Nutritional rickets in suburbia

Vitamin D, rickets and child abuse: controversies and evidence

Suboptimal vitamin D status is a global health issue that affects children and adults worldwide. The prevalence of vitamin D deficiency and insufficiency has been well documented in the pediatric population in the United States. Although vitamin D deficiency is common, radiographic findings are uncommon and can be subtle. Additionally, because of the high prevalence of pediatric vitamin D insufficiency, it is commonly identified in young children with fractures. However, the majority of pediatric fractures are caused by trauma to healthy bones. Some, especially in infants and toddlers, are caused by non-accidental trauma. A small percentage is related to medical disease, including those associated with disorders of collagen, disorders of mineralization, and non-fracture mimics. Despite the scientific evidence, among disorders of mineralization, non-rachitic disorders of vitamin D have become a popular non-scientific theory to explain the fractures identified in abused children. Although infants and young children with rickets can fracture bones, the vast majority of fractures identified in abused infants are not caused by bone disease. Here we present a review of the literature on bone disease in the setting of accidental and non-accidental trauma. This context can help physicians remain vigilant about identifying vulnerable young children whose injuries are caused by non-accidental trauma.

Evaluation of vitamin D status bone mineral density and dental health in children with cholestasis

BACKGROUND

Hepatic osteodystrophy caused by vitamin D and calcium malabsorption is thought to develop in children with cholestatic liver disease leading to secondary hyperparathyroidism and rickets or osteomalacia. The aim of this study was to evaluate the dental and bone mineral densities and the serum level of vitamin D in cholestatic infants and children and to correlate this process with clinical and laboratory parameters.

METHODS

This is a cross-sectional study that include 50 patients presenting with cholestasis. Thirty age and sex matched controls recruited not complaining of liver disease. All cases were subjected to full history taking, clinical and dental examination, 25(OH)D level, ALT, AST, bilirubin, albumin, GGT, alkaline phosphatase, PT, INR, calcium, corrected calcium, phosphorus and DXA scan to those above 5 years old. Controls were subjected to measuring the serum levels of 25(OH)D, total bilirubin, direct bilirubin, ALT, GGT, AST, PT, INR, alkaline phosphatase, albumin, calcium and phosphorus.

RESULTS

Out of the 50 cases; 23 were females (46%), with a mean age of 6.17±3.9 years ranging from 1.1 to 17 years. Twenty-eight of the cases had signs of rickets (56%), 6 of them had bone fracture (12%) and 42.8% had milky teeth caries. The level of 25(OH) vitamin D was below normal range in around half of the patients. There was significant difference between cases and controls in calcium and phosphorus levels, ALT and alkaline phosphatase. Low bone mineral density (BMD) was present in 50% and 5 cases (17.9%) were diagnosed as having osteoporosis. There was a negative correlation between the Z-score, BMD of total body, BMD and bone mineral content (BMC) of spine and total and direct bilirubin. There was a positive correlation between (BMD of total body, spine and BMC of spine) and serum phosphorus, alkaline phosphatase and albumin. There was a positive correlation between the Z-score of total body and serum calcium.

CONCLUSION

Decreased level of 25-OH vitamin D is present in more than half of cholestatic patients, and is correlated positively to serum calcium. Decreased BMD was present in more than half of studied cholestatic patients correlated to the low serum calcium rather than the vitamin D level. The decreased BMD and the dental affection in cholestatic children is related to the level of hyperbilirubinemia.

