal age, parity, age of menarche, height, and body mass index were not associated with having had a child with rickets in multivariate analysis. Nutritional rickets in Nigerian children was not associated with maternal forearm aBMD. Other unidentified maternal characteristics and practices likely contribute to the risk of rickets in Nigerian children.
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Affiliation(s)
- Jennifer Hsu
- Mayo Medical School, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States; Department of Pediatrics, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, United States.
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States.
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, 2193 Johannesburg, South Africa.
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States; Department of Family Medicine, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State 930241, Nigeria.
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17
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. Horm Res Paediatr 2016; 85:83-106. [PMID: 26741135 DOI: 10.1159/000443136] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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18
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Thacher TD, Smith L, Fischer PR, Isichei CO, Cha SS, Pettifor JM. Optimal Dose of Calcium for Treatment of Nutritional Rickets: A Randomized Controlled Trial. J Bone Miner Res 2016; 31:2024-2031. [PMID: 27311415 DOI: 10.1002/jbmr.2886] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 06/01/2016] [Accepted: 06/12/2016] [Indexed: 02/05/2023]
Abstract
Calcium supplementation is indicated for the treatment of nutritional rickets. Our aim was to determine the optimal dose of calcium for treatment of children with rickets. Sixty-five Nigerian children with radiographically confirmed rickets were randomized to daily supplemental calcium intake of 500 mg (n = 21), 1000 mg (n = 23), or 2000 mg (n = 21). Venous blood, radiographs, and forearm areal bone density (aBMD) were obtained at baseline and at 8, 16, and 24 weeks after enrollment. The primary outcome was radiographic healing, using a 10-point radiographic severity score. The radiographic severity scores improved in all three groups, but the rate of radiographic healing (points per month) was significantly more rapid in the 1000-mg (-0.29; 95% confidence interval [CI] -0.13 to -0.45) and 2000-mg (-0.36; 95% CI -0.19 to -0.53) supplementation groups relative to the 500-mg group. The 2000-mg group did not heal more rapidly than the 1000-mg group. Of those who completed treatment for 24 weeks, 12 (67%), 20 (87%), and 14 (67%) in the 2000-mg, 1000-mg, and 500-mg groups, respectively, had achieved a radiographic score of 1.5 or less (p = 0.21). Serum alkaline phosphatase decreased and calcium increased similarly in all groups. Forearm diaphyseal aBMD improved significantly more rapidly in the 2000-mg group than in the 500-mg and 1000-mg groups (p < 0.001). Daily calcium intakes of 1000 mg or 2000 mg produced more rapid radiographic healing of rickets than 500 mg, but 2000 mg did not have greater benefit than 1000 mg. Some children require longer than 24 weeks for complete healing of nutritional rickets. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Stephen S Cha
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, AZ, USA
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Thacher TD, Pludowski P, Shaw NJ, Mughal MZ, Munns CF, Högler W. Nutritional rickets in immigrant and refugee children. Public Health Rev 2016; 37:3. [PMID: 29450045 PMCID: PMC5810111 DOI: 10.1186/s40985-016-0018-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
Immigrant and refugee populations bring public health challenges to host nations. In the current global refugee crisis, children are the most vulnerable subpopulation. Diseases that were considered rare in the host nation may be highly prevalent among immigrant children. The prevalence of nutritional rickets is increasing in high-income countries, largely driven by an influx of immigrant populations. Nutritional rickets is a bone disease in early childhood resulting in bone pain, delayed motor development, and bending of the bones, caused by vitamin D deficiency and/or inadequate dietary calcium intake. The consequences of nutritional rickets include stunted growth, developmental delay, lifelong bone deformities, seizures, cardiomyopathy, and even death. Nutritional rickets is most commonly seen in children from the Middle East, Africa, and South Asia in high-income countries. Dark skin pigmentation, sun avoidance, covering the skin, and prolonged breast feeding without vitamin D supplementation, are important risk factors for vitamin D deficiency, and combined with a lack of dairy products in the diet, these deficiencies can result in insufficient calcium supply for bone mineralization. We recommend screening all immigrant and refugee children under 5 years of age from these ethnic groups for nutritional rickets, based on clinical features, and confirming the diagnosis with radiographs of the wrists and knees. Because nutritional rickets is entirely preventable, public health policies must address the need for universal vitamin D supplementation and adequate dietary calcium to protect children from this scourge. Vitamin D supplementation of all infants and children with 400 IU/d during the first year of life and dietary or supplemental intakes of at least 600 IU/d of vitamin D and 500 mg/d of calcium thereafter, will effectively prevent nutritional rickets. We call on national health authorities of host countries to implement health check lists and prevention programs that include screening for micronutrient deficiencies, in addition to assessing infections and vaccination programs. Due to their high prevalence of vitamin D deficiency, refugee children of all ages from these ethnic groups should be supplemented with vitamin D, beginning upon arrival.
