Global Health Disparities in Childhood Rickets

Nutritional rickets is a global health problem reflecting both historical and contemporary health disparities arising from racial, ethnic, environmental, and geopolitical circumstances. It primarily affects marginalized populations and can contribute to long-term morbidity. Deficits in bone health in childhood may also contribute to osteomalacia/osteoporosis. Solutions require a global public health approach.

Impact of a Prenatal Vitamin D Supplementation Program on Vitamin D Deficiency, Rickets and Early Childhood Caries in an Alaska Native Population

Background: Early childhood rickets increased in Alaska Native children after decreases in vitamin D-rich subsistence diet in childbearing-aged women. We evaluated the impact of routine prenatal vitamin D supplementation initiated in Alaska’s Yukon Kuskokwim Delta in Fall 2016. Methods: We queried electronic health records of prenatal women with 25(OH) vitamin D testing during the period 2015−2019. We evaluated 25(OH)D concentrations, vitamin D3 supplement refills, and decayed, missing, and filled teeth (dmft) scores and rickets in offspring. Results: Mean 25(OH)D concentrations increased 36.5% from pre- to post-supplementation; the percentage with deficient 25(OH)D decreased by 66.4%. Women with ≥ 60 vitamin D3 refill days had higher late pregnancy 25(OH)D concentrations than those with no refill days (p < 0.0001). Women with late pregnancy insufficient 25(OH)D concentrations had offspring with higher dmft scores than those with sufficient 25(OH)D (RR 1.3, p < 0.0001). Three children were diagnosed with nutritional rickets during the period 2001−2021, and none after 2017. Conclusions: These findings suggest that prenatal vitamin D supplementation can improve childhood outcomes in high-risk populations with high rates of rickets.

The Development of Rickets in Children and Nursing Contributions to Treatment

Rickets is one of the most prevalent non-communicable diseases in children in the developing world. It is often found in cultures in which children follow strict vegetarian diets and are not exposed to vitamin D-enhanced foods. While a rare occurrence, X-linked hypophosphatemic rickets may be the most frequent type of the disease seen outside the Third World today. However, there is not much credible information on the extent of the development of rickets. Therefore, pediatric nurses must be able to recognize children at risk and provide best practice care for the prevention and treatment of rickets. When caring for children in hospitals, communities or classrooms, nurses play a vital role in identifying children at risk for hypovitaminosis D and advising families to, if possible, follow safe diets and take supplements in order to avoid health complications associated with low levels of vitamin D. This study examines the prevalence and variables contributing to rickets, including hypovitaminosis vitamin D, the consequent orthopedic problems and the role of nurses in preventing and managing the pathogenesis of rickets and ultimately avoiding extreme deficits that result in bone deformities and the need for corrective surgery.

Vitamin D deficiency, supplementation and testing: have we got it right in New Zealand?

BACKGROUND

Severe prolonged vitamin D deficiency can cause rickets or osteomalacia. Both can be prevented by sunshine exposure or vitamin D supplementation. Although New Zealand guidance does not recommend vitamin D supplementation for the general population, it can be considered for individuals at risk of vitamin D deficiency. Routine measurement of 25-hydroxyvitamin D (25OHD) is also considered unnecessary.

METHODS

We investigated the rates of vitamin D supplementation, rickets and osteomalacia in New Zealand, and of 25OHD results in Auckland, over the last two decades.

RESULTS

Vitamin D prescriptions increased 14-fold, from 86,295/year to 1,215,507/year, between 2003 and 2019, with medication costs alone in 2019 being >$1 million. Despite these changes, the annual prevalence of hospital admissions for rickets, osteomalacia and unspecified vitamin D deficiency remained low and stable (10-20/year). 25OHD concentrations increased between 2002 and 2003 and between 2009 and 2019, and in the later time-period, 25OHD tests mainly identified individuals without vitamin D deficiency (40-50% >75nmol/L, 65-70% >50nmol/L and only 7-12.5% <25nmol/L).

CONCLUSIONS

Osteomalacia and rickets persist at low rates despite widespread, increasingly costly vitamin D supplementation and testing, which largely identifies individuals without vitamin D deficiency. These results suggest that vitamin D guidance and practice in New Zealand should change.

Can the palaeoepidemiology of rickets during the industrialisation period in France be studied through bioarchaeological grey literature and French medico-historical literature of the 18th-early 20th centuries? Preliminary examination of a complex topic

OBJECTIVE

This study explores whether data relating to rickets from the French medico-historical literature (FMHL) and bioarchaeological grey literature are useful in evaluating its epidemiology during the industrialisation of France. Unlike other European countries such as England, industrialisation in France was a slow and continuous process with two phases: the first in 1830-1870 and the second in 1870-1914.

MATERIALS AND METHODS

A bibliographical analysis of 2800 FMHL sources from the 18th to the early 20th centuries and 50 archaeological excavation reports from the last 21 years was undertaken.

RESULTS

The FMHL data is very heterogeneous and predominantly dates to the second phase of industrialisation. The bioarchaeological data is very incomplete and predominantly relates to the period before industrialisation. At the same time, knowledge improvement and institutional changes to protect children could explain more systematic registration of cases of rickets.

CONCLUSIONS

No solid conclusions can be made regarding the prevalence of rickets at present, however these data hold great potential.

SIGNIFICANCE

In comparison to England, no systematic investigation of rickets prevalence during the period of industrialisation in France has been undertaken to date.

LIMITATIONS

The lack of archaeological excavations from this period and the limited paleopathological analysis of the sites excavated have contributed to our current lack of understanding regarding the impact of industrialization on the prevalence of rickets on the French population.

SUGGESTIONS FOR FURTHER WORK

The FMHL data needs to be homogenized and osteoarchaeological collections need to be restudied with a common protocol focusing on signs of vitamin D deficiency.

A joint medico-historical and paleopathological perspective on vitamin D deficiency prevalence in post-Medieval Netherlands

OBJECTIVE

By applying a joint medico-historical and paleopathological perspective, this paper aims to improve our understanding of factors influencing past vitamin D deficiency in ten Dutch 17th to 19th-century communities of varying socioeconomic status and settlement type.

MATERIALS

Vitamin D deficiency is evaluated in 733 individuals of both sexes and all age groups: Silvolde (n = 16), Rotterdam (n = 23), Rhenen (n = 24), Noordwijkerhout (n = 27), Gouda1and 2 (n = 40; n = 59), Roosendaal (n = 51), Den Haag (n = 93), Hattem (n = 113), and Beemster (n = 287).

