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January 2012

Is this the return of rickets?

The news

In the last few weeks, it has been reported that 1 in 4 toddlers are lacking in vitamin D (1). This has lead to one case of rickets a month in hospitals causing experts to believe that daily recommendations on vitamin D supplementation are not being followed (2). According to a study, nearly three-quarters of parents and more than half of health professionals are unaware of the recommendations. This comes after the shocking case of the death of baby Jayden Wray, whose parents last month were acquitted of his murder, following medical reports that Jayden was suffering from rickets, which could be to blame for the complications which lead to his death. With this highlighted case and others being discovered now, it is now vital  that awareness regarding the importance of vitamin D supplements is increased, to decrease the number of cases of rickets and prevents headlines such as those seen in the figure below.

 

What is rickets?

 

Rickets is a disease that affects children that is caused by weakening and softening of the bones. The weight of the upper torso puts intense pressure onto the leg bones, which causes them to bow or change shape and in severe cases even break. Rickets gets its name from the Old English word “wricken” meaning twisted. This disease in adults is called osteomalacia.

 

During the 1600s, rickets was epidemic in England due to reduced sunlight caused by smog and smoke. The cause of rickets was not identified until the 1920’s when the Government issued a public health programme advising children received plentiful milk, vitamin D and calcium. This lead to the near eradication of rickets in the UK and other industrialized countries. In the 1950’s, rickets cases began to fall and with it so did awareness of vitamin D.

 

The most common type of rickets is nutritional rickets and occurs due to deficiency of vitamin D, calcium and phosphate.

Vitamin D

Vitamin D is a group of fat-solube secosteroids similar to steroids, but with a broken ring. It is required for the absorption of calcium in the  gut. Without enough calcium, bones deformities can occur. Vitamin D is found in a variety of common dietary foods, including oily fish, eggs, cereals and milk. However, vitamin D requires conversion from its inactive state to its active state. This is conducted by UV light in the sun. The capacity to convert 7-dehydrocholesterol in keratinocytes into vitamin D (calciferol) depends on exposure to ultraviolet B rays. Therefore, the prevention of rickets requires sufficient dietary vitamin D and sufficient sunlight. Vitamin D is synthesized in the body, and therefore is not actually a vitamin, but a prohormone.

 

Signs and symptoms

Common symptoms of rickets include:

  • soft skull bones
  • delayed closing of the soft spot at the top of a baby’s head
  • poor growth
  • floppy limbs and body due to muscle disease or weakness
  • teeth taking longer to come through
  • weak tooth enamel that may lead to tooth decay
  • bone pain in the arms, legs, spine and pelvis
  • fractures (3).

Diagnosis

If rickets is suspected in a child, x-rays are taken to examine for features of rickets in the bones such as  bowing, fractures and shape abnormalities (as shown in the image above). Following x-ray examination, the cause of rickets can be determined by blood tests which measure levels of calcium, phosphorous and vitamin D.

 

Prevention and treatment

The incidence of vitamin D deficiency is rising worldwide, yet in the vast majority of patients, the condition remains undiagnosed and untreated. Public health recommendations imposed by the Government advise vitamin D supplements. It has been clinically proven that vitamin D doses greater than 800 IU/day have beneficial effects on the musculoskeletal system, improving skeletal homeostasis, thus leading to fewer falls and fractures.

 

Most people can get all the vitamin D required through eating a balanced diet and getting a little sun. Vitamin D is easily accessible in foods such as oily fish, eggs and milk. However, the Department of Health recommends a daily vitamin D supplement for the following people:

  • all children aged six months to five years
  • all pregnant and breastfeeding women
  • all people aged 65 and over
  • people who aren’t exposed to much sun, for example people who cover up their skin for cultural reasons, or people who are housebound (stay indoors) for long periods of time
  • people with darker skin, such as people of African-Caribbean and South Asian origin

 

Why is rickets making a come back?

 

The main reason that the number of cases of rickets is increasing is because public awareness regarding of vitamin D has fallen. If parents are not educated as to the importance of vitamin D for their children then can unintentionally put their children at risk of deficiency. Yet if the information needs to get to parents in the first place. Ultimately, then it is the role of Doctors, midwives and health care assistants to educate parents. Once this is established, then lifestyle changes can be made.

In order to maintain a healthy balanced life, children need to establish a balance between spending  time outside in the fresh air getting exercise and maintaining a healthy, balanced diet. Due to warnings about the rick of skin cancer, the public are over cautious in the sun and excessively cover up their skin, preventing their body from accessing sufficient vitamin D. However, a little sun is healthy and can protect against rickets.

I hope by writing this article, I am doing my bit towards increasing awareness of the importance of vitamin D and the risk of rickets.

References

(1) http://www.mirror.co.uk/news/health-news/2012/01/25/rickets-returns-as-1-in-4-toddlers-found-to-be-lacking-in-vitamin-d-115875-23718769/

(2) http://www.bbc.co.uk/news/health-16700833

(3) http://www.bbc.co.uk/news/uk-england-16107085

(4) http://www.bupa.co.uk/individuals/health-information/directory/r/rickets#textBlock259205

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