Variable presentations of rickets in children in the emergency department

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

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.

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.

Eight-year-old Boy with New-onset Seizure

An eight-year-old boy presented to the emergency department for a first-time seizure. The patient had only signs of mild dehydration on physical exam and had an uneventful postictal recovery. First-time seizures in pediatric patients are often benign and require only an outpatient workup; some are dangerous. This case takes the reader through the differential diagnosis and systematic work-up of new-onset pediatric seizures, leading to an unanticipated diagnosis.

Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

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.

Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

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.

Vitamin D and skeletal health in infancy and childhood

During growth, severe vitamin D deficiency in childhood can result in symptomatic hypocalcaemia and rickets. Despite the suggestion from some studies of a secular increase in the incidence of rickets, this observation may be driven more by changes in population demographics than a true alteration to age, sex and ethnicity-specific incidence rates; indeed, rickets remains uncommon overall and is rarely seen in fair-skinned children. Additionally, the impact of less severe vitamin D deficiency and insufficiency has received much interest in recent years, and in this review, we consider the evidence relating vitamin D status to fracture risk and bone mineral density (BMD) in childhood and adolescence. We conclude that there is insufficient evidence to support the suggestion that low serum 25-hydroxyvitamin D [25(OH)D] increases childhood fracture risk. Overall, the relationship between 25(OH)D and BMD is inconsistent across studies and across skeletal sites within the same study; however, there is evidence to suggest that vitamin D supplementation in children with the lowest levels of 25(OH)D might improve BMD. High-quality randomised trials are now required to confirm this benefit.

Does low vitamin D have a role in pediatric morbidity and mortality? An observational study of vitamin D in a cohort of 52 postmortem examinations

Vitamin D is required for calcium absorption and normal bone mineralization; it has a key role in immune regulation against infections and is believed to be involved in immunomodulation in asthma. We did a retrospective analysis of 52 postmortem cases (aged 2 days to 10 years). Seventeen children had vitamin D deficiency (<25 nmol/L); 24 children had vitamin D insufficiency (25-49 nmol/L); 10 children had suboptimal vitamin D levels (50-79 nmol/L); and only 1 child had adequate levels (≥80 nmol/L). Three infants had fractures. Growth plate histology was abnormal in 10 cases with vitamin D deficiency (59%), but radiology was abnormal in only 3 of those cases. Eight infants (33%) with vitamin D insufficiency had abnormal histology, but radiology was normal in all cases. In 3 children hypocalcemia due to vitamin D deficiency was considered accountable for death; they all showed radiological and histological rickets: 2 babies had cardiomyopathy and a 3-year-old had hypocalcemic seizures. Children from all ethnic groups had a high proportion of low vitamin D levels. Vitamin D deficiency (the most common form of pediatric metabolic bone disease) is preventable and treatable. Profound hypocalcemia due to severe vitamin D deficiency can cause unexpected death in babies and young children. Measuring serum vitamin D levels postmortem may provide invaluable information on sudden unexplained death in 'at-risk' children. Vitamin D deficiency may be relevant in childhood asthma and in children with multiple infections and babies with bone fractures. Postmortem vitamin D levels are stable and easy to measure.

Trampoline related injuries in children: risk factors and radiographic findings

BACKGROUND

Backyard trampolines are immensely popular among children, but are associated with an increase of trampoline-related injuries. The aim of this study was to evaluate radiographs of children with trampoline related injuries and to determine the risk factors.

METHODS

Between 2003 and 2009, 286 children under the age of 16 with backyard trampoline injuries were included in the study. The number of injuries increased from 13 patients in 2003 to 86 in 2009. The median age of the 286 patients was 7 years (range: 1-15 years). Totally 140 (49%) patients were males, and 146 (51%) females. Medical records and all available diagnostic imaging were reviewed. A questionnaire was sent to the parents to evaluate the circumstances of each injury, the type of trampoline, the protection equipment and the experience of the children using the trampoline. The study was approved by the Institutional Ethics Committee of the University Hospital of Bern.

