Nutritional Rickets In Infancy And Childhood Re-Emergence Of A Preventable Problem

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Nutritional Rickets In Infancy And Childhood
Re-Emergence Of A Preventable Problem

• Arlette Soros, MD, Jayashree Rao, MD, Ricardo
  Gómez, MD, Stuart A. Chalew, MD, and Alfonso
  Vargas, MD
• Department of Pediatrics, Division of
  Endocrinology
• Louisiana State University Health Sciences Center
  and Childrens Hospital New Orleans

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Nutritional Vitamin D Deficiency

• Increase in prevalence in the USA and other
  developed countries.
• Vitamin D is required for calcium absorption and
  promotes normal bone mineralization, being its
  mayor function to maintain calcium and phosphorus
  levels within the normal range.
• ? vitamin D ? ?calcium absorption ? ?serum
  ionized calcium level ? stimulates PTH ?
  mobilizes calcium and phosphorus from the bone to
  restore serum calcium levels.

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Holick M Journal of Clinical Investigation, 2006,
1162062-72
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Holick M Journal of Clinical Investigation, 2006,
1162062-72
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Characteristics

• Serum 25(OH)-vitamin D lt20 ng/mL
• Peak age between 3 and 18 months
• Dark skinned mothers
• Maternal nutritional vitamin D deficiency
• Chelating natural or pharmaceutical agents
• Malabsorption syndromes
• Congenital or perinatal liver disease

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Description of Clinical Cases

• Four patients between 0.3 and 3.3 years of age
  presented to our clinics with
• Tetany, carpo-pedal spasms, and/or seizure
• Bony deformities (bowed legs, widening of wrists
  and ankles, rachitic rosary)
• All breastfed without vitamin D supplementation
• After weaning from breast milk had negligible
  intake of vitamin D fortified milk or dairy
  products.
• Very limited exposure to solar UVB radiation.

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Table 1a.
Patient Age (yrs) Ethnic Group Total Ca IonizedCa2 P
1 0.3 Arabic 6.1 2.6 6.1
2 3.3 AA 6.9 4.3
3 2.8 AA 6.3 2.2 4.4
4 1.5 AA 7.0 4.3 5.0
Normal 8.7-10.3 mg/dL 4.3-5.9 mg/dl 4.0-9.5 mg/dL
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Table 1b.
Mg Alkaline Phosphatase PTH 25(OH)- vitamin D 1,25(OH)2- vitamin D
1.7 694 25 21 195
1.9 1158 44 8.1 133.9
2.0 1127 454 5.9 186
1.5 391 156 5.0 93
1.7-2.2 mg/dL 70-250 U/L 10-60 pg/mL 20-60 ng/mL 15-90 pg/mL
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Description and Progress

• Renal and liver functions were normal.
• All had complete or near complete resolution of
  their medical problems with appropriate
  therapeutic doses of intravenous and then oral
  calcium plus oral ergocalciferol or calcitriol.

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Risk Factors (1)

• Duration of breast feeding without vitamin D
  supplementation.
• Maternal vitamin D deficiency.
• High phytic acid dietary content.
• Vegetarian diet and/or poor dietary intake of
  dairy products.
• Dark skin pigmentation.

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Risk Factors (2)

• Seasonal Increased incidence from late fall to
  early spring
• Living at latitudes gt35
• Environmental factors air pollution, cloud
  cover, ozone layer

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Signs and Symptoms (1)

• Bony deformities
• Bowing of the legs (genu-varum, tibiae vara)
• Knock-knees (genu-valgum)
• Rachitic rosary costochondral junctions
• Swelling of the epiphysial growth plates
• Frontal bossing of the skull
• Pathological fractures.
• Poor growth
• Delayed dentition

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Signs and Symptoms (2)

• Slow motor development.
• Muscle weakness.
• Extra skeletal
• Tetany
• Seizures
• Laryngospasm
• Hypocalcemic myocardiopathy
• Death.

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Biochemical Indicators

• Serum 25(OH)-vitamin D lt20 ng/mL. Seasonal
  fluctuation.
• Serum 1,25(OH)2-vitamin D low, normal, or
  elevated but not enough to compensate
• Serum PTH normal or elevated
• Serum Ca low
• Serum P (HPO4) low
• Serum Mg normal
• Serum Alkaline phosphatase elevated

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Treatment (1)

• Vitamin D2 (ergocalciferol)
• Vitamin D3 (cholecalciferol)
• 200,000 600,000 IU orally with adequate dietary
  calcium.
• 2,0004,000 IU daily for 3 6 months.
• Single therapy

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Treatment (2)

• Vitamin D 100,000 IU every 3 4 months
  maintains serum 25(OH)-vitamin D concentration
  within normal range.
• Subcutaneous or intramuscular in children with
  malabsorption.
• Calcium supplementation by IV infusion if tetany
  or seizure are the presenting symptoms.
• Adequate oral calcium intake

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Prevention (1)

• Vitamin D 400 IU daily and adequate calcium
  intake
• Breastfed infant supplement with 400 IU vitamin D
• Infant taking lt500 mL/day of vitamin D fortified
  milk/formula supplement 400 IU
• Infants with low serum 25(OH)-vitamin D may need
  gt400 1,000 IU of vitamin D/day
• Adequate sunlight exposure.

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Prevention (2)

• All formula sold in the USA contains at least 400
  IU/L vitamin D.
• If daily intake is gt500ml but lt1000ml of
  fortified milk or formula add 200 IU of vitamin D
  .

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Vitamin D Deficiency - Long Term Effects.

• Osteoporosis in later life.
• Cancer of the colon, prostate, breast, ovary,
  esophagus, etc.
• Autoimmune diseases like type 1 Diabetes
  Mellitus, Crohns disease.
• Hypertension and heart diseases.

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Bibliography (1)

• Holick, Michael Resurrection of Vitamin D
  Deficiency and Rickets. J Clin Invest
  1162062-72, 2006
• American Academy of Pediatrics, Gartner LM, Greer
  FR, Section on Breastfeeding and Committee on
  Nutrition. Prevention of rickets and vitamin D
  deficiency New guidelines for vitamin D intake.
  Pediatrics 111908-910, 2003
• DeLucia MC, Mitnick ME, Carpenter TO.
  Nutritional rickets with normal circulating
  25-hydroxy vitamin D a call for reexamining the
  role of dietary calcium intake in North American
  infants. J Clin Endocrinol Metab 883539-3545,
  2003

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Bibliography (2)

• Ashraf M, Mick J, Atchison J, Petrey B,
  Abdullatif H and McCormick K Prevalence of
  hypovitaminosis D in early infantile
  hypocalcemia. J Pediatr Endocrinol Metabol
  191025, 2006
• Finberg L Vitamin D deficiency and rickets. J
  Pediatr Endocrinol Metabol 19203, 2006
• McAllister JC, Lane AT and Buckingham BA Vitamin
  D deficiency in the San Francisco Bay area. J
  Pediatr Endocrinol Metab 19205, 2006
• Shaikh U and Alpert PT Nutritional rickets in
  Las Vegas, Nevada. J Pediatr Endocrinol Metabol
  19209, 2006

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Bibliography (3)

• Shetty AK, Thomas T, Rao J, Vargas A Rickets and
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• Chesney RW EDITORIAL - A new form of rickets
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