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Affiliation(s)
- Tom D Thacher
- 1Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Pawel Pludowski
- 2Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nick J Shaw
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - M Zulf Mughal
- 4Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Craig F Munns
- 5The Children's Hospital at Westmead, Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Wolfgang Högler
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK.,6Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab 2016; 101:394-415. [PMID: 26745253 PMCID: PMC4880117 DOI: 10.1210/jc.2015-2175] [Citation(s) in RCA: 628] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Jones HL, Jammeh L, Owens S, Fulford AJ, Moore SE, Pettifor JM, Prentice A. Prevalence of rickets-like bone deformities in rural Gambian children. Bone 2015; 77:1-5. [PMID: 25871880 PMCID: PMC4456426 DOI: 10.1016/j.bone.2015.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 04/01/2015] [Accepted: 04/06/2015] [Indexed: 11/20/2022]
Abstract
The aim of this study was to estimate the burden of childhood rickets-like bone deformity in a rural region of West Africa where rickets has been reported in association with a low calcium intake. A population-based survey of children aged 0.5-17.9 years living in the province of West Kiang, The Gambia was conducted in 2007. 6221 children, 92% of those recorded in a recent census, were screened for physical signs of rickets by a trained survey team with clinical referral of suspected cases. Several objective measures were tested as potential screening tools. The prevalence of bone deformity in children <18.0 years was 3.3%. The prevalence was greater in males (M = 4.3%, F = 2.3%, p < 0.001) and in children <5.0 years (5.7%, M = 8.3%, F = 2.9%). Knock-knee was more common (58%) than bow-leg (31%) or windswept deformity (9%). Of the 196 examined clinically, 36 were confirmed to have a deformity outside normal variation (47% knock-knee, 53% bow-leg), resulting in more conservative prevalence estimates of bone deformity: 0.6% for children <18.0 years (M = 0.9%, F = 0.2%), 1.5% for children < 5.0 years (M = 2.3%, F = 0.6%). Three of these children (9% of those with clinically-confirmed deformity, 0.05% of those screened) had active rickets on X-ray at the time of medical examination. This emphasises the difficulties in comparing prevalence estimates of rickets-like bone deformities from population surveys and clinic-based studies. Interpopliteal distance showed promise as an objective screening measure for bow-leg deformity. In conclusion, this population survey in a rural region of West Africa with a low calcium diet has demonstrated a significant burden of rickets-like bone deformity, whether based on physical signs under survey conditions or after clinical examination, especially in boys < 5.0 years.
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Affiliation(s)
- Helen L Jones
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK; MRC Keneba, The Gambia
| | | | - Stephen Owens
- MRC Keneba, The Gambia; Northumbria Healthcare NHS Foundation Trust, UK
| | - Anthony J Fulford
- MRC Keneba, The Gambia; MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sophie E Moore
- MRC Keneba, The Gambia; MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ann Prentice
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK; MRC Keneba, The Gambia.
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Thacher TD, Bommersbach TJ, Pettifor JM, Isichei CO, Fischer PR. Comparison of Limestone and Ground Fish for Treatment of Nutritional Rickets in Children in Nigeria. J Pediatr 2015; 167:148-54.e1. [PMID: 25799193 DOI: 10.1016/j.jpeds.2015.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 01/20/2015] [Accepted: 02/04/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether children with calcium-deficiency rickets respond better to treatment with calcium as limestone or as ground fish. STUDY DESIGN Nigerian children with active rickets (n = 96) were randomized to receive calcium as powdered limestone (920 mg of elemental calcium) or ground fish (952 mg of elemental calcium) daily for 24 weeks. Radiographic healing was defined as achieving a score of 1.5 or less on a 10-point scale. RESULTS The median (range) age of enrolled children was 35 (6-151) months. Of the 88 children who completed the study, 29 (66%) in the ground fish group and 24 (55%) in the limestone group achieved the primary outcome of a radiographic score of 1.5 or less within 6 months (P = .39). The mean radiographic score improved from 6.2 ± 2.4 to 1.8 ± 2.2 in the ground fish group and from 6.3 ± 2.2 to 2.1 ± 2.4 in the limestone group (P = .68 for group comparison). In an intention to treat analysis adjusted for baseline radiographic score, age, milk calcium intake, and serum 25-hydroxyvitamin D concentration, the response to treatment did not differ between the 2 groups (P = .39). Younger age was associated with more complete radiographic healing in the adjusted model (aOR 0.74 [95% CI 0.57-0.92]). After 24 weeks of treatment, serum alkaline phosphatase had decreased, calcium and 25-hydroxyvitamin D increased, and bone mineral density increased in both groups, without significant differences between treatment groups. CONCLUSION In children with calcium-deficiency rickets, treatment with calcium as either ground fish or limestone for 6 months healed rickets in the majority of children.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN.