METHODS

Rickets and residual rickets are macroscopically assessed using established criteria. Hypotheses formulated based on medico-historical texts are investigated via multivariate statistical analysis of vitamin D deficiency prevalence.

RESULTS

Vitamin D deficiency prevalence ranges from 13.7 % (7/51) in Roosendaal to 48.1 % (13/27) in Noordwijkerhout, with an onset of < 4 years, and higher rates in cities, conforming to medico-historical texts. Patterns of child labor are likely key. In contrast, socioeconomic status did not statistically significantly influence vitamin D deficiency prevalence rates.

CONCLUSION

Systematically collected paleopathological data enabled evaluation of medico-historical texts and provided insights into the role that socioeconomic status and settlement type played on the prevalence of vitamin D deficiency.

SIGNIFICANCE

Combining medico-historical texts and large-scale paleopathological data enables disease patterning to be embedded in a comprehensive biocultural perspective.

LIMITATIONS

Comparisons may be limited by the small sample size of high socioeconomic status nonadults and some of the collections.

SUGGESTIONS FOR FUTURE RESEARCH

Analysis of more individuals and sites would improve our understanding of disease patterns.

Aetiology of nutritional rickets in rural Bangladeshi children

OBJECTIVES

A high prevalence of rickets of unknown aetiology has been reported in Chakaria, Bangladesh. Classically, rickets is caused by vitamin D deficiency but increasing evidence from Africa and Asia points towards other nutritional deficiencies or excessive exposure to some metals. The aim of this study was to investigate the aetiology of rickets in rural Bangladeshi children.

METHODS

64 cases with rickets-like deformities were recruited at first presentation together with age-sex-village matched controls. Data and sample acquisition included anthropometry, radiographs, fasted plasma and urinary samples, 24 h weighed dietary intake together with a 24 h urine collection, and ¹³C-breath tests to detect Helicobacter (H.) pylori infection.

RESULTS

One child had active rickets and frank hypovitaminosis D (F, n = 1) and one had deformities with radiological features of Blount disease (M, n = 1). The remaining cases were grouped into those with active rickets, defined as a radiographic Thacher score ≥1.5 (Group A, n = 24, 12M, 12F) and rickets-like bone deformities but not active rickets (Group B, n = 38, 28M, 10F). All children had a low dietary calcium intake, but this was lower in Group A than their controls (mean (SD): 156 (80) versus 323 (249) mg/day, p = 0.005). Plasma 25-hydroxyvitamin D (25OHD) was lower in Group A compared to controls; 63% of Group A and 8% of controls had a concentration <25 nmol/L (p ≤ 0.0001). There was, however, no evidence of differences in skin sunshine exposure. Group A had lower plasma calcium and phosphate and higher 1,25-dihydroxyvitamin D (1,25(OH)₂D) and parathyroid hormone (PTH). 88% of Group A and 0% of controls had undetectable plasma intact fibroblast growth factor (iFGF23), with c-terminal FGF23 (cFGF23) concentrations in the normal range. Urinary phosphate and daily outputs of environmental metals relative to creatinine were higher and tubular maximal phosphate reabsorption per unit glomerular filtration rate (TmP/GFR) was lower in Group A compared to controls. Although less pronounced than Group A, Group B had higher alkaline phosphatase, 1,25(OH)₂D and PTH concentrations than controls but similar calcium intake, TmP/GFR, iFGF23 and cFGF23 concentrations. Mean 25OHD concentrations were also similar to controls and there was no significant difference in the percentage <25 nmol/L (Group B: 13%, controls: 5%, p = 0.2) No group differences were seen in prevalence of anaemia, iron deficiency or H. pylori infection.

CONCLUSION

Nutritional rickets in this region is likely to be predominantly due to low calcium intake in the context of poor vitamin D status and exposure to environmental metals, but not H. pylori infection, anaemia or iron deficiency.

Assessment of Preptin peptide level in the sera of rachitic children and in breast milk of their mothers

BACKGROUND

Preptin is a 34-residue pancreatic hormone that stimulates osteoblast proliferation and reduces osteoblast apoptosis.

RESEARCH AIMS

To measure levels of serum Preptin in rachitic children and in breastmilk of their mothers and to compare with levels in healthy non-rachitic children.

METHODS

Thirty children with rickets and another 30 non-rachitic age and sex matched controls were subjected to detailed history, physical examination including anthropometric measurements, assessment of signs of rickets and laboratory measurement of serum vitamin D, calcium, phosphorus, alkaline phosphatase and Preptin. Mothers' breast milk Preptin were also measured.

RESULTS

Significantly lower serum Preptin (p < 0.001) in rachitic children with a significant negative correlation between serum Preptin and alkaline phosphatase (P < 0.0001). Lower breastmilk Preptin levels in mothers of rachitic children (P < 0.001) with a negative correlation between breastmilk Preptin and both maternal weight and BMI(P < 0.01&P < 0.02). Mothers' milk Preptin is positively correlated with serum Preptin and calcium in non-rachitic children(P < 0.001&0.04), but negatively correlated with their mothers' age (P < 0.01).

CONCLUSION

Preptin may play a role in the etiology of rickets in children. Further studies are recommended to evaluate Preptin role in treatment of rickets in children.

The association between body lead levels and childhood rickets: A meta-analysis based on Chinese cohort

China has serious lead pollution and a high incidence of childhood rickets. High lead levels have been reported in childhood rickets, but the results were inconsistent.To evaluate the association between body lead levels and childhood rickets.After a systematic literature search, we identified 15 studies determining body lead levels between rickets children and healthy controls, and 4 studies focusing on the cases of different disease severity. Standard mean differences (SMD) and the corresponding 95% confidence intervals (CI) were pooled to compare the lead levels between different groups.Sixteen case-control studies were included with a total of 5082 cases and 6054 controls. Compared with healthy controls, the body lead levels in rickets children were significantly higher (SMD (95%CI): 0.67 (0.41-0.93)), and subgroup analyses showed consistent results. The cases with moderate-to-severe disease activity also had a significantly higher lead level than mild-to-moderate cases (SMD (95%CI): 0.64 (0.31-0.97)).This meta-analysis suggested an association between body lead levels and childhood rickets, and lead exposure might be a risk factor for rickets.