RESULTS

The questionnaires and radiographs of the 104 patients were available for evaluation. A fracture was sustained in 51 of the 104 patients. More than 75% of all patients sustaining injuries and in 90% of patients with fractures were jumping on the trampoline with other children at the time of the accident. The most common fractures were supracondylar humeral fractures (29%) and forearm fractures (25%). Fractures of the proximal tibia occurred especially in younger children between 2-5 years of age.

CONCLUSIONS

Children younger than 5 years old are at risk for specific proximal tibia fractures ("Trampoline Fracture"). A child jumping simultaneously with other children has a higher risk of suffering from a fracture.

Prevalence of vitamin D insufficiency in Swiss teenagers with appendicular fractures: a prospective study of 100 cases

BACKGROUND

The significance of subclinical vitamin D deficiency in the pathogenesis of fractures in children and adolescents currently remains unclear.

OBJECTIVE

We aimed to determine the prevalence of vitamin D insufficiency and its effect on bone mineral density (BMD) and bone mineral content (BMC) values in a collective of Swiss Caucasian children with a first episode of appendicular fracture.

DESIGN AND METHODS

One hundred teenagers with a first episode of appendicular fracture [50 upper limb fractures (group 1) and 50 lower limb fractures (group 2)] and 50 healthy controls (group 3) were recruited into a cross-sectional study. The BMC and BMD values were measured by dual-energy X-ray absorptiometry, and serum 25 hydroxyvitamin D [25(OH)D] was assessed by electrochemiluminescence immunoassays.

RESULTS

From the 100 injured teenagers in the study, 12 % had deficient vitamin D levels (<20 ng/mL; <50 nmol/L) and 36 % had insufficient levels (≥20 <30 ng/mL; ≥50 <78 nmol/L), whereas 6 and 34 % of healthy controls were, respectively, vitamin D deficient and insufficient. There were no significant differences for serum 25(OH)D levels, L2-L4 BMD Z-score, and L2-L4 BMC Z-score variables (p = 0.216) between the three groups nor for the calcaneal BMD Z-score variables (p = 0.278) between healthy controls and lower limb fracture victims. Investigations on the influences of serum 25(OH)D on BMD and BMC showed no correlation between serum 25(OH)D and L2-L4 BMD Z-scores (r = -0.15; p = 0.135), whereas low but significant inverse correlations were, surprisingly, detected between serum 25(OH)D and calcaneal BMD Z-scores (r = -0.21; p = 0.034) and between serum 25(OH)D and L2-L4 BMC Z-scores (r = -0.22; p = 0.029).

CONCLUSIONS

A significant proportion of Swiss Caucasian teenagers were vitamin D insufficient, independent of limb fracture status, in our study. However, this study failed to show an influence of low vitamin D status on BMD and/or BMC of the lumbar spine and heel.

Incidental Rickets in the Emergency Department Setting

Vitamin D deficiency rickets is a childhood osteomalacia, with impaired skeletal development and potentially skeletal deformities. The radiographic findings of rickets are many but include widening, fraying, and cupping of the metaphysis. Developmental delay and related complications of seizure and tetany have also been reported. This medical entity is often thought of as a classic medical disease of the past. However, it persists, and the recognition of rickets is on the rise. The reemergence of rickets correlates with the increase in the number of children exclusively breastfed and with the frequent use of sun block in the pediatric population. We present two cases of rickets, diagnosed through a visit to the Emergency Department made for unrelated symptoms. These two cases illustrate the importance of diagnosing rickets as an “incidental” finding. With early detection, dietary supplementation can be initiated potentially sparing the patient symptomatic disease.

Forearm fractures in children and bone health

PURPOSE OF REVIEW

Summary highlighting the evidence that bone health may affect forearm fracture risk in children.

RECENT FINDINGS

Although the incidence of other fractures and injuries are decreasing, the incidence of forearm fractures is increasing in otherwise healthy children. There is a growing volume of research that forearm fracture risk in children may be related to deficiencies in parameters of bone health. Available evidence of this relationship was summarized and included direct links to bone health (measurement of bone properties), indirect links to bone health (diet, vitamin D status, BMI), and genetic analyses.