| | | | - John M Pettifor
- Medical Research Council/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Christian O Isichei
- Department of Chemical Pathology, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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Dabas AG, Khadgawat R. Developing Indigenous Therapeutic Calcium Supplementation for Treating Nutritional Rickets. J Pediatr 2015; 167:12-4. [PMID: 25934070 DOI: 10.1016/j.jpeds.2015.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/06/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Aashima G Dabas
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
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Högler W. Complications of vitamin D deficiency from the foetus to the infant: One cause, one prevention, but who's responsibility? Best Pract Res Clin Endocrinol Metab 2015; 29:385-98. [PMID: 26051298 DOI: 10.1016/j.beem.2015.03.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Calcium and phosphorus represent building material for bones. The supplier of these bone minerals is the hormone calcitriol, which originates from vitamin D, itself made by sunshine in human skin. Requirement for bone minerals is highest during phases of rapid growth, and no one grows faster than the foetus and the infant, making them particularly vulnerable. Deprivation of calcium, whether through low calcium intake or low vitamin D, leads to serious health consequences throughout life, such as hypocalcaemic seizures, dilated cardiomyopathy, skeletal myopathy, congenital and infantile rickets, and osteomalacia. These 5 conditions are often summarised as 'symptomatic vitamin D deficiency', are fully reversible but also fully preventable. However, the increasing prevalence of rickets and osteomalacia, and the deaths from hypocalcaemic cardiomyopathy, demand action from global health care providers. Clarification of medical and parental responsibilities is a prerequisite to deliver successful prevention programmes. The foetus and infant have the human right to be protected against harm, and vitamin D supplementation has the same public health priority as vaccinations.
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Affiliation(s)
- Wolfgang Högler
- Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, United Kingdom.
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25
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Das RR, Singh M, Naik SS. Vitamin D as an adjunct to antibiotics for the treatment of acute childhood pneumonia. Hippokratia 2015. [DOI: 10.1002/14651858.cd011597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Rashmi R Das
- All India Institute of Medical Sciences (AIIMS); Department of Pediatrics; Sijua Bhubaneswar Odisha India 751019
| | - Meenu Singh
- Post Graduate Institute of Medical Education and Research; Department of Pediatrics; Sector 12 Chandigarh India 160012
| | - Sushree S Naik
- SCB Medical College; Department of Obstetrics and Gynecology; Ranihat Cuttack India 753007
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Abstract
OBJECTIVE To determine whether children with calcium-deficiency rickets have a better response to treatment with vitamin D and calcium than with calcium alone. DESIGN Randomised controlled trial. SETTING Jos University Teaching Hospital, Jos, Nigeria. POPULATION Nigerian children with active rickets treated with calcium carbonate as limestone (approximately 938 mg elemental calcium twice daily) were, in addition, randomised to receive either oral vitamin D2 50,000 IU (Ca+D, n=44) or placebo (Ca, n=28) monthly for 24 weeks. MAIN OUTCOME MEASURE Achievement of a 10-point radiographic severity score ≤1.5 and serum alkaline phosphatase ≤350 U/L. RESULTS The median (range) age of enrolled children was 46 (15-102) months, and baseline characteristics were similar in the two groups. Mean (±SD) 25-hydroxyvitamin D (25(OH)D) was 30.2±13.2 nmol/L at baseline, and 29 (43%) had values <30 nmol/L. Baseline alkaline phosphatase and radiographic scores were unrelated to vitamin D status. Of the 68 children (94% of original cohort) who completed 24 weeks of treatment, 29 (67%) in the Ca+D group and 11 (44%) in the Ca group achieved the primary outcome (p=0.06). Baseline 25(OH)D did not alter treatment group effects (p=0.99 for interaction). At the end of 24 weeks, 25(OH)D values were 55.4±17.0 nmol/L and 37.9±20.0 nmol/L in the Ca+D and Ca groups, respectively, (p<0.001). In the Ca+D and Ca groups, the final 25(OH)D concentration was greater in those who achieved the primary outcome (56.4±17.2 nmol/L) than in those who did not (37.7±18.5 nmol/L, p<0.001). CONCLUSIONS In children with calcium-deficiency rickets, there is a trend for vitamin D to improve the response to treatment with calcium carbonate as limestone, independent of baseline 25(OH)D concentrations. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT00949832.