Co-morbidity, treatment outcomes and factors affecting the recovery rate of under -five children with severe acute malnutrition admitted in selected hospitals from Ethiopia: retrospective follow up study

BACKGROUND

In spite of the availability of guidelines for the management of severe acute malnutrition (SAM) in Ethiopia, high comorbidity and poor treatment outcomes are still observed in therapeutic feeding centers among under -five children with SAM. The aim of this study was to assess comorbidity, treatment outcomes and factors affecting the recovery rate of children aged 1-59 months with SAM admitted into Therapeutic Feeding Centers (TFCs).

METHODS

A total of 413 records of children with SAM admitted in three selected hospitals from July 2013 to July 2015 G.C were retrospectively reviewed. Descriptive analysis was used to compare performance indicator values with SPHERE project reference standards (the minimum standard to be attained during nutritional therapy). Cox-proportional hazard regression analysis was performed to estimate the predictors of recovery rate at p-value < 0.05.

RESULT

The mean age of children was 16 months (95% CI, 15.0, 17.0). Out of 413 children with SAM, 231 (55.9%) recovered, 24 (5.8%) died and 16.3% were defaulted from TFCs. The mean weight gain (in gram per weight of kilogram per day) for recovered children was 15.61 g/kg/day (95% CI, 14.15, 17.07). The overall median recovery time for these children was 12 days (95% CI, 11.22, 12.78). Moreover, most (77.5%) of children admitted with SAM were marasmic followed by Kwash (16%). Pneumonia (54.8%), diarrhea (41.8%) and rickets (21.4%) were co-morbidities which affected SAM children. A child being admitted at Mehal Meda Hospital (Adjusted Hazard Ratio (AHR) = 2.01; 95% CI: 1.34, 2.91), edematous form of malnutrition (AHR = 0.59; 95% CI: 0.39, 0.90) and being a child infected with pneumonia (AHR = 0.71; 95% CI: 0.51, 0.98) were predictors of nutritional recovery rate.

CONCLUSION

Under five pneumonia, diarrhea and rickets were co-morbidities that should be prevented. Recovery rate was poor when compared to SPHERE project reference value (which is > 75%). Predictors, namely presence of pneumonia and edematous form of malnutrition reduced nutritional recovery rate. Whereas, being admitted at Mehal Meda Hospital improved recovery rate. Therefore, hospitals should work in collaboration with health extension workers to prevent co-morbidities and strengthen screening and referral of malnutrition cases at community level. Moreover, Zonal Health Department and District Health Offices should facilitate experience sharing among health facilities.

The epidemiology of rickets in the 17th-19th centuries: Some contributions from documentary sources and their value to palaeopathologists

This article considers the nature of written sources on the epidemiology of rickets in the post-Mediaeval period, and examines the value of these sources for palaeopathologists. There is a progression from 17th-18th century sources, which generally make ex cathedra, qualitative statements on rickets frequency to, in the 19th century, semi-quantitative geographical surveys of its occurrence, through to reports of percentage prevalence in various groups. Of course, even these latter cannot be directly compared with prevalences calculated from excavated skeletal remains, but there are also considerable difficulties in comparing them with one another, and this effectively precludes synthesis to provide reliable information on geographic and temporal trends at anything more than a very broad-brush level. Their problematic nature mandates a cautious approach when using written sources to shed light on the epidemiology of rickets. For palaeopathologists, a useful way of incorporating these sources into a biocultural approach may be to use them in order to formulate hypotheses that can then be evaluated using skeletal evidence.

Rare paleopathological insights into vitamin D deficiency rickets, co-occurring illnesses, and documented cause of death in mid-19th century London, UK

Growing evidence suggests that vitamin D supports immune responses to infections, autoimmune conditions and cancers, although evidence from large-scale studies is limited. There is scope to better understand how vitamin D deficiency interacted with other diseases to affect health in past groups. This study investigated paleopathological evidence and documentary records of individual cause of death to examine disease co-occurrence in a group of mid-19th century child burials from London, UK. Twenty-one percent of children had vitamin D deficiency rickets (138/642) and 36 children with rickets had an identified cause of death. Cyclical episodes of metabolic and nutritional deficiencies (rickets and scurvy) had occurred during childhood. Active rickets co-occurred with respiratory and gastrointestinal infections in a small number of children, likely reflecting vitamin D's role in supporting immune function. Consideration of the stage of the vitamin D deficiency showed that the majority of children were affected by chronic disease loads indicative of multiple episodes of illness. Reconstructions of the wider health consequences of vitamin D deficiency in past groups are dependent on recognising whether the deficiency was active or healed. The variability of diseases identified illustrates the high disease burden that affected children in this socially disadvantaged group.

Vitamin D insufficiency: Definition, diagnosis and management

Severe vitamin D deficiency can be defined as the dose of vitamin D or serum 25OHD concentrations needed to prevent nutritional rickets or osteomalacia. There is large international consensus that these diseases can be prevented by 400 IU of vitamin D/d and 25OHD above 30 nmol/l (12 ng/ml). Vitamin D deficiency can also accelerate the risk of fractures and probably also of falls in elderly subjects but there is no consensus on the required daily doses or minimal 25OHD threshold for these endpoints. The majority of experts consider 800 IU/d and serum 25OHD above 50 nmol/l (20 ng/ml) as sufficient, with a minority opinion aiming for 75 nmol/l or even higher. For other extra-skeletal endpoints, no hard evidence is available to define whether or not this is causally related to vitamin D status. Therefore, for these endpoints no minimal dosage or 25OHD threshold can be defined.

Prevention of rickets and osteomalacia in the UK: political action overdue

The consequences of vitamin D and dietary calcium deficiency have become a huge public health concern in the UK. The burden of disease from these deficiencies includes rickets, and hypocalcaemic seizures, dilated cardiomyopathy and mostly occult myopathy and osteomalacia. The increasing burden of the disease is intrinsically linked to ethnicity and the population demographic changes in the UK. Three facts have led to the resurfacing of the English disease: (1) the UK has no ultraviolet sunlight for at least 6 months of the year, (2) dark skin produces far less vitamin D than white skin per unit ultraviolet light exposure, and (3) non-European Union immigration over the last century. To date, the UK government demonstrates incomplete understanding of these three facts, and its failure to adjust its prevention programmes to changing demographics is endangering the health and life of UK residents with dark skin, of whom infants are the most vulnerable. Establishing accountability through the implementation of monitored antenatal and infantile supplementation programmes and mandatory food fortification is overdue.

