Rickets Reemerging in United States

August 18, 2000

New York (MedscapeWire) Aug 18 — Two articles in the August issue of the Journal of Pediatrics draw attention to an emerging epidemic of a crippling childhood disorder that was nearly eliminated in the early part of the 20th century.

The condition, nutritional rickets, usually results from a dietary deficiency of vitamin D. This impairs the body's ability to absorb calcium from the diet, resulting in poor bone development. If rickets occurs in infancy or early childhood, the weak bones can become severely deformed, occasionally resulting in the need for major surgery.

Most individuals produce their own vitamin D when their skin is exposed to sunlight. Other sources of vitamin D include foods to which the vitamin is added in processing, such as milk, and most vitamin preparations. At the beginning of the 20th century, nutritional rickets was a common disease, particularly among infants in urban areas of the United States. With the advent of routine vitamin D supplements, however, the problem virtually disappeared by mid-century.

The study and the editorial accompanying it conclude that the reemergence of rickets is due to an increase in breast-feeding in infants who do not receive supplemental vitamins.

"To understand vitamin D deficient rickets today, one need only consider the population of infants affected," says Thomas R. Welch, MD, director of nephrology and hypertension at Cincinnati Children's Hospital Medical Center and coauthor of the editorial. "The Healthy People 2000 initiative has set a target of 75% of American infants breast-feeding for at least 6 months. Unless this is accompanied by the provision of vitamin D supplementation to replace that currently derived from formula, an epidemic of rickets seems inevitable."

The editorial accompanies a study of rickets in infants in North Carolina. The study, conducted at Wake Forest University and the University of North Carolina, described 30 children in whom nutritional rickets was diagnosed over a 10-year period. All infants were African-American and breast-fed without supplemental vitamin D. The researchers, led by Shelly Kreiter, MD, of Wake Forest University, suggested that the lack of vitamin D in the diet, combined with deficient production of the vitamin because of their heavily pigmented skin, predisposed these infants to rickets.

Using data from physician surveys and the North Carolina Women, Infants and Children (WIC) program, the researchers noticed that the new cases of rickets occurred as the incidence of breast-feeding in the area increased. They also noted that local pediatricians frequently neglected to recommend vitamin D supplements for breast-fed babies.

But the increase in nutritional rickets is not confined geographically. In the accompanying editorial, the authors point out that cases of rickets are increasing throughout the United States.

Dr. Welch, an associate editor of the Journal of Pediatrics, says that Cincinnati Children's Hospital has treated several infants recently with nutritional rickets, including at least one who required admission to the pediatric intensive care unit. All those treated at Cincinnati Children's have been dark-skinned, breast-fed infants not receiving vitamin D.

In a 1997 position paper, the American Academy of Pediatrics stopped short of recommending routine vitamin D supplements for nursing infants, even though most standard textbooks of infant nutrition clearly do so, according to Dr. Welch. In addition, he says, some "how to" manuals for nursing mothers go even further, suggesting that any supplemental vitamins are unnecessary. The authors of both articles stress that human milk is clearly the most optimal food for infants.

While the North Carolina researchers stress the importance of supplements for dark-skinned infants, the Cincinnati and Syracuse physicians broaden the advice to include all infants who are exclusively breast-fed.

It's ironic, Dr. Welch says, that "in an era of expensive, high-tech medicine, a serious disease is reappearing because of neglect of a decades-old intervention that costs pennies a day, is completely safe, and 100% effective."

J Pediatr. 2000;137:143-145,153-1

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