Spiral Fracture in Young Infant Causing a Diagnostic Dilemma: Nutritional Rickets versus Child Abuse

Fractures are uncommon in young, nonambulatory infants. The differential diagnosis includes nonaccidental injury (NAI) and metabolic bone disease, including rickets. While rickets typically present after six months of age, multiple cases have been reported in younger infants. We report a case of an 11-week-old male infant who presented with a spiral fracture of the humerus and no radiologic evidence of rickets. A detailed psychosocial assessment failed to reveal any risk factors for NAI. The patient had elevated alkaline phosphatase and PTH with low 25 hydroxyvitamin D and 1,25 dihydroxyvitamin D levels. Additionally, the mother was noncompliant with prenatal vitamins, exclusively breastfeeding without vitamin D supplementation, and had markedly low vitamin D levels 15 weeks postpartum. The biochemical data and history were consistent with rickets. Given the diagnostic dilemma, the working diagnosis was rickets and the patient was started on ergocalciferol with subsequent normalization of his laboratory values and healing of the fracture. These findings are consistent with nutritional rickets largely due to maternal-fetal hypovitaminosis D. This case highlights that in young infants rickets should be considered even in the absence of positive radiologic findings. Additionally, it illustrates the importance of maintaining adequate vitamin D supplementation during pregnancy and early infancy.

Human Milk and Allergic Diseases: An Unsolved Puzzle

There is conflicting evidence on the protective role of breastfeeding in relation to the development of allergic sensitisation and allergic disease. Studies vary in methodology and definition of outcomes, which lead to considerable heterogeneity. Human milk composition varies both within and between individuals, which may partially explain conflicting data. It is known that human milk composition is very complex and contains variable levels of immune active molecules, oligosaccharides, metabolites, vitamins and other nutrients and microbial content. Existing evidence suggests that modulation of human breast milk composition has potential for preventing allergic diseases in early life. In this review, we discuss associations between breastfeeding/human milk composition and allergy development.

Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia

Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.

Vitamin D status in abused and nonabused children younger than 2 years old with fractures

OBJECTIVE

To examine vitamin D levels in children with (1) suspected abusive and accidental fractures, (2) single and multiple fractures, and (3) fracture types highly associated with inflicted trauma.

DESIGN AND METHODS

A study of children younger than 2 years of age with fractures admitted to a large children's hospital was performed. Bivariate analysis and test for trend were performed to test for the association of vitamin D status and biochemical markers of bone health with the primary outcomes of fracture etiology, number, and type.

RESULTS

Of 118 subjects in the study, 8% had deficient vitamin D levels (<20 ng/mL; <50 nmol/L), 31% were insufficient (≥20 < 30 ng/mL; ≥50 < 78 nmol/L), and 61% were sufficient (≥30 ng/mL; ≥78 nmol/L). Lower vitamin D levels were associated with higher incidences of hypocalcemia (P = .002) and elevated alkaline phosphatase (P = .05) but not hypophosphatemia (P = .30). The majority of children sustained accidental fractures (60%); 31% were nonaccidental and 9% were indeterminate. There was no association between vitamin D levels and any of the following outcomes: child abuse diagnosis (P = .32), multiple fractures (P = .24), rib fractures (P = .16), or metaphyseal fractures (P = .49).

CONCLUSIONS

Vitamin D insufficiency was common in young children with fractures but was not more common than in previously studied healthy children. Vitamin D insufficiency was not associated with multiple fractures or diagnosis of child abuse. Nonaccidental trauma remains the most common cause of multiple fractures in young children.

Modern India and the vitamin D dilemma: evidence for the need of a national food fortification program

India is located between 8.4 and 37.6 degrees N latitude with the majority of its population living in regions experiencing ample sunlight throughout the year. Historically, Indians obtained most of their vitamin D through adequate sun exposure; however, darker skin pigmentation and the changes which have accompanied India's modernization, including increased hours spent working indoors and pollution, limit sun exposure for many. Inadequate sun exposure results in reduced vitamin D synthesis and ultimately poor vitamin D status if not compensated by dietary intake. Dietary vitamin D intake is very low in India because of low consumption of vitamin D rich foods, absence of fortification and low use of supplements. All these factors contribute to poor vitamin D status as measured by low circulating levels of 25-hydroxy vitamin D. Our review searches the published literature specific to India for evidence that would confirm the need to fortify food staples with vitamin D or stimulate public health policies for vitamin D supplementation and dietary guidelines tailored to the Indian diet. This review documents findings of widespread vitamin D deficiency in Indian populations in higher and lower socioeconomic strata, in all age groups, in both genders and people in various professions. Moreover, poor vitamin D status in India is accompanied by increased bone disorders including osteoporosis, osteomalacia in adults and rickets and other bone deformities in children. Without a concerted national effort to screen for vitamin D status, to implement policies or guidelines for vitamin D fortification and/or supplementation and to re-assess recommended dietary intake guidelines, dramatic increase in the number of bone disorders and other diseases may lie ahead.

