Florid rickets associated with prolonged breast feeding without vitamin D supplementation
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7175.39 (Published 02 January 1999) Cite this as: BMJ 1999;318:39All rapid responses
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Editor
With reference to the paper re. Vit D deficiency in mainly breast fed
Asian children by Mughal et al, I wish to report on a case of nutritional
rickets in one of twins.
The patient, the first and the bigger of twin girls of non
consanguinous Asian parents, who arrived in the U.K. two years previously,
presented at the age of 18 months with clinical signs of rickets.
She had been exclusively breast fed up to four months and accepted
weaners thereafter in only very small amounts, resulting in a diet of
mainly breast milk.
The second twin was formula fed from the age of two months as she
refused breast milk.
Neither twin received any vitamin or iron supplements.
The patient was slower in starting to walk, had a waddly gait and
tended to fall easily, as compared to her twin, and also was the shorter
of the two.
On examination she had markedly bowed legs, and swelling of end of
long bones with mild frontal bossing of skull.
Biochemistry:- Serum Ca++ 1.73 nmol/l, PO4 - 0.72 nmol/l, Alk.Ph 3707
iu/l. Classical radiological changes of rickets with osteopenia, widening
of growth plates, and cupping and fraying of metaphyses were also seen.
Vitamin D deficiency was confirmed by a low level of 25-OH-D - 4.6 mgms/l,
while 1-25-OH2-D level was apparently normal at 46 mgms/l, reflecting
secondary hyperparathyroidism.
She began to walk steadily and showed complete resolution of
biochemical and radiological changes within six months of treatment with
Vit.D supplements.
Her twin was normal on examination, and had normal bone biochemistry
with Ca++ 2.57, PO4 - 1.63, and Alk Ph 690.
This interesting case with a perfectly matched control in her twin
focuses on the causes of Vit.D deficiency, and the need for supplements in
Asian babies fed almost exclusively on breast milk.
The patient also had iron deficiency anaemia, strengthening the
comments by Lawson, Thomas, and Wharton in the same journal.
The Department of Health recommendations of Vit. D supplements to all
children under five years seems not to be carried out as a routine
practice. The need for its implementation, especially in Asian children,
perhaps even with iron supplements, cannot be over emphasised.
Indra Ariyawansa
Consultant Paediatrician
Birch Hill Hospital
Rochdale
1 Mughal, Salma, Greenway, Laing, Mawer. Florid Rickets associated
with prolonged breast feeding without Vit D supplementation. B.M.J.
2.Jan.99.
2 Lawson, Thomas,. Vit D concentration in Asian children aged 2
years living in England; population survey. B.M.J. 2.Jan.99.
3 Kocturk, Zetterstrom. Thoughts about rates of breast feeding.
Acta Paed. 88'99.
4 Wharton. Low plasma Vit.D in Asian toddlers in Britain. BMJ 2 Jan
99
Editorial note
The little patient's mother gave written consent to the publication of the above mentioned material
Competing interests: No competing interests
Vitamin D deficiency in non-Caucasian populations in the UK is a
problem which clearly has not gone away (1, 2). Readers should be reminded
that manifestations of vitamin D deficiency may also present acutely.
A four-month old male infant was admitted with respiratory arrest and
fitting: he had a blue face, tongue and lips and blood gases confirmed a
respiratory acidosis (pH 6.932; pCO2 12.4 kPa). He was immediately
intubated on 100% oxygen. His mother gave a 2 day history of rapid
breathing and coughing and on the morning of admission had noted jerking
movements of the limbs. His previous medical history was unremarkable: he
had been born at full term by normal vaginal delivery to non-
consanguineous Turkish Muslim parents and had been exclusively breast fed.
Initial investigations revealed hypocalcaemia (1.17 mmol/L, phosphate 2.47
mmol/L, albumin 37 g/L) and increased alkaline phosphatase (510 U/L, age-
related reference range 65-265 U/L).
There was no clinical or radiological evidence of rickets but a chest
X-ray showed right upper lobe consolidation; influenza B virus was later
isolated. Subsequently, the child was shown to have vitamin D deficiency
(25-hydroxy vitamin D 6 nmol/L, reference range 15-100 nmol/L) and
appropriate secondary hyperparathyroidism (PTH 135 ng/L, reference range
10-65 ng/L). Magnesium was normal (0.63 mmol/L). He was treated with
Amoxil, calcium supplements (i.v. calcium gluconate at first, followed by
Sandocal 3 mg qds) and alfacalcidol (400 ng od) and his calcium returned
to normal after 18 days.
Hypocalcaemia can cause laryngeal spasm and stridor in children,
which may precipitate respiratory arrest: in this case it may have been
exacerbated by bronchiolitis. (Indeed, there is some evidence that vitamin
D deficiency may increase susceptibility to infection (3)). There are
sporadic reports of hypocalcaemia presenting in this manner (4, 5); the
former of these cases also occurred in non-Caucasian infants.
Paediatricians should be aware of this unusual presentation of vitamin D
deficiency, particularly in susceptible populations.