Incidence rate and characteristics of symptomatic vitamin D deficiency in children: a nationwide survey in Japan

There is concern that vitamin D deficiency is prevalent among children in Japan as well as worldwide. We conducted a nationwide epidemiologic survey of symptomatic vitamin D deficiency to observe its incidence rate among Japanese children. A questionnaire inquiring the number of new patients with vitamin D deficiency rickets and/or hypocalcemia for 3 years was sent to 855 randomly selected hospitals with a pediatrics department in Japan. In this survey, we found that 250 children were diagnosed with symptomatic vitamin D deficiency. The estimated number of patients with symptomatic vitamin D deficiency per year was 183 (95% confidence interval (CI): 145-222). The overall annual incidence rate among children under 15 years of age was 1.1 per 100,000 population (95% CI: 0.9-1.4). The second survey has provided detailed information on 89 patients with symptomatic vitamin D deficiency under 5 years of age in hospitals in the current research group. The nationwide and second surveys estimated the overall annual incidence rate of symptomatic vitamin D deficiency in children under 5 years of age to be 3.5 (2.7-4.2) per 100,000 population. The second survey revealed 83% had bowed legs, 88% had exclusive breastfeeding, 49% had a restricted and/or unbalanced diet and 31% had insufficient sun exposure among the 89 patients. This is the first nationwide survey on definitive clinical vitamin D deficiency in children in Japan. Elucidating the frequency and characteristics of symptomatic vitamin D deficiency among children is useful to develop preventative public health strategies.

Nutritional rickets in Norway: a nationwide register-based cohort study

OBJECTIVES

Poor vitamin D status has been reported to be highly prevalent in many non-western immigrant groups living in Norway and other western countries. However, data on rickets are scarce, and the aim of the current study was to identify new cases of nutritional rickets in Norway in the period 2008-2012 among children under the age of 5 years.

DESIGN

Register-based cohort study.

SETTING

The Norwegian population from 2008 to 2012.

PARTICIPANTS

Children with nutritional rickets under the age of 5 years.

MAIN OUTCOME MEASURE

Nutritional rickets. Patients with ICD10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) diagnosis code E55.0 (active rickets) treated at all Norwegian hospitals were identified in the Norwegian Patient Registry. We were able to review 85% of the medical records for diagnosis confirmation. In addition, we identified patients with the diagnoses E55.9, E64.3 and E83.3 to identify individuals with rickets who had been given other diagnoses.

RESULTS

Nutritional rickets was confirmed in 39 children aged 0-4 years with the diagnosis of E55.0. In addition, three patients with the diagnosis of unspecified vitamin D deficiency (E55.9) were classified as having nutritional rickets, giving a total of 42 patients. Mean age at diagnosis was 1.40 years (range 0.1-3.5 years), and 93% had a non-western immigrant background. The incidence rate of rickets was estimated to be 0.3 per 10 000 person-years in the total Norwegian child population under the age of 5 years and 3.1 per 10 000 person-years in those with an immigrant background from Asia or Africa.

CONCLUSION

The number of children with nutritional rickets in Norway remained low in the period 2008-2012. Nearly all children had a non-western immigrant background.

Screening for nutritional rickets in a community

Concern has been expressed about the rising incidence of nutritional rickets with its associated long-term sequelae in children globally. In order to address the condition worldwide, it is imperative that accurate figures of its incidence are available particularly in at-risk communities. In order to obtain these figures, various screening tools and diagnostic criteria have been used with no standardization of methodologies, resulting in varying prevalences which may under- or over-estimate the prevalence depending of the techniques used. This review discusses the advantages and disadvantages of various screening tests used to diagnose rickets in communities. Clinical signs characteristic of rachitic deformities have been used extensively, but are likely to over-estimate the prevalence and are dependent on the clinical skills of the observer. Biochemical tests such as alkaline phosphatase and 25-hydroxyvitamin D have also been proposed. There is no consensus on the usefulness of alkaline phosphatase as a screening tool, while there is general agreement that the measurement of vitamin D status is unhelpful in screening for rickets. Finally, the confirmation of the presence of active rickets in suspected infants and children is dependent on radiographic findings, although these may be less helpful in adolescents whose growth plates might be closed or nearly so. In order to obtain uniformity in screening for rickets globally, the is a need for consensus among public health specialists, paediatric endocrinologists and those interested in paediatric bone disease as to the best methods to be employed to determine the prevalence of rickets, particularly in communities with limited resources.

Prevention and treatment of nutritional rickets

Nutritional rickets continues to be a significant health problem for children worldwide with recent evidence of increasing incidence in many developed countries. It is due to vitamin D deficiency and/or inadequate dietary calcium intake with variation in the relative contributions of each of these dependant on environmental factors such a dietary intake and sunlight exposure. Key to the prevention of rickets is ensuring that pregnant women and their infants receive vitamin D supplementation with good evidence from randomised controlled trials that infants who receive 400iu daily can achieve levels of 25 hydroxyvitamin D of >50nmol/l. However, public health implementation of daily supplementation is more challenging with a need to revisit food fortification strategies to ensure optimal vitamin D status of the population. Treatment of nutritional rickets has traditionally been with vitamin D2 or D3, often given as a daily oral dose for several weeks until biochemical and radiological evidence of healing. However, other treatment regimes with single or intermittent high doses have also proved to be effective. It is now recognised that oral calcium either as dietary intake or supplements should be routinely used in conjunction with vitamin D for treatment.

Prevention and consequences of vitamin D deficiency in pregnant and lactating women and children: A symposium to prioritise vitamin D on the global agenda

The Department of Nutrition for Health and Development of the World Health Organization (WHO) in collaboration with the Executive Committee of the 18th Vitamin D Workshop (VDW), organised a joint symposium on the prevention and consequences of vitamin D deficiency in pregnant women and children, convening experts on vitamin D, clinicians and policy-makers. The overall aim was to identify priority areas for research and to discuss the need for global options for policy, with a focus on the prevention of rickets in infants and children and vitamin D deficiency in pregnant women. The scope and purpose were: (i) to present the WHO research strategy for health, addressing vitamin D-related public health problems and the process for the development of evidence-informed guidelines in general and how vitamin D interventions in diverse populations could be prioritised; (ii) to provide an overview of vitamin D status in children and pregnant and lactating women across the world; (iii) to review the health risks associated with vitamin D deficiency in children and in pregnant women and their offspring; (iv) to understand the aetiology of vitamin D deficiency in pregnant women and children; (v) to identify and interpret biomarkers to assess vitamin D status and to consider possible clinical and biochemical screening tools for determining the prevalence of nutritional rickets in at risk groups or communities; and (vi) to provide an overview of policies and recommendations on vitamin D across the world. The format of the symposium was a composite of comprehensive scientific presentations and a panel debate with international experts on WHO guidelines, nutritional rickets, nutritional policy and consequences of vitamin D deficiency during pregnancy. This paper summarizes the content and outcomes of the panel debate.