Prevention of rickets and vitamin D deficiency in infants, children, and adolescents

Rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continues to be reported in the United States. There are also concerns for vitamin D deficiency in older children and adolescents. Because there are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase the risk of skin cancer, the recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed and older children and adolescents. It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. The current recommendation replaces the previous recommendation of a minimum daily intake of 200 IU/day of vitamin D supplementation beginning in the first 2 months after birth and continuing through adolescence. These revised guidelines for vitamin D intake for healthy infants, children, and adolescents are based on evidence from new clinical trials and the historical precedence of safely giving 400 IU of vitamin D per day in the pediatric and adolescent population. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer. The new data may eventually refine what constitutes vitamin D sufficiency or deficiency.

Apparent efficacy of food-based calcium supplementation in preventing rickets in Bangladesh

To determine whether increased Ca intakes can prevent rickets in a susceptible group of children living in a rickets-endemic area of Bangladesh, we conducted a 13-month long, double-blind, clinical trial with 1-to 5-year-old children who did not present with rickets but ranked in the upper decile of plasma alkaline phosphatase (AP) activity of a screening cohort of 1,749 children. A total of 158 children were randomized to a milk-powder-based dietary supplement given daily, 6 days/week, and providing either 50, 250, or 500 mg Ca, or 500 mg Ca plus multivitamins, iron, and zinc. Upon initial screening, 194 healthy children presented with no rachitic leg signs and had serum AP in the upper decile (>260 u/dl) of the cohort. When 183 of those subjects were re-screened after a 7-month pre-trial period, 23 (12.6%) had developed rachitic leg signs, suggesting an annual risk of 21.5% in this cohort. Of those still not presenting with leg signs and completing 13 months of dietary intervention, none showed rachitic leg signs, none showed significant radiological evidence of active rickets, and all showed carpal ossification normal for age after that intervention. These results are consistent with even the lowest amount of supplemental Ca (50 mg/day) being useful in supporting normal bone development in this high-risk population.

Scurvy and rickets masked by chronic neurologic illness: revisiting "psychologic malnutrition"

The North American epidemic of overeating, combined with a sedentary lifestyle, has led to a growing prevalence of obesity, diabetes, and the "metabolic syndrome" in children. Excessive caloric intake does not imply adequate nutrition, and vitamin-deficiency syndromes still occur in some American children. Here we describe cases of scurvy and vitamin D deficiency in 2 children with cognitive disorders. Thorough dietary histories suggested the diagnosis in each patient and, had they been obtained at presentation, would likely have obviated invasive diagnostic workup, unnecessary stress to the patients and their families, and significant functional disability. Overnutrition and malnutrition may coexist, particularly among those with abnormal cognition or autistic spectrum disorders. Classic nutritional deficiencies must not be omitted from the differential diagnosis. A comprehensive dietary history and screening for vitamin deficiencies in at-risk children are important aspects of preventive health care and are essential for prompt diagnosis and treatment.

Vitamin D levels in children of asylum seekers in The Netherlands in relation to season and dietary intake

