Food for Thought: Rickets on the Rise?

From the WebMD Archives

March 29, 2001 -- When Bianca Arrington's breastfed 7-month-old son Japhet had a seizure one day, she never thought the diagnosis would ultimately be rickets, a disease essentially caused by a kind of malnutrition and thought to be a disease of the past in industrialized nations.

"We were doing our regular routine when all of a sudden he fell back and started foaming at the mouth," recalls the young mother. "His eyes rolled to the side and his limbs tightened up, and he was shaking and gagging."

At the hospital, the 7-month-old was examined, but he was released quickly. Bianca was told that many babies have one seizure and then never have another.

But the next day, when she was following up with her pediatrician, Japhet had another seizure, and Bianca went back to the hospital. Although the CAT scan was normal, blood work revealed that Japhet's calcium, magnesium, and phosphorous levels were extremely low, and he was immediately transported to a larger hospital in Atlanta.

That's where Bianca met Norman Carvalho, MD, a staff pediatrician at Children's Health Care of Atlanta. Carvalho set out to find out why Japhet's mineral levels were so low.

"Dr. Carvalho said it was rickets," Bianca says. "I didn't know what rickets was; I had never heard of it."

Rickets is a disease typically caused by vitamin D deficiency; the classic symptom is weakened or deformed bones. The disease was common a century ago during the Industrial Revolution when children went malnourished and without regular exposure to the sun, which triggers the body to make vitamin D. But now, thanks to a better understanding of nutrition, and fortification of certain foods, rickets is preventable and extremely rare in the U.S.

So how could this have happened to Japhet?

"Throughout my pregnancy I read everything, I went to breastfeeding classes, I spoke to a lactation consultant, and I never heard of rickets, never heard of giving a baby [a] vitamin supplement," his mom says.

While numbers are hard to pin down because there is no national surveillance system or mandatory reporting for these diseases, some experts like Carvalho believe there may be an increase in the number of children with severe malnutrition. Carvalho himself reported two cases (including Japhet's) to the Georgia Department of Human Resources; in turn, the GDHR asked the Centers for Disease Control and Prevention (CDC) to investigate cases of severe malnutrition in Georgia.

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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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"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 fortoddlers. 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."

On the issue of vitamin D supplementation, the American Academy of Pediatrics essentially leaves the decision up to the pediatrician, but the organization currently is re-examining that policy.

Two months after his ordeal, Bianca reports that Japhet, now 9 months old, has recovered.

"He is happy, strong, and very smart," she says. "He's crawling and even starting to walk. He is very, very healthy."

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