The Return of Congenital Rickets, Are We Missing Occult Cases?

Congenital rickets is the term given to fetus born with clinical features of rickets, but those born with biochemical evidence of rickets without obvious clinical features still can be considered occult congenital rickets. Some of the affected babies with this disease have the intrauterine rachitic environment, but a calcium trans-placental pump prevents the fetus from having clinical features of rickets. They may present with hypocalcemia few days after birth or later with more florid features of rickets. Congenital rickets cases born with florid features reported over the last 40 years are few and can be divided into two groups. The first due to severe maternal osteomalacia in which their bones were so decalcified to have enough calcium to be pumped to their fetus. Another group in which newborn babies were hypocalcemic due to other maternal diseases as malabsorption, celiac disease, pre-eclampsia, and prematurity. All inherited rickets cases per se, or as part of other syndromes can be considered congenital rickets. Most cases seen in our region are due to maternal vitamin D deficiency with symptoms becoming obvious when the infants are breastfed, or may present with hypocalcemic convulsions or craniotabes. This is a review of congenital rickets with the aim of shedding light on this potentially acute disease that needs more attention and awareness in the neonatal period to avoid rare serious complications as cardiomyopathy or myelofibrosis and the complications of hypocalcemic convulsions. Congenital rickets cases seen simulate a tip of an ice-burg and its prevention is an important issue, especially with the tremendous urbanization with tall buildings living in sun-deprived flats as the commonest type of residence leading to the increasing incidence of maternal osteomalacia and rickets.

Prevalence of rickets-like bone deformities in rural Gambian children

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.

CYP2R1 Mutations Impair Generation of 25-hydroxyvitamin D and Cause an Atypical Form of Vitamin D Deficiency

CONTEXT

Production of the active vitamin D hormone 1,25-dihydroxyvitamin D requires hepatic 25-hydroxylation of vitamin D. The CYP2R1 gene encodes the principal vitamin D 25-hydroxylase in humans.

OBJECTIVE

This study aimed to determine the prevalence of CYP2R1 mutations in Nigerian children with familial rickets and vitamin D deficiency and assess the functional effect on 25-hydroxylase activity.

DESIGN AND PARTICIPANTS

We sequenced the CYP2R1 gene in subjects with sporadic rickets and affected subjects from families in which more than one member had rickets.

MAIN OUTCOME MEASURES

Function of mutant CYP2R1 genes as assessed in vivo by serum 25-hydroxyvitamin D values after administration of vitamin D and in vitro by analysis of mutant forms of the CYP2R1.

RESULTS

CYP2R1 sequences were normal in 27 children with sporadic rickets, but missense mutations were identified in affected members of 2 of 12 families, a previously identified L99P, and a novel K242N. In silico analyses predicted that both substitutions would have deleterious effects on the variant proteins, and in vitro studies showed that K242N and L99P had markedly reduced or complete loss of 25-hydroxylase activity, respectively. Heterozygous subjects were less affected than homozygous subjects, and oral administration of vitamin D led to significantly lower increases in serum 25-hydroxyvitamin D in heterozygous than in control subjects, whereas homozygous subjects showed negligible increases.

CONCLUSION

These studies confirm that CYP2R1 is the principal 25-hydroxylase in humans and demonstrate that CYP2R1 alleles have dosage-dependent effects on vitamin D homeostasis. CYP2R1 mutations cause a novel form of genetic vitamin D deficiency with semidominant inheritance.

Cord blood vitamin D levels of term neonates

We estimated cord blood 25-hydroxy vitamin D levels of 50 term healthy neonates born in a tertiary care center of Kozhikode, Kerala, India. Vitamin D levels were normally distributed with a mean (SD) value of 11.36 (4.75) ng/mL and median (range) values of 10.85 (3.9-24.9) ng/mL. Majority of babies had values between 5 to 15 ng/mL. This study shows that even in tropical climates most of our neonates are born with deficient vitamin D levels.

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.

[Osteoporosis]

The quality of the management of patients with osteoporosis varies by country. The recommendations of the Swiss Association against osteoporosis propose intervention thresholds based on the results of the FRAX tool. Despite increasing number of observational studies with several hundred thousands of patients, it is not possible to conclude to a clear increased risk of cardiovascular disease with calcium intakes. A persistent effect of zoledronic acid is observed even after one single injection. There is no increased fracture risk within 7 months following Denosumab treatment cessation.

Nutritional rickets around the world

Nutritional rickets is a major public health problem in many countries of the world. The disease is characterized by deformities of the long bones, enlargement of the wrists and costochondral junctions, hypotonia and, in infants, craniotabes and delayed fontanelle closure. Predominantly caused by severe vitamin D deficiency, rickets can also be associated with hypocalcemic seizures and cardiac failure. First presentation is typically at 6-24 months of age, although hypocalcemia may be evident in younger infants. In many affluent industrialized countries, the prevalence of rickets in the general population diminished after the introduction of clean-air legislation and dietary supplementation. However, in such countries, vitamin-D deficiency rickets has re-emerged in recent years, particularly among groups with limited exposure to UVB-containing sunshine. Infants at risk of rickets tend to be those whose mothers had poor vitamin D status during pregnancy and those exclusively breast-fed for a prolonged period with little skin exposure to UVB. In other countries of the world, the prevalence of rickets can be high, even in regions with abundant year-round UVB-containing sunshine. In general, this is also due to vitamin D deficiency related to limited sun exposure. However, reports from Africa and Asia suggest that there may be other etiological factors involved. Studies in South Africa, Nigeria, The Gambia and Bangladesh have identified rickets in children, typically 3-5 years old at first presentation, in whom plasma 25-hydroxyvitamin D concentrations are higher than those characteristic of primary vitamin D deficiency. Calcium deficiency has been implicated, and in some, but not all, disturbances of phosphate metabolism, renal compromise and iron deficiency may also be involved. Continuing studies of the etiology of nutritional rickets will provide evidence to underpin guidelines for the prevention and treatment of rickets world-wide. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Prevalence of classic signs and symptoms of rickets and vitamin D deficiency in Mongolian children and women