Low dietary intake and limited sun exposure during Dutch winters, in particular when combined with highly pigmented skin, could compromise the vitamin D status of asylum seekers' children in The Netherlands. We determined the vitamin D status of children living in The Netherlands, but originating from Africa, Central Asia, or Eastern Europe. In a subgroup, we reassessed the vitamin D status after the summer, during which the children had been assigned at random to remain unsupplemented or to receive vitamin D supplementation. In total 112 children (median age 7.1 yr, range 2-12 yr) were assessed for serum concentrations of 25-Hydroxyvitamin D [25(OH)D], intact parathyroid hormone (I-PTH) and plasma alkaline phosphatase (ALP). Vitamin D deficiency (VDD) and hypovitaminosis D were defined as 25(OH)D below 30 or 50 nmol/L, respectively. Dietary intake of vitamin D and calcium was estimated using a 24 h recall interview. In mid-spring, 13% of the children had VDD, and 42% had hypovitaminosis D. I-PTH and ALP levels were significantly higher in children with VDD. The dietary intake of vitamin D was below 80% of the recommended daily allowances (RDA) in 94% of the children, but the dietary calcium intake was not significantly related to the s-25(OH)D levels found. After the summer, median s-25(OH)D increased with +35 nmol/L (+85%) and +19 nmol/L (+42%) in children with or without supplementation, respectively. The effect of supplementation was most prominent among African children. VDD and hypovitaminosis D are highly prevalent in mid-spring among asylum seekers' children in The Netherlands. Although 25(OH)D levels increase in African children during Dutch summer months, this does not completely correct the compromised vitamin D status. Our data indicate that children from African origin would benefit from vitamin D supplementation.

High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates

In utero or early-life vitamin D deficiency is associated with skeletal problems, type 1 diabetes, and schizophrenia, but the prevalence of vitamin D deficiency in U.S. pregnant women is unexplored. We sought to assess vitamin D status of pregnant women and their neonates residing in Pittsburgh by race and season. Serum 25-hydroxyvitamin D (25(OH)D) was measured at 4-21 wk gestation and predelivery in 200 white and 200 black pregnant women and in cord blood of their neonates. Over 90% of women used prenatal vitamins. Women and neonates were classified as vitamin D deficient [25(OH)D<37.5 nmol/L], insufficient [25(OH)D 37.5-80 nmol/L], or sufficient [25(OH)D>80 nmol/L]. At delivery, vitamin D deficiency and insufficiency occurred in 29.2% and 54.1% of black women and 45.6% and 46.8% black neonates, respectively. Five percent and 42.1% of white women and 9.7% and 56.4% of white neonates were vitamin D deficient and insufficient, respectively. Results were similar at <22 wk gestation. After adjustment for prepregnancy BMI and periconceptional multivitamin use, black women had a smaller mean increase in maternal 25(OH)D compared with white women from winter to summer (16.0+/-3.3 nmol/L vs. 23.2+/-3.7 nmol/L) and from spring to summer (13.2+/-3.0 nmol/L vs. 27.6+/-4.7 nmol/L) (P<0.01). These results suggest that black and white pregnant women and neonates residing in the northern US are at high risk of vitamin D insufficiency, even when mothers are compliant with prenatal vitamins. Higher-dose supplementation is needed to improve maternal and neonatal vitamin D nutriture.

Advances in the diagnosis and treatment of osteoporosis

Although severely low bone density is relatively rare in the pediatric population, it can be a significant problem in many patients with chronic illness. As peak bone formation occurs during adolescence, it is crucial that pediatricians and other care providers for this patient population recognize the significance of attainment of adequate bone. Dietary intake of vitamin D and calcium should be optimized, and correction of underlying causes of poor bone density should occur whenever possible. Assessment of bone density is difficult, as each technology available has problems, and none of the technologies are well-associated with fracture risk in pediatric patients. Once diagnosis of severely low bone density is established, treatment options are limited and poorly studied. The benefits of bisphosphonate therapy appear to outweigh the risks in patients with low bone density and frequent fragility fractures, and it appears that most improvement with bisphosphonates occurs within the first 2 to 4 years. Evidence, however, is emerging that once off therapy, bone turnover remains decreased for at least several years. During that time, improvements in bone density are decreased. Many questions remain regarding duration of therapy with bisphosphonate therapy and the long-term effects on the children who receive this medication. Anabolic therapies may become important in the future, but there is currently extremely limited information regarding their use in pediatrics.