Edmund Lamb,
Consultant Clinical Biochemist,
Kent and Canterbury Hospitals NHS Trust,
Canterbury, Kent CT1 3NG
References
1 Mughal MZ, Salama H, Greenaway T, Laing I, Mawer EB. Florid rickets
associated with prolonged breast feeding without vitamin D
supplementation. BMJ 1999; 318: 39-40.
2 Lawson M, Thomas M. Vitamin D concentrations in Asian children
aged 2 years living in England: population survey. BMJ 1999; 318: 28.
3 Bikle DD. A bright future for the sunshine hormone. Scientific
American March/April 1995: 59-67.
4 Train JJA, Yates RW, Sury MRJ. Hypocalcaemic stridor and infantile
nutritional rickets. BMJ 1995; 310: 48-9.
5 Halterman JS, Smith SA. Hypocalcemia and stridor: an unusual
presentation of vitamin D-deficient rickets. J Emerg Med 1998; 16: 41-3.
Competing interests: No competing interests
Firstly it would be helpful to clarify the definition of
breastfeeding used and then what is 'prolonged'. Also it would be
important to know when solids were introduced and what other foods the
children have been eating. That the mothers also had very limited exposure
to sunlight during and after pregnancy seems important. How do you measure
the influence of this? How can you measure or explain the effects of other
factors? Are you implying that breastmilk is deficient in vitamin D? It
seems to be an easy target for "blame". If it is, how did we survive as a
species till now? If the vitamin D levels are different now than 100 or
1000 years ago, why. So, in light of this article, what, if any are the
authors' recommendations?
Competing interests: No competing interests
The authors do not define "prolonged" breastfeeding. Since the World
Health Organization recommends exclusive breastfeeding for four to six
months, with appropriate introduction of solid foods, and the continuation
of breastfeeding for at least two years, the term "prolonged" sounds out
of date. There are accepted definitions for breastfeeding research (see
Labbok), which do not appear to have been used in this study.
Competing interests: No competing interests
Prevention of Rickets, is the message getting through?
Dear Sir
10 years ago a group of 6 children were diagnosed with vitamin D deficient
rickets in Manchester, and were presented in the BMJ as a ‘Lesson of The
Week’ highlighting the need to implement the government’s policy on
vitamin D supplementation(1).
In Tayside in the last 4 months we have diagnosed 5 infants with vitamin D
deficient rickets in an almost identical scenario to the Manchester
report. None of these children or mothers had received vitamin D
supplementation. Their families were unaware of the need for this. This
is despite the UK government recommendations for the universal use of
vitamin supplements to all breast feeding infants to prevent rickets which
have existed for over 10 years(2). This recommendation is particularly
important for those of Asian, African, Afro-Caribbean or Middle Eastern
origin with reduced exposure to sunlight. Continuing concern in the
medical literature highlights this (3,4,5).
The public is not receiving this message so clearly. The NHS direct
website is not specific and leaves an ambiguous message about the need for
vitamin supplements(6). The recommendations are more clearly laid out as a
component of the ‘Healthy Start Initiative’ which has replaced the welfare
food scheme, but the uptake of vitamins was particularly low when this
scheme was last audited(7). None of the affected families we saw are
eligible for this scheme as it is mainly directed at the poor and
disadvantaged, and not specifically immigrant groups(8).
The scientific advisory committee on nutrition (SACN) have just
published a position statement on vitamin D, with particular reference to
preventing rickets, in which they highlight the need for a public health
campaign on the issue, emphasising the need to supplement infants in high
risk groups with vitamin D(9). This is the same message which has been re-
iterated in the literature through the last decade. Evidence that it is
getting through is lacking(3,5), and our own experience highlights this.
Rickets remains an unusual condition to many general practitioners. The
signs and symptoms were only recognised by the GP in one of the cases we
saw.
The SACN report is timely, but it is now imperative to disseminate the
message to all health visitors and general practitioners across the UK,
as they are in a position to carry it out and eradicate this epidemic.
1. Mughal MZ, Salama H, Greenaway T, Laing I, Mawer EB. Lesson of the
week: Florid rickets associated with prolonged breast feeding without
vitamin D supplementation. BMJ 1999; January 2;318(7175):39-40.
2. HMSO. Department of Health COMA report on Weaning and the Weaning Diet.
; 1994. Report No.: 45.
3. Allgrove J. Is nutritional rickets returning?. Arch Dis Child 2004;
August 1;89(8):699-701.
4. Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating
a new concern. Arch Dis Child 2002; March 1;86(3):147-9.
5. Callaghan AL, Moy RJD, Booth IW, Debelle G, Shaw NJ. Incidence of
symptomatic vitamin D deficiency. Arch Dis Child 2006; July 1;91(7):606-7.
6. Do I need vitamin supplements? Available at:
http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1122. Accessed
06/05, 2007.
7. Department of Health. Scientific Review of the Welfare Food Scheme.
London: TSO.; 2002. Report No.: 51.
8. Healthy Start. Available at: http://www.healthystart.nhs.uk/. Accessed
06/01, 2007.
9. Scientific Advisory committee on Nutrition. Update on Vitamin D.
Position statement by the Scientific Advisory Committee on Nutrition. ;
2007 May.
Competing interests:
None declared
Competing interests: No competing interests