Reflection Questions Rachitic X-ray changes include flaring of the mother and foetus from Vitamin D deficiency. Postnatal costochondral junctions and frayed, cupped long bone administration of Vitamin D to Vitamin D deficient lactating 1. Are there any of the high risk groups metaphyses, with generalised osteopaenia. The typical mothers needs to be approximately 6 times the adult RDI for Vitamin D deficiency amongst the radiological appearances of rickets are shown in Figure 2. to correct their infants Vitamin D deficiency, indicating that c p r Community Pædiatric Review clients that you see? These radiological changes represent ongoing osteoid it is preferable to give Vitamin D replacement to the being laid down in bone that is then poorly mineralised. mother and infant separately. Vitamin D deficiency may be A NATIONAL PUBLICATION FOR COMMUNITY CHILD HEALTH NURSES AND OTHER PROFESSIONALS 2. Consider the issues that you would Radiologically gross metaphyseal changes are frequently prevented in at risk groups, by providing mothers with the not seen in infants under 3 months of age, however RDI of Vitamin D 800iu during pregnancy and lactation, have to discuss with a very fair st generalised osteopaenia remains characteristic, and and 200iu at other times. Vitamin D supplementation of www.rch.org.au/ccch Rickets in the 21 century skinned mother about obtaining occasionally “periosteal reactions” are also seen in the 400iu daily to exclusively breast fed “at risk” infants, or VOL 14 NO 2 MAY 2005 Introduction Causes and risks factors adequate Vitamin D for herself, and long bone X-rays, giving rise to the radiological Vitamin D supplemented infant formula feeds totally Rickets may have been thought to be a “thing World-wide the most common cause of rickets her equally fair skinned breast-fed differential diagnosis of osteomyelitis or scurvy, which prevents the development of Vitamin D deficiency rickets An initiative of the may be excluded on clinical grounds. in otherwise normal infants. Currently the only Centre for Community of the past”. In fact at the beginning of the is due to Vitamin D deficiency. Individuals at infant. Characteristic biochemical features include: commercially available preparation of Vitamin D syrup is Child Health, 20th century, it has been estimated that 85% risk for Vitamin D deficiency include those with: of children living in northern hemisphere urban 1. limited sunlight exposure, 3. What alternatives are available to • raised alkaline phosphatase (bone specific alkaline the multivitamin preparation “Infant Pentavite” which Royal Children’s phosphatase, BSAP), due to increased bone turnover contains 400iu Vitamin D per dose. Hospital, Melbourne industrialised cities had rickets. Major public 2. highly pigmented skin, or those who do not get adequate health initiatives were then introduced to tackle 3. malabsorption syndromes. • raised parathyroid hormone, in response to Food type Vitamin D content – hypocalcaemia this problem. exposure to sunlight to meet the iu per 100gm EXECUTIVE INDEX Specific social and cultural settings that may • low or undetectable 25 OHD3 In “sunny Australia” rickets has not been predispose individuals to Vitamin D deficiency requirements for the body to Cod liver oil 8,000 – 28,000 Other biochemical changes such as serum 1,25 OHD , Rickets in the 21st 1 considered a significant health problem until include: manufacture Vitamin D? 3 Oily fish (e.g. salmon, sardines) 200 – 480 calcium and phosphate levels are variable, and century the last decade or so, when a rising incidence • reduced sun exposure in institutionalised Margarine 200 – 240 dependent on the course of the disease. 1,25 (OH) D of Vitamin D deficiency rickets occurring in and “house bound” individuals, especially 2 3 Eggs 40 – 80 may often be within the upper end of the reference range southern states in particular, has been the chronically disabled, Breast milk 12 – 60 iu/l or frankly elevated. Both serum calcium and serum observed, however as yet there has been no • the practice of Hajjab in the Islamic Infant formulas 400 iu/l phosphate may be low or within the normal range, hence systematic approach to prevention. This article tradition, where women are almost entirely covered for reasons of modesty, measurement of these parameters is unhelpful in Conclusion will outline both the pathophysiology and diagnosis. Serum phosphate is characteristically clinical features of rickets, highlighting • highly pigmented individuals who are Although Vitamin D deficiency rickets almost exclusively decreased in long standing rickets, due to the recognition of infants and children at risk. socially isolated, particularly apartment occurs in a very small at risk group, it remains a major phosphaturic action