Shedding light on hypovitaminosis D and rickets

The recent resurgence of the ancient disease of vitamin D deficiency rickets and the widespread presence of hypovitaminosis D across the age spectrum pose significant challenges for today's clinicians. Furthermore, new research into previously unsuspected actions of vitamin D in multiple cell systems offer the possibility that vitamin D will play an increasingly important role in our understanding of a wide variety of disease states.

Vitamin D deficiency in breastfed infants in Iowa

OBJECTIVE

The purpose of this work was to assess the vitamin D status of breastfed infants living in Iowa (latitude: 41 degrees N).

METHODS

Blood samples and dietary records from 84 breastfed infants participating in another study were used for a survey of vitamin D status at 280 days of age. The vitamin D status of those (35 infants) who did not receive preformed vitamin D at 280 days of age (unsupplemented infants) was assessed longitudinally between 112 days and 15 months of age. Plasma 25-hydroxyvitamin D and, in most cases, parathyroid hormone and alkaline phosphatase were determined.

RESULTS

At 280 days of age, 10% of breastfed infants were vitamin D deficient (25-hydroxyvitamin D < 11 ng/mL). Deficiency was significantly more prevalent among dark-skinned infants and during winter and occurred exclusively in unsupplemented infants. During winter, 78% of unsupplemented infants were vitamin D deficient. During summer, only 1 infant who had dark skin pigmentation was vitamin D deficient. Longitudinal assessment of unsupplemented infants similarly showed that the majority of breastfed infants were vitamin D deficient during winter. Severe deficiency (25-hydroxyvitamin D < 5 ng/mL) was common and was accompanied by elevation of parathyroid hormone and alkaline phosphatase. The prevalence of vitamin D deficiency decreased with age but was still 12% at 15 months of age if no preformed vitamin D was received.

CONCLUSIONS

Vitamin D deficiency, including severe deficiency, was common among breastfed infants in Iowa who did not receive preformed vitamin D. Deficiency occurred mostly during winter but was not completely absent during summer. It affected infants with light as well as dark skin pigmentation. Consumption of preformed vitamin D from vitamin supplements or formula is effective in preventing vitamin D deficiency. Vitamin D supplementation should be provided to all breastfed infants.

Nutritional rickets around the world: causes and future directions

INTRODUCTION

Nutritional rickets has been described from at least 59 countries in the last 20 years. Its spectrum of causes differs in different regions of the world.

METHODS

We conducted a systematic review of articles on nutritional rickets from various geographical regions published in the last 20 years. We extracted information about the prevalence and causes of rickets.

RESULTS

Calcium deficiency is the major cause of rickets in Africa and some parts of tropical Asia, but is being recognised increasingly in other parts of the world. A resurgence of vitamin D deficiency has been observed in North America and Europe. Vitamin D-deficiency rickets usually presents in the 1st 18 months of life, whereas calcium deficiency typically presents after weaning and often after the 2nd year. Few studies of rickets in developing countries report values of 25(OH)D to permit distinguishing vitamin D from calcium deficiency.

CONCLUSIONS

Rickets exists along a spectrum ranging from isolated vitamin D deficiency to isolated calcium deficiency. Along the spectrum, it is likely that relative deficiencies of calcium and vitamin D interact with genetic and/or environmental factors to stimulate the development of rickets. Vitamin D supplementation alone might not prevent or treat rickets in populations with limited calcium intake.

The Chakaria food system study: household-level, case-control study to identify risk factor for rickets in Bangladesh

OBJECTIVE

A comprehensive, multiround survey of local food systems in a rickets-endemic area of Bangladesh was conducted to identify household-level risk factors for rickets.

DESIGN

A household-level, case-control study was conducted in a rickets-endemic area, Chakaria, with planned comparisons between households with one or more rachitic child and neighboring households with no affected children.

SETTING

A rickets-endemic area of southeastern Bangladesh, Chakaria.

SUBJECTS AND METHODS

An interview-based survey was conducted in six villages in Chakaria with 199 households with at least one child showing physical signs consistent with rickets and 281 households with no affected children.

