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Rickets Vs. Abuse: a National and International Epidemic

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Rickets Vs. Abuse: a National and International Epidemic Pediatr Radiol DOI 10.1007/s00247-008-1001-z COMMENTARY Rickets vs. abuse: a national and international epidemic Kathy A. Keller & Patrick D. Barnes Received: 4 November 2007 /Revised: 28 July 2008 /Accepted: 18 August 2008 # Springer-Verlag 2008 Keywords Rickets . Child abuse . Metabolic bone disease . women 18 to 29 years of age in Boston. A recent study of Nonaccidental injury healthy infants and toddlers aged 8 to 24 months in Boston found an insufficiency rate of 40% and a deficiency rate of 12.1% [4]. In the May 2007 issue of Pediatric Radiology, the article In September 2007, a number of articles about congen- “Can classic metaphyseal lesions follow uncomplicated ital rickets were published in the Archives of Diseases in caesarean section?” [1] suggested that enough trauma could Childhood including an international perspective of mother occur under these circumstances to produce fractures previ- and newborn DD reported from around the world [5]. ously described as “highly specific for child abuse” [2]. Concentrations of 25-hydroxyvitamin D [25(OH)D] less However, the question of whether the metaphyses were normal than 25 nmol/l (10 ng/ml) were found in 18%, 25%, 80%, to begin with was not raised. Why should this be an issue? 42% and 61% of pregnant women in the UK, UAE, Iran, Vitamin D deficiency (DD), initially believed to primarily northern India and New Zealand, respectively, and in 60 to affect the elderly and dark-skinned populations in the US, is 84% of non-western women in the Netherlands. Currently, now being demonstrated in otherwise healthy young adults, most experts in the US define DD as a 25(OH)D level less children, and infants of all races. In a review article on than 50 nmol/l (20 ng/ml). Levels between 20 and 30 ng/ml vitamin D published in the New England Journal of are considered to indicate insufficiency, reflecting increas- Medicine last year [3], Holick reviewed some of the recent ing parathyroid hormone (PTH) levels and decreasing literature, showing deficiency and insufficiency rates of calcium absorption [3]. With such high prevalence of DD 52% among Hispanic and African-American adolescents in in our healthy young women, congenital deficiency is Boston, 48% among white preadolescent females in Maine, inevitable, since neonatal 25(OH)D concentrations are 42% among African American females between 15 and approximately two-thirds the maternal level [6]. 49 years of age, and 32% among healthy white men and Bodnar et al. [7] at the University of Pittsburgh, in the largest US study of mother and newborn infant vitamin D Editor’s note: See related articles in this issue: Slovis TL, Chapman S levels, found deficient or insufficient levels in 83% of black doi:10.1007/s00247-008-0997-4; Chesney RW doi:10.1007/s00247- women and 92% of their newborns, as well as in 47% of 008-0993-8; Jenny C doi:10.1007/s00247-008-0995-6; Slovis TL, Chapman S doi:10.1007/s00247-008-0994-7 white women and 66% of their newborns. The deficiencies were worse in the winter than in the summer. Over 90% of K. A. Keller these women were on prenatal vitamins. Research is Pediatric Radiology of America, Stanford, CA 94305, USA currently underway to formulate more appropriate recom- mendations for vitamin D supplementation during pregnan- P. D. Barnes (*) cy (http://clinicaltrials.gov, ID: R01 HD043921). ’ Department of Radiology, Lucile Packard Children s Hospital, The obvious question is, “Why has DD once again 725 Welch Road, ” Palo Alto, CA 94304, USA become so common? Multiple events have led to the high e-mail: [email protected] rates of DD. In the past, many foods were fortified with Pediatr Radiol vitamin D. At present, milk is the only product required to best location to search for radiographic evidence of congenital be fortified in the US, although studies have shown that up rickets and nutritional rickets in infants less than 3 months to 70% of sampled milk does not contain the required of age is in the cranium [19]. The skull, as a reflection of amount of vitamin D. There are few other natural food rapid brain growth in early life, is the most affected bone at sources of vitamin D. While exposure to the sun’s UVB this age. Softening of the skull (craniotabes), especially in rays remains the best natural source of vitamin D, during the occipital region with palpable enlargement of the sutures the winter months, above the 35° latitude (at the level of and fontanelles, was a common clinical finding with Atlanta, Georgia) there is a loss of UVB rays that are congenital rickets in the past, and is once again being necessary for skin synthesis of vitamin D. In addition, described in association with newborn DD [20]. Demineral- along with the concern for skin cancer and skin aging, there ized sutures create a diastatic appearance with poorly defined has been a significant increase in