of PTH. dwellers, who spend minimal time exposed cause of morbidity in affected individuals, with Rickets is broadly defined as undermineralised to direct sunlight. Sources and preparations of Vitamin D bone, particularly at the metaphyseal growth Note from the Editor hypocalcaemic seizures occurring in young infants, bone Vitamin D metabolism (see Figure 1) involves plates, in growing children. The skeleton is a Vitamin D preparations used for Vitamin D deficiency pain with or without gross motor delay in older children, multiple organ systems, namely the skin, liver, • We hope that you continue to gain value from this complex structure comprising mineral ions include ergocalciferol (D ) and cholecalciferol (D ) and and osteomalacia with bone pain and increased risk of kidney, placenta, gut and bone. For this publication. If you are looking for any back copies 2 3 which precipitate on a predominantly collagen either preparation is effective in restoring Vitamin D osteoporotic fractures in at risk mothers. Cultural reaction to take place there must be direct go to: www.rch.org.au/ccch/pub framework of bone matrix proteins, to form the stores in Vitamin D deficiency. The active form of Vitamin sensitivity towards and clinical awareness of this readily exposure to sunlight or other sources of UV B, • Please feel free to let us know of any topics/issues preventable medical condition is needed to ensure that rigid, strong structure characteristic of normal D, 1,25 (OH)2 Vitamin D3 (calcitriol) should not be used as this wavelength of UV radiation is not that you would like to have addressed in this bone. Reinforced concrete may be considered to treat Vitamin D deficiency as it “bypasses” the Vitamin D deficiency rickets once again become “a transmitted through glass or clothing. Both publication. an analogy of bone structure, as the steel regulating step of 1 alpha hydroxylation in the kidney, and disease of the past”. dietary Vitamin D and D , and skin provides tensile strength, analogous with the 2 3 • A parent information sheet is supplied with this may lead to hypercalcaemia. Furthermore, calcitriol does Author synthesized Vitamin D are hydroxylated in the bone collagen and the concrete provides 3 edition. This master copy is designed for you to not build up hepatic stores of 25 OH Vitamin D. Dr Christine Rodda. PhD, FRACP liver to form 25 hydroxyvitamin D3 (25OH D3), photocopy and distribute to parents. Another rigidity analogous with bone mineral ion Expectant and lactating mothers have an increased Head, Paediatric Endocrinology and Diabetes which is the storage form of Vitamin D, and original copy can be accessed from deposition. In growing infants and children, Vitamin D requirement, 2 to 4 times the RDI for healthy Monash Medical Centre, Clayton this hydroxylation step is largely unregulated. www.rch.org.au/ccch/pub or contact bone growth, involving laying down of a adults. Identification of pregnant mothers at risk for Honorary Senior Lecturer Further hydroxylation of 25OH D3 to form 1,25 Wyeth Nutrition on 1800 552 229. collagen framework, which is subsequently Department Biochemistry and Molecular Biology dihydroxyvitamin D (1,25(OH) D ), occurs in Vitamin D deficiency and providing Vitamin D mineralised, predominantly occurs at the meta- 3 2 3 Email: [email protected] Monash University, Clayton the kidney, through the stimulation of 1 alpha supplementation during pregnancy, will protect both the physeal growth plates, within the long bones. hydroxylase by parathyroid hormone (PTH), Unmineralised osteoid, as occurs in rickets in hypocalcaemia (probably indirectly via PTH) c p r Community Pædiatric Review Editors Production Editor SUPPORTED BY AN children, results in soft, pliable bones. Professor Frank Oberklaid Vicki Attenborough Raelene McNaughton EDUCATIONAL GRANT FROM SUPPORTED BY AN EDUCATIONAL GRANT FROM Sharon Foster Carolyn Briggs CENTRE FOR COMMUNITY CHILD HEALTH Michele Meehan Jenny Donovan ROYAL CHILDREN’S HOSPITAL, MELBOURNE Dr Jane Redden-Hoare Libby Dawson TEL 1800 55 2229 For further information contact the Centre for Community Child Health, Royal Children’s Hospital, Melbourne. Phone 03 9345 6150 or Fax 03 9347 2688 www.rch.org.au/ccch TEL 1800 55 2229 © COPYRIGHT 2005. THIS PUBLICATION IS COPYRIGHT. APART FROM ANY FAIR DEALING FOR THE PURPOSE OF PRIVATE STUDY, RESEARCH, CRITICISM OR REVIEW AS PERMITTED UNDER THE COPYRIGHT ACT, NO PART MAY BE REPRODUCED BY ANY CENTRE FOR COMMUNITY CHILD HEALTH, ROYAL CHILDREN’S HOSPITAL, MELBOURNE PROCESS OR PLACED IN COMPUTER MEMORY WITHOUT WRITTEN PERMISSION. ENQUIRIES SHOULD BE MADE TO THE PRODUCTION EDITOR. In populations where there is no Vitamin D supplemented receives 25 OHD3 from transplacental transfer from the foodstuffs, approximately 90%