RESULTS

Households with rachitic children in Chakaria had more children, more pregnant or lactating women, and fewer adults than unaffected households in that community. Affected households tended to rely on farming for their livelihood and tended to have less economic activity as indicated by less outstanding debt than their neighbors. Households with rickets were at significantly greater risk of pneumonia than were other households. Calcium undernutrition was severe and widespread in Chakaria due to a food system that offered very little of the element in accessible forms. Household diets were based on cereals and starchy vegetables. Rice and fish constituted the major source of calcium for most households, although dairy products, when used, were very important calcium sources, particularly for young children. In fact, the use of dairy products was the only household choice that led to substantial increases in the calcium intakes of children, and households that used dairy products tended to show increased calcium intakes for all of their members.

CONCLUSIONS

The risk of a Chakarian household having a child with rickets appeared to be related to its economic status. Although this might be expected to be manifest as limitations in food access and/or use, rickets households failed to show a dietary pattern associated with rickets. Calcium undernutrition was prevalent and, thus, would appear to be a predisposing factor for rickets; however, calcium undernutrition was prevalent in Chakarian households with and without rickets. Therefore, it is probable that another precipitating factor(s) play a role(s) in the etiology of rickets in Chakaria.

Pediatric hypocalcemic seizures: a case of rickets

Although cases of Vitamin D-deficient Rickets have declined since the Industrial Revolution, certain populations remain at risk. Risk factors for developing vitamin D-deficient Rickets include breast-feeding without formula or vitamin supplementation, very dark skin and inadequate exposure to sunlight. We describe a case of Rickets in a breastfed infant with dark skin who presented with hypocalcemic seizures. The pathophysiology of Rickets is briefly described along with the emergency management of infants presenting with hypocalcemic seizure.

Vitamin D insufficiency in North America

Vitamin D insufficiency is a term that has been used to describe the finding of biochemical evidence of deficiency, without obvious clinical signs or symptoms, such as rickets or osteomalacia. The condition is most commonly diagnosed by a serum 25-hydroxyvitamin D below 40 nmol/L (16 microg/L). This paper reviews North American studies addressing the prevalence of the problem, and the growing body of evidence that vitamin D insufficiency predisposes individuals to poor bone and muscle health. The term insufficiency is somewhat misleading, as patients with this condition are really just part of the spectrum of vitamin D deficiency. If the more generous definition of this condition is used (serum 25-hydroxyvitamin D < 80 nmol/L), a much larger proportion of the population has the problem. The response to vitamin D supplementation in clinical trials suggests current recommendations for dietary intake of this vitamin are too low and that a higher adequate intake should be recommended.

Issues in establishing vitamin D recommendations for infants and children

In 1963, the American Academy of Pediatrics Committee on Nutrition recommended 400 IU of vitamin D per day for all infants and children. After the late 1970s, this became an inconsistent recommendation, particularly for breast-feeding infants. In 2003, however, the Committee on Nutrition of the American Academy of Pediatrics recommended 200 IU/d vitamin D for all infants and children. This was in response to the vitamin D adequate intake recommendations made by the Institute of Medicine in 1997, the increasing number of reports of nutritional rickets in certain populations of American infants, and the Healthy People 2010 goal of having 75% of infants breast-fed for the first 6 mo of life. In making these recommendations, many issues were taken into consideration, including the following. 1) Vitamin D deficiency is more than rickets, which is the final stage of the deficient state among growing children. 2) Adequate sunlight exposure cannot be determined exactly for every subject. 3) There is new awareness of the hazards of ultraviolet-B light exposure in childhood and the subsequent development of skin cancer in adulthood. 4) There is decreasing intake of vitamin D-fortified foods among older children and adolescents. More research is needed in the pediatric population to determine the recommended dietary allowance of vitamin D. A new definition of vitamin D deficiency that would make use of normal serum concentrations of 25-hydroxyvitamin D3 in a given population is needed. The recommended intake of 200 IU/d may not be enough. More data are needed to support the adequacy of the present and possibly even higher recommended vitamin D daily intakes.

Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003

Reports of hypovitaminosis D among adults in the United States have drawn attention to the vitamin D status of children. National data on hypovitaminosis D among children are not yet available. Reports from 2000 and 2001 of rickets among children living in North Carolina, Texas, Georgia, and the mid-Atlantic region, however, confirmed the presence of vitamin D deficiency among some US children and prompted new clinical guidelines to prevent its occurrence. We reviewed reports of nutritional rickets among US children <18 y of age that were published between 1986 and 2003. We identified 166 cases of rickets in 22 published studies. Patients were 4-54 mo of age, although in 17 studies the maximal age was <30 mo. Approximately 83% of children with rickets were described as African American or black, and 96% were breast-fed. Among children who were breast-fed, only 5% of records indicated vitamin D supplementation during breast-feeding. The American Academy of Pediatrics (AAP) recently recommended a minimal intake of 200 IU/d vitamin D for all infants, beginning in the first 2 mo of life. AAP recommends a vitamin D supplement for breast-fed infants who do not consume at least 500 mL of a vitamin D-fortified beverage. Given our finding of a disproportionate number of rickets cases among young, breast-fed, black children, we recommend that education regarding AAP guidelines emphasize the higher risk of rickets among these children. Education should also emphasize the importance of weaning children to a diet adequate in both vitamin D and calcium.

Variable presentations of rickets in children in the emergency department

Vitamin D-deficient rickets is uncommon but becoming more prevalent in the pediatric population likely related to increases in breast-feeding. It should be considered in many clinical situations. We present 3 cases of rickets presenting acutely to the emergency department. Their presentations included a fracture concerning for child abuse, tetany, and hypocalcemic seizures. In all cases, laboratory and radiographic evaluations were consistent with the diagnosis of nutritional rickets and their symptoms were related to rickets resolved with appropriate treatment. Although uncommon, vitamin D-deficient rickets should be considered in children with the above presentations.

Secondary prevention of vitamin D-deficiency rickets

Reports of vitamin D-deficiency rickets and its associated morbidity continue among inadequately supplemented, dark-skinned breastfed infants. Despite the new vitamin D dietary guidelines, there remain significant numbers of unsupplemented breastfed infants. Here we report a case of subclinical vitamin D-deficiency rickets. This patient had biochemical and radiographic but not clinical evidence for rickets. We propose a new step of screening high-risk infants for subclinical rickets using wrist films paired with 25-hydroxyvitamin D levels.

A comparison of breastfed children with nutritional rickets who present during and after the first year of life

This study compares the patient characteristics of breastfed children in Baltimore, Maryland from 1990 to 2000 diagnosed with nutritional rickets at 12 months or younger to those older than 12 months to gain a better understanding of nutritional and environmental factors. All 30 of the patients were African American. Patients 12 months or younger (n=15) compared to those older than 12 months (n=15) were more likely to be born during the summer and to present with seizures and hypocalcemia. We recommend vitamin D supplementation of all breastfed infants at an early age and that supplementation continue throughout the duration of breastfeeding.

Radiological and biochemical resolution of nutritional rickets with calcium

AIMS

To determine the response to oral calcium in Nigerian children with rickets.

METHODS

In a teaching hospital in Western Nigeria, 26 children (13 boys, 13 girls, aged 2-5 years) with confirmed rickets received calcium lactate (2.7 g/day).

RESULTS

Within one month of treatment leg pain was relieved and the children were more active. The mean x ray score improved from 3.3 at baseline to 1.7 at three months and 0.9 at six months (arbitrary scoring system, 0-6). Twelve cases were healed radiologically after six months, 11 others improved considerably, two showed no significant improvement, and a non-compliant patient was worse. There was progressive reversal of biochemical features. Median plasma alkaline phosphatase fell from 519 (range 178-1078) to 283 (209-443) IU/l (p = 0.04) in four months, while mean 1,25-dihydroxyvitamin D fell from 473 (251-1057) to 281 (155-481) pmol/l (p = 0.04), and mean plasma calcium increased from 2.26 (1.63-2.54) to 2.37 (2.06-2.54) mmol/l (p = 0.13). Parathyroid hormone fell from 5.3 (0.4-21.5) to 1.7 (0.45-7.4) pmol/l. Type I collagen carboxy terminal cross linked telopeptide was very high at baseline (20 (7.2-103) to 14 (11-24) micro g/l) (p = 0.03) and fell promptly to normal.