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Wang M, Yang X, Ren L, Li S, He X, Wu X, Liu T, Lin L, Li Y, Sun C. Biomarkers identified by urinary metabonomics for noninvasive diagnosis of nutritional rickets. J Proteome Res 2014; 13:4131-42. [PMID: 25051233 DOI: 10.1021/pr500517u] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nutritional rickets is a worldwide public health problem; however, the current diagnostic methods retain shortcomings for accurate diagnosis of nutritional rickets. To identify urinary biomarkers associated with nutritional rickets and establish a noninvasive diagnosis method, urinary metabonomics analysis by ultra-performance liquid chromatography/quadrupole time-of-flight tandem mass spectrometry and multivariate statistical analysis were employed to investigate the metabolic alterations associated with nutritional rickets in 200 children with or without nutritional rickets. The pathophysiological changes and pathogenesis of nutritional rickets were illustrated by the identified biomarkers. By urinary metabolic profiling, 31 biomarkers of nutritional rickets were identified and five candidate biomarkers for clinical diagnosis were screened and identified by quantitative analysis and receiver operating curve analysis. Urinary levels of five candidate biomarkers were measured using mass spectrometry or commercial kits. In the validation step, the combination of phosphate and sebacic acid was able to give a noninvasive and accurate diagnostic with high sensitivity (94.0%) and specificity (71.2%). Furthermore, on the basis of the pathway analysis of biomarkers, our urinary metabonomics analysis gives new insight into the pathogenesis and pathophysiology of nutritional rickets.
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Affiliation(s)
- Maoqing Wang
- National Key Disciplines of Nutrition and Food Hygiene, Department of Nutrition and Food Hygiene, School of Public Health, Harbin Medical University , 157 Baojian Road, Nangang District, Harbin 150081, P. R. China
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Edwards JK, Thiongó A, Van den Bergh R, Kizito W, Kosgei RJ, Sobry A, Vandenbulcke A, Zuniga I, Reid AJ. Preventable but neglected: rickets in an informal settlement, Nairobi, Kenya. Public Health Action 2014; 4:122-7. [PMID: 26399212 PMCID: PMC4539038 DOI: 10.5588/pha.14.0009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/21/2014] [Indexed: 11/10/2022] Open
Abstract
SETTING The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya. OBJECTIVE To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013. DESIGN Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data. RESULTS Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%. CONCLUSIONS This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.
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Affiliation(s)
| | - A. Thiongó
- Médecins Sans Frontières, Nairobi, Kenya
| | - R. Van den Bergh
- Medical Department, Luxembourg Operational Research Unit (LuxOR), Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - W. Kizito
- Médecins Sans Frontières, Nairobi, Kenya
| | - R. J. Kosgei
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - A. Sobry
- Médecins Sans Frontières, Nairobi, Kenya
| | | | - I. Zuniga
- Medical Department, Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - A. J. Reid
- Medical Department, Luxembourg Operational Research Unit (LuxOR), Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
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Umaretiya PJ, Thacher TD, Fischer PR, Cha SS, Pettifor JM. Bone mineral density in Nigerian children after discontinuation of calcium supplementation. Bone 2013; 55:64-8. [PMID: 23567161 DOI: 10.1016/j.bone.2013.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 03/12/2013] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Nigerian toddlers with low dietary calcium intakes increased forearm bone mineral density (BMD) after 18 months of calcium supplementation compared with placebo. However, it is not known if this bone mineral accretion is sustained after calcium supplement withdrawal. We therefore investigated the influence of prior calcium supplementation on forearm BMD 12 months after withdrawal of the supplement. METHODS Nigerian toddlers aged 12-18 months from three urban communities were enrolled in a controlled trial of calcium supplementation. Two communities received daily calcium supplements, one as calcium carbonate (400mg), and the other as ground fish (529±109 mg), for a duration of 18 months, and all three communities received vitamin A (2500 IU daily) as placebo. Forearm BMD was measured 5 times during 18 months of calcium supplementation and at 12 months after supplement withdrawal. RESULTS Of 647 children enrolled, 390 completed the trial of calcium supplementation and 261 of these returned for the final follow-up 12 months after discontinuation of supplementation. During the 18 months of supplementation, an adjusted model demonstrated that the increase in both distal and proximal forearm BMD over time was significantly greater in the calcium supplemented groups than in the placebo group (P<0.04). However, after supplement withdrawal, the increase in BMD over time was largely attenuated and only remained significant at the proximal forearm in the ground fish group (P=0.03). CONCLUSION The benefit of calcium supplementation on forearm BMD in young Nigerian children is not sustained after supplement withdrawal.
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