In order to assess the current nutrition status of Mongolian population, including rickets and vitamin D deficiency of children and women, the Fourth National Nutrition Cross-Sectional Survey was conducted in 21 aimags (provinces) of 4 economic regions of the country and capital city Ulaanbaatar in 2010. Children of age under five years, and non-pregnant women of reproductive age were used as subjects for assessing rickets and vitamin D deficiency. A total of 400 households were randomly selected from each of 4 economic regions and Ulaanbaatar city. Clinical examinations were performed on 706 children of age under five years. Interviews were used to assess vitamin D supplement use. The serum level of 25-hydroxyvitamin D was measured in 524 children aged 6-59 months and in 867 women of reproductive age. This survey found that 21.8% of children had vitamin D deficiency, 20.6% had low vitamin D reserve, and 30.0% of women had vitamin D deficiency and 22.2% had low vitamin D reserve. The prevalence of vitamin D deficiency in children (35.0%, 95% CI, 24.7-47.0) and women (54.9%, 95% CI 45.5-64.0) in the Eastern Region was (35.0%, 95% CI, 24.7-47.0) significantly higher than in the Western, Khangai, Central Regions, and Ulaanbaatar. Further it was found that 27.4% of children under-two years had received vitamin D supplementation. The proportion of children, who did not receive vitamin D supplementation had a higher prevalence of vitamin D deficiency than that of the children of the Eastern Region. None of the women who were involved in this survey had received vitamin D supplementation; 10.2% of them had delivered in the past 12 months, and 22.5% were breastfeeding. The prevalence of classic signs and symptoms of rickets were commonly reported among children of age under five, and skeletal abnormalities more commonly reported in children aged 12-47 months. In conclusion, there is a high prevalence of classic signs and symptoms of rickets in children of age under five years. Vitamin D supplementation in adequate doses for the prevention and treatment of rickets in children is insufficient. Thus, a trial survey is needed to assess the safe and effective doses of vitamin D supplementation necessary for the maintenance of normal serum 25-hydroxyvitamin D concentrations in Mongolian children, and women. In addition, a vitamin D food fortification program is required. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota

OBJECTIVE

To determine temporal trends in incidence and risk factors of nutritional rickets in a community-based population.

PATIENTS AND METHODS

Rochester Epidemiology Project data were used to identify all children (aged <18 years) residing in Olmsted County, Minnesota, between January 1, 1970, and December 31, 2009, with diagnostic codes corresponding to rickets, vitamin D deficiency, hypovitaminosis D, rachitis, osteomalacia, genu varum, genu valgum, craniotabes, hypocalcemia, hypocalcemic seizure, and tetany. Record abstraction was performed to select individuals with radiographic confirmation of rickets. Age- and sex-matched controls were identified for the evaluation of risk factors. The main outcome measure was radiographic evidence of rickets without identifiable inherited, genetic, or nonnutritional causes. Incidence rates were calculated using Rochester Epidemiology Project census data.

RESULTS

Of 768 children with eligible diagnostic codes, 23 had radiographic evidence of rickets; of these, 17 children had nutritional rickets. All 17 children were younger than 3 years, and 13 (76%) were of nonwhite race/ethnicity. Clinical presentation included poor growth (n=12), leg deformity (n=8), motor delay (n=5), leg pain (n=3), weakness (n=3), and hypocalcemia or tetany (n=2). The incidence of nutritional rickets in children younger than 3 years was 0, 2.2, 3.7, and 24.1 per 100,000 for the decades beginning in 1970, 1980, 1990, and 2000, respectively (P=.003 for incidence trend). Nutritional rickets was associated with black race, breast-feeding, low birth weight, and stunted growth (P<.05 for all). Four of 13 patients (31%) who underwent 25-hydroxyvitamin D testing had values less than 10 ng/mL.

CONCLUSION

Nutritional rickets remains rare, but its incidence has dramatically increased since 2000. Not all cases of rickets can be attributed to vitamin D deficiency.

High incidence of rickets in extremely low birth weight infants with severe parenteral nutrition-associated cholestasis and bronchopulmonary dysplasia

Risk factors for rickets of prematurity have not been re-examined since introduction of high mineral formula, particularly in ELBW infants. We analyzed the incidence and the risk factors of rickets in extremely low birth weight (ELBW) infants. As a retrospective case-control study from 2004 to 2008, risk factors were analyzed in 24 patients with rickets versus 31 patients without. The frequency of rickets in ELBW infants was 24/55 (44%). Infants with rickets were diagnosed at 48.2 ± 16.1 days of age, and improved by 85.3 ± 25.3 days. By radiologic evaluation, 29% were grade 1 rickets, 58% grade 2 and 13% grade 3. In univariate analysis, infants with rickets had significantly higher incidence of patent ductus arteriosus, parenteral nutrition associated cholestasis (PNAC), severe PNAC and moderate/severe bronchopulmonary dysplasia (BPD). In multiple regression analysis, after adjustment for gestation and birth weight, rickets significantly correlated with severe PNAC and with moderate/severe BPD. Serum peak alkaline phosphatase levels were significantly elevated in rickets (P < 0.001). In ELBW infants, the incidence of rickets of prematurity remains high and the incidence of severe PNAC and moderate/severe BPD was significantly increased 18 and 3 times, respectively.

Spatial distribution of calcium in food, water and soil and its possible influence on rickets disease in Northern Nigeria

Since the 1990s, children of the Gbagyi tribe in Northern Nigeria have been suffering severe rickets with an incidence of up to 40% in the children's generation. The disease seems to be prevalent in an area of approximately 100 km(2) south-east of Kaduna. According to broad medical studies in that area, there is no evidence for a genetic disposition but for a nutritional cause of the disease. A lack of calcium was found in blood and was calculated to originate from diet. We therefore checked parent material, soil, maize cobs (Zea mays) and drinking water for their specific Ca contents from a region with rickets problem (study area A) and compared the results to Ca amounts in similar samples from a region where rickets is unknown among the Gbagyi population (study area B). It thereby became apparent that there are no differences in mineralogical composition of the parent material between the study areas, but that Ca contents in soil, maize cobs and drinking water are 47.6%, 26.6%, respectively, 79.1% lower in study area A compared to study area B. This result suggests that there may indeed be a nutritionally and/or environmentally influence on rickets disease. Nevertheless, further research on this topic is required.