CONCLUSION

Calcium supplementation alone effected healing of rickets in most of these Nigerian children and may provide sufficient treatment in this environment.

[Nutritional rickets in childhood: analysis of 62 cases]

BACKGROUND AND OBJECTIVE

Until recently, rickets secondary to vitamin D deficiency was considered a medical oddity rather than a clinical reality in Catalonia (Spain). However, recent data show a reemergence of the disease in the infancy.

PATIENTS AND METHOD

Retrospective clinical survey of epidemiologic and clinical features of infants and children (34 boys and 28 girls) diagnosed of nutritional rickets in pediatric departments of Catalonia (Spain) over the last 10 years.

RESULTS

Mean age (SD) at diagnosis was 9.9 (7) months (range: 3-36), 35.5% were under 6 months. Race distribution: blacks 61.3%, dark-skinned 36%; white 6.4%. Country of origin: Sub-Saharan Africa 59.7%, Morocco 33.9%, Catalonia 3.2%, Pakistan 1.6%. Seasonal distribution: 60% were diagnosed in autumn and winter. At diagnosis, 72% were following an exclusive milk diet (48% maternal milk alone) without vitamin D supplementation. Most common clinical presentation in infants under 6 months was: hypocalcemic tetany/seizures; in children aged 6-12 months: failure to thrive; and in children over 12 months: skeletal deformities. Weight and height expressed as z-score value at diagnosis was 0.67 and 0.91, respectively.

CONCLUSIONS

Nutritional rickets is a current reality in Catalonia and it mainly affects immigrant infants and children from Sub-Saharan Africa and Morocco, black or dark-skinned, fed with maternal milk alone, without vitamin D supplementation and with little sun exposure. Systematic, preventive supplementation with vitamin D is essential in these populations.

Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake

Rickets in infants attributable to inadequate vitamin D intake and decreased exposure to sunlight continues to be reported in the United States. It is recommended that all infants, including those who are exclusively breastfed, have a minimum intake of 200 IU of vitamin D per day beginning during the first 2 months of life. In addition, it is recommended that an intake of 200 IU of vitamin D per day be continued throughout childhood and adolescence, because adequate sunlight exposure is not easily determined for a given individual. These new vitamin D intake guidelines for healthy infants and children are based on the recommendations of the National Academy of Sciences.

Hypocalcemia in children: pathogenesis and management

Hypocalcemia can be devastating if unrecognized. Neuromuscular dysfunction occurs in severe cases. A review and an update on the topic may assist general pediatricians. The authors provide a general overview of pathogenesis and management of hypocalcemia in children.

Nutritional rickets in African American breast-fed infants

OBJECTIVE

To analyze the characteristics of infants and children diagnosed with nutritional rickets at two medical centers in North Carolina in the 1990s.

STUDY DESIGN

The physical and radiographic findings, calcium, phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D levels of infants and children diagnosed with nutritional rickets at two medical centers were reviewed. Breast-feeding data were obtained from the North Carolina Women, Infants and Children Program (WIC).

RESULTS

Thirty patients with nutritional rickets were first seen between 1990 and June of 1999. Over half of the cases occurred in 1998 and the first half of 1999. All patients were African American children who were breast fed without receiving supplemental vitamin D. The average duration of breast-feeding was 12.5 months. The age at diagnosis was 5 to 25 months, with a median age of 15.5 months. Growth failure was common: length was <5th percentile in 65% of cases, and weight was <5th percentile in 43%.

CONCLUSION

Factors that may have contributed to the increase in referrals of children with nutritional rickets include more African American women breast-feeding, fewer infants receiving vitamin D supplements, and mothers and children exposed to less sunlight. We recommend that all dark-skinned breast-fed infants and children receive vitamin D supplementation.