the use of sunscreen and margins on radiographs (pseudodiastasis). The skull is better protective clothing. A sun protection factor of 8 blocks evaluated on the head CT scan, which should be done to about 95% of the UVB rays, and with regard to vitamin D, exclude sutural diastasis from increased intracranial pressure. sunscreen use produces the same effect as a burka worn by Indistinctness of the facial bones and the orbital roof make certain Islamic women, who, even in the sunny climate of the teeth and petrous bones appear relatively dense on the Middle East, continue to have high rates of DD. The radiographs [21]. increase in obesity is another important factor since fat Metaphyseal changes of the long bones appear first at storage of this vitamin decreases its availability to the rest the most recently formed metaphyseal margin, the Laval- of the body. In a recently published study, the vitamin D Jeantet ring. These metaphyseal changes are usually status of neonates born to obese mothers was found to be symmetric, and will occur first in the fastest-growing long poorer than the vitamin D status of neonates born to lean bones (the femurs, tibiae and fibulae). The metaphyseal mothers [8]. changes in the distal femurs and proximal tibiae occur first Over the past few decades, there has been a significant along the medial aspects [22], and the early metaphyseal increase in the frequency and the duration of breast-feeding, changes in the distal ulnar can be found even when the both of which are risk factors for infant nutritional DD. In distal radial metaphyses appear normal [23]. While the 2003, the American Academy of Pediatrics published physeal and metaphyseal changes can be subtle in early guidelines recommending that all breast-fed infants receive infancy, with treatment, the metaphyses may become 100% of their daily vitamin D requirement from supple- increasingly sclerotic and deformed [23]. While these early mentation. Research has demonstrated breast milk to be so metaphyseal changes may mimic Salter-Harris II fractures, deficient in vitamin D that the average lactating woman they are asymptomatic and, with treatment, usually resolve must feed her infant 8 l (about 89 three-ounce bottles) of without the interval stages of fracture healing (subperiosteal breast milk per day to provide the recommended daily new bone formation, callous, and remodeling) within a few vitamin D intake of 200 IU [9]. Even infants born to weeks. When subperiosteal changes are present, particularly mothers who are replete with vitamin D demonstrate in the tibiae, a lateral view may reveal early bowing decreasing levels within 8 weeks if not supplemented deformity. Bowing deformities of the long bones prior to [10]. Ziegler et al. [11] at the University of Iowa, during a weight bearing are not common, but when present, they study of iron levels in breast-fed infants, incidentally found reflect positional stresses or musculotendinous forces, that the majority of their unsupplemented infants had DD, such as the “saber shin deformity” where the pull of the with severe DD common in the winter. Recent literature Achilles tendon on the calcaneus causes the tibiae to bow suggests that supplementing lactating women with 2,000 to anteriorly [19]. 4,000 IU per day (rather than the current recommendation Rachitic flaring of the anterior rib ends will also be of 400 IU per day) is required to provide both the mother subtle on radiographs in the acute stage at this age, but may and her breast-fed infant with adequate vitamin D [12]. become more pronounced with healing. Loss of cortical What are the radiographic findings of congenital and distinction, subperiosteal new bone formation in the long nutritional rickets in infants younger than 6 months old, the bone diaphyses, insufficiency fractures and Looser zones age at which we typically first see the fraying and cupping (i.e. pseudofractures) of the ribs and forearms have all been associated with rickets? The appearance of DD in early described in infants [19, 23, 24]. It may be particularly infancy will vary with many factors, including age at difficult to distinguish rib fractures from Looser zones in presentation, prenatal maternal DD, nutritional history, infants on radiographs alone. Timing of fractures in children geographic location, sun exposure, skin color, and season. with rickets is not possible since published parameters Past case reports of congenital rickets range from normal- assume normal underlying bone. The only assumption that appearing bones to diffuse bone rarefaction, fractures at can be made of fractures in an infant with DD is that the birth, and metaphyseal fraying and cupping [13–18]. The healing will be delayed. Pediatr Radiol It is also important to remember when searching for have shown that adults with osteoporosis have 30–40% radiographic evidence of vitamin deficiencies that multiple bone mineral loss before it becomes evident on radio- deficiencies are the rule and may modify the radiographic graphs.
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