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Nutritional Rickets a REVIEW of DISEASE BURDEN, CAUSES, DIAGNOSIS, PREVENTION and TREATMENT

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Nutritional Rickets a REVIEW of DISEASE BURDEN, CAUSES, DIAGNOSIS, PREVENTION and TREATMENT Nutritional rickets A REVIEW OF DISEASE BURDEN, CAUSES, DIAGNOSIS, PREVENTION AND TREATMENT Nutritional rickets A REVIEW OF DISEASE BURDEN, CAUSES, DIAGNOSIS, PREVENTION AND TREATMENT Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment ISBN 978–92–4-151658–7 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover design and layout: Alberto March (Barcelona, Spain) Printed in Switzerland Contents Acknowledgements IX Financial support IX Abbreviations X Introduction 1 Background 2 Scope and purpose 2 What is rickets? 3 History of diagnosis of rickets 4 Development of rickets 4 The magnitude and distribution of nutritional rickets: disease burden in infants, 7 children and adolescents Screening and diagnosis of nutritional rickets 8 The prevalence of rickets in infants, children and adolescents 15 Understanding the diverse causes or determinants of nutritional rickets 19 Vitamin D status 20 Calcium status 29 Other nutritional causes 32 Preterm birth and low birth weight 32 VII Developing solutions or interventions that could prevent or mitigate nutritional rickets 33 in infants, children and adolescents Screening 34 Prevention of nutritional rickets 35 Treatment of nutritional rickets 37 Implementing or delivering solutions through policies and programmes 39 Regulatory considerations 40 Ethical considerations 41 Evaluating the actions for prevention or treatment of nutritional rickets 43 Knowledge gaps 45 Final considerations 46 References 47 Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment VIII Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment Acknowledgements he development of this document was coordinated by the World Health Organization (WHO) Department T of Nutrition for Health and Development. Dr Juan Pablo Peña-Rosas and Dr Lisa Rogers (in alphabetical order) oversaw the preparation of this publication. We would like to thank Dr Cristina Palacios for the preparation of this review and subsequent technical revisions. Dr Maria Nieves Garcia-Casal and Dr Pura Rayco-Solon provided technical expertise for the conceptualization and the final revisions of the document. WHO is grateful to the following individuals (in alphabetical order) who provided technical input to the final document: Anshu Banerjee, Francesco Branca, Filiberto Beltran Velazquez, Jaden Bendabenda, Luz Maria De-Regil, Monica Flores Urrutia and Helena Pachon. We would like to thank all those who generously gave their time to comment on the document (in alphabetical order): Dr Daniel Roth and Dr Inez Schoenmakers. We acknowledge the Executive Committee of the 18th Vitamin D Workshop and the experts from the Global Rickets Consensus Group for the impetus for the preparation of this review addressing this topic. We gratefully acknowledge Rhaiza Aponte and Everest Turner, who helped update the tables on vitamin D status and the prevalence of rickets. We thank Ms Katerina Ainali for overall programme support to this work. Financial support WHO gratefully acknowledges the financial contribution of Global Affairs Canada and the Bill & Melinda Gates Foundation towards the preparation and publication of this document. IX Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment Abbreviations 25(OH)D 25-hydroxycholecalciferol 1,25(OH)2D 1,25-dihydroxycholecalciferol CDC United States Centers for Disease Control and Prevention DACH the joint committee for nutritional recommendations in Germany, Austria and Switzerland EFSA European Food Safety Authority FAO Food and Agriculture Organization of the United Nations GINA Global database on the Implementation of Nutrition Action IOM Institute of Medicine LC-MS liquid chromatography–tandem mass spectrometry NNR Nordic Nutrition Recommendations PTH parathyroid hormone RDA recommended daily allowance RNI recommended nutrient intake SACN Scientific Advisory Committee on Nutrition UK United Kingdom of Great Britain and Northern Ireland X USA United States of America UV ultraviolet VDDR-I type I (hypocalcaemic) vitamin D-dependent rickets VDR vitamin D receptor VMNIS Vitamin and Mineral Nutrition Information System WHO World Health Organization Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment INTRODUCTION 1 Nutritional rickets: a review of disease burden, causes, diagnosis, prevention and treatment Background Rickets is a disease that occurs in growing children, owing to failure of mineralization of the growth plate and osteoid matrix (1–4). Specifically, it results in defective chondrocyte differentiation and mineralization of the epiphyseal growth plates and defective osteoid mineralization. Bone matrix formation as well as mineralization is also delayed, leading to an accumulation of unmineralized matrix on microscopic bone surfaces (5). The skeleton then loses its stiffness and becomes severely deformed (bowed legs and misshapen pelvis), ultimately leading to stunted growth. Clinical and radiological features of widened growth plates are usually used to diagnose rickets. The main causes of rickets are deficient intakes of vitamin D and/or calcium, or physiological problems associated with the metabolism of these nutrients. The peak incidence of rickets occurs among infants and young children aged 6–23 months and adolescents aged 12–15 years, though it may also occur in children aged between 2 years and 11 years (6–9). Rickets in childhood has devastating consequences but these are often poorly recognized by health systems and in society. It is associated mainly with growth problems, bone pain, muscle weakness, limb and pelvic deformities, failure to thrive, developmental delay (such as gross motor delays in sitting, crawling and walking) and dental anomalies (8–12). In addition, rickets results in poor sleep and restlessness (13) and could delay eruption of the deciduous teeth, which then alters the sequence of eruption, affecting mainly the permanent incisors, cuspids and first molars (14). In the long term, rickets could lead to osteomalacia (abnormal matrix mineralization in established bone), low bone mass in adulthood and narrowing of the pelvic outlet, which then can result in obstructed labour and maternal and fetal death (4). Scope and purpose This document aims to provide a literature review of nutritional rickets among infants,
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