Iron status and fibroblast growth factor-23 in Gambian children

A relationship between iron and fibroblast growth factor-23 (FGF23) metabolic pathways has been proposed. Iron deficiency anaemia is prevalent in The Gambia and concentrations of fibroblast growth factor-23 FGF23 are elevated in a large percentage of Gambian children with rickets-like bone deformity. We speculate that low iron status may be involved in the aetiology of Gambian rickets. The aim of this study was to determine if there was a relationship between haemoglobin, as a marker of iron status, and FGF23 in samples from children with and without a history of rickets-like bone deformities in The Gambia. We conducted a retrospective analysis of studies carried out from 2006 to 2008 in children from a rural community in The Gambia where iron deficiency anaemia is endemic and where elevated circulating concentrations of FGF23 have been found. To investigate the relationship between circulating FGF23 and haemoglobin concentrations we used an age-adjusted linear regression model on data from children <18y of age with a family or personal history of rickets-like bone deformity (BD) (n=108) and from the local community (LC) (n=382). We found that circulating concentration of FGF23 was inversely correlated with haemoglobin concentration. This effect was more pronounced in BD children compared with LC children (interaction: P≤0.0001). Anaemia and elevated FGF23 were more prevalent in BD children compared to LC children (P=0.0003 and P=0.0001 respectively). In conclusion, there is a stronger relationship between FGF23 and haemoglobin in Gambian children with a history of rickets compared to local community children. This study provides support for the contention that iron may be involved in FGF23 metabolic pathways.

Time to see the light

There is growing concern about low vitamin D levels in the UK population, and children from a range of backgrounds are now presenting with rickets, the bone disease associated with poor nutrition in the 19th century. However, the evidence linking vitamin D deficiency to a range of conditions unconnected to bone health, such as heart disease and multiple sclerosis, is inconclusive.

Rickets in Denmark

Rickets is a heterogeneous group of diseases of the growing child caused by defect mineralization of bone. Nutritional rickets is caused by deficiency of vitamin D, calcium or both. Several hereditary forms of rickets exist where the disease proceeds into adulthood. Nutritional rickets was common in the past, but by introduction of preventative administration of cod liver oil and vitamin D supplementation, nutritional rickets became a rarity. During the last decades, case reports of nutritional rickets reappear in the industrialized countries. It is the general conception that in the industrialized countries, hereditary rickets is the most prevalent cause of rickets today. However, the incidence of nutritional rickets and the incidence and prevalence of hereditary rickets in Scandinavia are unknown. The most common form of hereditary rickets is hypophosphatemic rickets (HR). The geno- and phenotype among Scandinavian patients have not been characterized. Especially, the disease in adult patients is not well described. Moreover, there are conflicting reports of the benefits of medical treatment throughout childhood, and in addition on gender differences in disease severity.

Prevalence of vitamin D deficiency and rickets in children with cholestasis in Iran

This study was aimed to determine prevalence of vitamin D deficiency and rickets in children with cholestatic liver diseases. Forty eight children with established cholestatic liver disease who referred to gastrointestinal clinic of Children Medical Center (Tehran, Iran) between April 2010 and March 2011 were enrolled in a cross-sectional study. Laboratory analysis including calcium, phosphate, albumin, total and direct bilirubin, aminotransferases, alkalinephosphatase (ALP), prothrombin time (PT), parathyroid hormone (PTH), total protein determined by routine laboratory techniques. Mean age of participants was 299.1 ± 676.8 days (range 2-3600 days) whereas twenty one were female (43.8%) and 27 (56.3%) were male. Twenty two (45.8%) had evidences of rickets in X-ray evaluation. Three children with rickets and two with normal X-ray had vitamin D deficiency while ten in rickets group and 16 in normal group had vitamin D insufficiency. The main underlying diseases were anatomical biliary atresia in cases with rickets and idiopathic in other group. Rickets and vitamin D deficiency should be considered in chronic cholestatic children.

Vitamin D deficiency and prevention: Turkish experience

A nationwide 'vitamin D prophylaxis augmentation programme' initiated in 2005 in Turkey reduced the prevalence of rickets from 6% in 1998 to 0.1% in 2008 in children under 3 years of age. The programme included free distribution of vitamin D drops to all newborns and infants (0-12 months) visiting primary health stations throughout the country. Free disposal of vitamin D to infants is an effective strategy for preventing vitamin D-deficient rickets.

Rickets: concerns over the worldwide increase

Rickets is a childhood disease that causes a softening of the bones, potentially leading to fractures and deformity. Eighty years ago it was thought to have largely been eradicated from the U.K. However a recent increase in cases of rickets, not just in Britain but around the world, has proven this isn't the case. Today the disease affects children from all types of socio-economic backgrounds, not just the poorer ones, and it is primarily caused by low levels of vitamin D and certain foods. In January 2011 the government's chief medical officer Dame Sally Davies recommended all children aged six months to five should be given vitamin D supplements, particularly during winter months when natural sunshine is limited. The irony is that the advice in recent years for children to wear a high factor sunscreen and remain covered up while playing outdoors are partly felt to be behind the reason for its re-emergence. Parents and health professionals alike were shocked when it was revealed that a school girl living on the Isle of Wight developed rickets precisely because of her mother's vigilance at following sun safety rules. NICE, in their latest report (Jan 2011) stated that: "Exposure to the sun has a number of benefits. For example, it increases people's sense of wellbeing, allows them to synthesise vitamin D and provides opportunities for physical activity". A tendency for children to stay indoors and watch TV or play on computer games, rather than play outside when the sun is shining, is arguably also another contributing factor.

An outbreak of rickets in Corriedale sheep: Evidence for a genetic aetiology

CASE HISTORY

A skeletal disease characterised by lameness, limb deformities and reduced growth rate occurred over two successive years in lambs born on a commercial sheep farm in Marlborough. A genetic aetiology was considered likely following exclusion of other known causes of rickets and because of the progressive nature of the disease, even after affected animals were transferred to another property.

CLINICAL FINDINGS

Affected lambs appeared normal at birth but developed clinical signs during the first 2 months of life. The most severely affected animals either died or were euthanised within the first year of life, but some survived to breeding age. Serum biochemistry revealed hypocalcaemia, hypophosphataemia and increased concentrations of 1,25 dihydroxyvitamin D. The mean serum 25 hydroxyvitamin D concentration was similar to that of control lambs.

