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Food for Thought: Rickets on the Rise?

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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.

"If you have a toddler and are going to use an alternative to milk, make sure it is fortified with vitamin D and adequate protein," he says. "Select products formulated for toddlers. Check the label carefully and run it past your pediatrician."

Beyond that, Carvalho suggests that mothers of the most at-risk babies -- black babies, infants who are breastfed longer than average, and those who get little sun exposure -- add vitamin D supplement to the babies' diets.

Tomashek agrees that vitamin D supplementation can be a good idea.

"If an infant is breastfed, parents and their [doctor] should discuss the need for supplementation," she says. "In addition, toddlers should be transitioned to vitamin D-fortified cow's milk or a beverage that is nutritionally equivalent to ensure adequate nutrition. Cheese, yogurt, and other dairy products typically do not contain vitamin D."

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