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    Food for Thought: Rickets on the Rise?

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    After reviewing hospital records between January 1997 and June 1999, the CDC identified six cases of children with rickets and three cases of children with another disease, called protein energy malnutrition (PEM), that were not related to abnormalities present at birth or to chronic infection. These cases are reported in the current issue of the CDC's Morbidity and Mortality Weekly Report.

    Nine cases may not sound like much, but it could be the tip of the iceberg.

    "Although we found only six children with rickets and three cases of PEM, we feel that this may be an underestimate of the total number of cases because these cases were from hospitalized children, and rickets is typically diagnosed at an outpatient clinic," study co-author Kay Tomashek, MD, MPH, tells WebMD.

    Tomashek, who at the time was working at the Georgia Division of Public Health and is now at the CDC's Pregnancy and Infant Health Branch, says that the CDC has received reports of other cases of severe malnutrition from physicians in other parts of the country. She wrote an editorial on the subject that appears in this month's issue of the scientific journal Pediatrics.

    Carvalho, who also has an article about his two patients that appears in Pediatrics, agrees.

    "The cases we see are the most severe cases requiring hospitalization," he says. "For every one hospitalized child, perhaps there are two or more that are not detected at all."

    And because rickets and PEM are so rare now, many physicians may not recognize them easily, Carvalho says.

    Why this increase? Carvalho attributes it to changes in social and environmental conditions.

    "Parents are working longer hours," he says. "Air quality has been poor, so kids stay indoors more. All in all, people are getting less sun exposure and that makes them more dependent on dietary sources for vitamin D requirement."

    Carvalho says that dark-skinned children are at higher risk since the melanin in their skin prevents them from absorbing as much sunshine as those with fair complexions.

    Another factor, Carvalho says, is "an increase in utilization of health food milk alternatives [like rice milk] which often don't contain vitamin D." Rice drinks in particular are a poor choice for infants, he says, since they also are low in protein and can lead to PEM.

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