PATHOLOGICAL FINDINGS

Gross lesions included enlarged costochondral junctions, bilateral irregularity of articular surfaces on humeral heads due to collapse of subchondral bone, thickened cortices in long bones and irregular thickening of physeal cartilages. Microscopically, tongues of hypertrophic chondrocytes extended from physes into metaphyseal regions; metaphyseal trabeculae were thick, disorganised and often lined by wide osteoid seams. Osteoclastic activity was excessive both in cortical and trabecular bone.

DIAGNOSIS

Inherited rickets in Corriedale sheep. CLINICAL RELEVANCE AND CONCLUSIONS: This disease is likely to be present in several Corriedale sheep flocks in New Zealand and may have been misdiagnosed as arthritis or other diseases causing lameness and/or poor growth. A defect in end-organ responsiveness to 1,25 dihydroxyvitamin D is the likely mechanism. This disease of sheep may be a useful model for studying vitamin D metabolism and the treatment of inherited forms of rickets in human beings.

Proceedings of the Rank Forum on Vitamin D

The Rank Forum on Vitamin D was held on 2nd and 3rd July 2009 at the University of Surrey, Guildford, UK. The workshop consisted of a series of scene-setting presentations to address the current issues and challenges concerning vitamin D and health, and included an open discussion focusing on the identification of the concentrations of serum 25-hydroxyvitamin D (25(OH)D) (a marker of vitamin D status) that may be regarded as optimal, and the implications this process may have in the setting of future dietary reference values for vitamin D in the UK. The Forum was in agreement with the fact that it is desirable for all of the population to have a serum 25(OH)D concentration above 25 nmol/l, but it discussed some uncertainty about the strength of evidence for the need to aim for substantially higher concentrations (25(OH)D concentrations>75 nmol/l). Any discussion of 'optimal' concentration of serum 25(OH)D needs to define 'optimal' with care since it is important to consider the normal distribution of requirements and the vitamin D needs for a wide range of outcomes. Current UK reference values concentrate on the requirements of particular subgroups of the population; this differs from the approaches used in other European countries where a wider range of age groups tend to be covered. With the re-emergence of rickets and the public health burden of low vitamin D status being already apparent, there is a need for urgent action from policy makers and risk managers. The Forum highlighted concerns regarding the failure of implementation of existing strategies in the UK for achieving current vitamin D recommendations.

Evaluation of children with nutritional rickets

AIM

To evaluate the clinical findings, risk factors, therapy and outcome in 946 children with nutritional rickets.

PATIENTS AND METHODS

This retrospective study included a review of medical records of patients with nutritional rickets between March 2004 and 2009. Patients who displayed both the biochemical inclusion criteria and the clinical signs/symptoms or radiological signs of rickets were included in the study.

RESULTS

The present study included 946 patients aged between 4 months and 15 years. Distribution of the cases showed a density between December and May. The age at diagnosis, showed two peaks and most of the patients were in the age range 0-23 months and 12.0-15 years. In infants and young children, most of the patients had been admitted to the hospital due to infectious diseases. In older children, short stature and obesity were the most common complaints.

CONCLUSION

Children aged between 0-23 months and 12.0-15 years were under most risk for nutritional rickets, especially in winter and spring and vitamin D should be given to them as supplementation dose.

Frequency of nutritional rickets in children admitted with severe pneumonia

OBJECTIVE

To determine the frequency of nutritional rickets in children hospitalized with severe pneumonia.

METHOD

This study was carried out at the department of paediatric medicine at National Institute of Child Health Karachi. It is a case series done over a period of six months from 15th November 2008 to 15th may 2009. Patients admitted (n=137) with severe pneumonia were included in the study and were investigated for presence of rickets with serum calcium, phosphorus and alkaline phosphatase. Those having low to normal calcium low phosphorus and raised alkaline phosphatase were labeled as having rickets. All data collected were entered on Performa. Children with familial, vitamin D dependent/resistant rickets, secondary rickets, and cerebral palsy or on anti convulsant therapy were excluded from this study.

RESULTS

Out of 137 patients, with severe pneumonia, 83 were male and 54 female. Frequency of nutritional rickets in children with severe pneumonia was observed in 101(74%) cases. Rickets was more common in 2 to 12 months of age, i.e., 79.8% (67/84) and in those children who were breast fed (85.3% vs. 40%). Frequency was higher in those children who were not exposed to sunlight.

CONCLUSION

Pneumonia is a very common presentation of rickets. This study suggests that rickets may be more common in children who are breast fed and those who have less exposure to sunlight.

Maternal vitamin D status: implications for the development of infantile nutritional rickets

The mother is the major source of circulating 25-hydroxyvitamin D concentration in the young infant. Maternal vitamin D status is an important factor in determining the vitamin D status of the infant and their risk of developing vitamin D deficiency and infantile nutritional rickets. There is evidence that the current supplementation recommendations, particularly for pregnant and lactating women, are inadequate to ensure vitamin D sufficiency in these groups. A widespread and concerted effort is needed to ensure daily supplementation of breastfed and other infants at high risk with vitamin D 400 IU from birth and of pregnant women in high-risk communities with 2000 IU. Future studies are required to determine the optimal doses of vitamin D supplementation in pregnancy and during lactation, and for normalizing vitamin D stores in infancy to reduce the prevalence of infantile nutritional rickets. Operational research studies are needed to understand the best methods of implementing supplementation programs and the factors that are likely to impede their success.

Nutritional rickets and vitamin D deficiency in infants, children and adolescents

Nutritional rickets continues to be a public health problem in many countries despite the presence of cheap and effective means of preventing the disease. Deficiency of vitamin D is associated with rickets in growing children and osteomalacia in adults. Vitamin D deficiency is attributed to a variety of causes including diet, atmospheric pollution, religious practices that restrict sunlight exposure (clothing), geographic latitude and altitude, season, and time of the day. The clinical findings of rickets can vary among stages of the disease. It is recommended that healthy infants, children and adolescents take at least 400 IU vitamin D per day to prevent rickets and vitamin D deficiency. Pediatricians and other healthcare professionals should try to ensure that children and adolescents receive daily vitamin D requirements appropriate for their risk factors, traditions, and customs. Additionally, it is important to use every opportunity to ensure that effective preventive strategies are put in practice.