SUMMARY

There is consistent and convincing evidence of an association between bone mineral density and forearm fracture risk in children. Studies of calcium intake and supplementation are less extensive in scope but suggest that effects of calcium deficiency on the radius may contribute to childhood forearm fracture risk. Forearm fracture risk in obese children is likely to reflect a combination of suboptimal bone health status and behavioral characteristics. Published data on the role of vitamin D status and genetic factors are limited but merit further consideration. Further investigation is needed to better understand the factors contributing to forearm fracture risk in children and translate this knowledge into effective clinical prevention and practice.

Prevalence of vitamin D insufficiency in African American children with forearm fractures: a preliminary study

OBJECTIVES

Forearm fractures account for a significant proportion of childhood injuries and seem to be increasing in incidence. Poor vitamin D status increases overall fracture risk in infants with rickets and adults with osteoporosis. Children with vitamin D insufficiency (serum 25-hydroxy vitamin D level <20 ng/mL) have decreased bone mineral density (BMD) compared with children having normal vitamin D status. The relationship between vitamin D status and childhood forearm fracture has not been investigated.

METHODS

This prospective study enrolled African American children, aged 5 to 9 years, with a forearm fracture. Bone health evaluation included measurement of serum 25-hydroxy vitamin D level and BMD by dual energy x-ray absorptiometry scan. Univariable analyses were used to test the associations between fracture status and the independent variables, serum vitamin D level and BMD.

RESULTS

Vitamin D levels were available for 17 cases. The mean (+/-SD) 25-hydroxy vitamin D level was 20.1 (+/-7.3) ng/mL with a range of 10 to 38 ng/mL. The mean of this group was at the cut point for vitamin D insufficiency. Ten cases (59%) were vitamin D insufficient. Dual energy x-ray absorptiometry scan results for these patients were consistent with normal bony mineralization for age.

CONCLUSIONS

A significant proportion of African American children with fractures in our study have vitamin D insufficiency. Analysis of serum 25-hydroxy vitamin D levels and BMD in additional cases and controls will determine the significance of these findings.

CLINICAL RELEVANCE

Vitamin D insufficiency may play a previously unrecognized role in childhood fractures. Strong consideration should be given to routine vitamin D testing in African American children with forearm fractures.

Hypocalcaemic fit in an adolescent boy with undiagnosed rickets

Rickets in early childhood has been well documented in the literature. We present the case of a teenage Somalian boy who had a generalised tonic-clonic fit (an unusual presentation of rickets in late childhood) and was diagnosed with vitamin D deficient rickets.

Diagnosis and treatment of vitamin D deficiency

The recent discovery--in a randomised, controlled trial--that daily ingestion of 1100 IU of colecalciferol (vitamin D) over a 4-year period dramatically reduced the incidence of non-skin cancers makes it difficult to overstate the potential medical, social and economic implications of treating vitamin D deficiency. Not only are such deficiencies common, probably the rule, vitamin D deficiency stands implicated in a host of diseases other than cancer. The metabolic product of vitamin D is a potent, pleiotropic, repair and maintenance, secosteroid hormone that targets > 200 human genes in a wide variety of tissues, meaning it has as many mechanisms of action as genes it targets. A common misconception is that government agencies designed present intake recommendations to prevent or treat vitamin D deficiency. They did not. Instead, they are guidelines to prevent particular metabolic bone diseases. Official recommendations were never designed and are not effective in preventing or treating vitamin D deficiency and in no way limit the freedom of the physician--or responsibility--to do so. At this time, assessing serum 25-hydroxy-vitamin D is the only way to make the diagnosis and to assure that treatment is adequate and safe. The authors believe that treatment should be sufficient to maintain levels found in humans living naturally in a sun-rich environment, that is, > 40 ng/ml, year around. Three treatment modalities exist: sunlight, artificial ultraviolet B radiation or supplementation. All treatment modalities have their potential risks and benefits. Benefits of all treatment modalities outweigh potential risks and greatly outweigh the risk of no treatment. As a prolonged 'vitamin D winter', centred on the winter solstice, occurs at many temperate latitudes, < or = 5000 IU (125 microg) of vitamin D/day may be required in obese, aged and/or dark-skinned patients to maintain adequate levels during the winter, a dose that makes many physicians uncomfortable.