Rickets: on the increase

Although a term that’s familiar to us, there’s still a world of unknown that surrounds rickets. Claudia MacCurvin explores the condition and how it became apparent to her everyday life.

ntil recently, when I heard of a case of rickets, there were generally two images that would spring to mind. The first was the idea of a malnourished child (ren) and the second is that of Timothy “Tiny Tim” Cratchit. However, further to my own daughter’s 18-month check with our Health Visitor, a home visit from her colleague and a subsequent appointment with a Consultant Paediatrician the image I now have is in fact of my own 20-month old daughter.

Although not overly concerned about Leila’s gross motor development we had noticed some unusual traits, which I had mentioned to our Health Visitor and GP at various stages:
• Although attempting to pull herself up to standing position, she was only weight bearing on one leg (foot flat on the ground). The other leg, her left, would remain in a kneeling position therefore bearing weight at her knee
• When held vertically she was reluctant to weight bear and adopted the sitting-on-air position or beckoned to go “down”, meaning to be assisted to return to the sitting position
• Crawling – she briefly crawled on two knees but quickly developed a pattern of asymmetric bum shuffling
• Her ankles and wrists bones were visibly enlarged, the latter I now know is a common symptom of rickets.

What prompted concern was the prominence of gross motor delay, which, coupled with the other symptoms instigated a referral to our local child development team where we met with a Consultant Paediatrician. The diagnosis itself came remarkably quickly, where the consultant spotted swollen wrists and strongly suspected that rickets was the underlying issue. Leila underwent a subtle physical examination and the consultant conducted a thorough exploration of our family medical history. As a result, Leila was promptly referred to our local hospital where they conducted blood tests and an X-Ray of Leila’s wrists, confirming she was suffering from rickets.

Rickets is a condition that affects bone development in children. It causes the bones to become soft which can lead to bone deformities and is caused by vitamin D deficiency, often associated with low calcium and iron levels. Rickets can be traced back to Ancient Rome where bone deformities in infants were attributed to the failure of mothers to nurture and clean their children. However it was particularly prominent during the 18th century when the air pollution of the Industrial Revolution obstructed sunlight needed for vitamin D production; resulting in the deaths of many children. The lack of vitamin D results in weak or soft bones along with slowed growth, skeletal development and damages its important function of regulating the amount of calcium and phosphate in the body. Vitamin D deficiency puts children aged 6-24 months at particular risk given that their skeletons are growing at an accelerated rate.

By large, rickets is “not uncommon” according to one consultant I talked to, who estimates that he sees an average ‘one to two cases per year’. Its potential to be overlooked was perhaps, one of the important conclusions following the tragic death of Baby Jayden Wray, prompting the Community Practitioners and Health Visitors Association (CPHVA) to announce that, ‘All health visitors and family nurse partnership nurses must ensure that they are able to recognise the symptoms of rickets and refer appropriately.’

Treatment rather depends on the individual but in general can include increased intake of vitamin D and calcium, and in some cases iron, over a period of weeks or months. Rarely, in more severe cases, surgery may be required to correct bone deformities.

The growing number of people with vitamin D deficiency continues to be a topic for debate among medical and health professionals. 83% of Paediatric Dieticians reported seeing an increase in rickets in the last 5 years, according to a survey conducted by Kellogg’s. These statistics together with the National Diet and Nutrition Survey (2008/9 and 2010/11) prompted the four Chief Medical Officers for the United Kingdom to issue a letter to related health professionals calling for explicit advice on supplements for at risk groups including:
• All pregnant and breastfeeding women, especially teenagers and young women
• Infants and young children under 5
• Older people aged 65 years and over
• People who have low or no exposure to the sun, for example those who cover their skin for cultural reasons, or confined indoors for long periods
• People who have darker skin (such as African, African-Caribbean and South Asian origin) as their bodies do not produce as much vitamin D.

In their letter, dated February 2010, they reflect upon key findings from the NDNS stating that it “demonstrates that up to a quarter of people in the UK have low levels of vitamin D in their blood, which means they are at risk of the clinical consequences of vitamin D deficiency”. The relevance to dietary consumption is important given that sources of vitamin D can be found in a small amount of foods such as oily fish, liver, meat and eggs. In the UK, processed and some powdered milks, margarine (a legal requirement) and breakfast cereals are also fortified with vitamin D, with Kellogg’s making a further promise to add vitamin D to all their children’s cereal range in a press release, November 2011.

While medical opinions and advice may change, or be conflicting, there is no confusion about the most reliable source of vitamin D being from sun-synthesis through the skin. “Regularly going outside for a matter of minutes around the middle of the day without sunscreen, while taking care to avoid sunburn, should be enough to provide the benefits of vitamin D without unduly raising the risk of skin cancer”, according to National Institute for Health and Clinical Excellence (NICE). How much a modern society contributes to this is yet to be proven but preliminary thoughts suggest that the costs of a nation that spend a large proportion of time in cars, on trains and inside our homes is yet to be seen.

Recommendations from the Department of Health and all UK Health Departments are as follows:
• All pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D, to ensure the mother’s requirements are met and to build adequate fetal stores for early infancy.
• All infants and young children aged 6 months to 5 years should take a daily supplement in the form of vitamin drops, to help meet the requirement set for this age group of 7-8.5 micrograms per day. However, those infants who are fed infant formula will not need vitamin drops until they are receiving less than 500ml of formula a day, as these products are fortified with vitamin D. Breastfed infants may need to receive drops containing vitamin D from one month of age if their mother has not taken supplements throughout pregnancy.
I personally think there’s much more to be done to prevent rickets from becoming widespread. Whilst I’m aware of the demands on midwives, I do feel a more in-depth review of my diet and medical history would have highlighted my need to take vitamin D supplements throughout my pregnancy and beyond – as would a standard blood test. Research and development is encouraging but without resources to support, it’s a fruitless plot.

Thankfully, Leila is responding well to medication, she is visibly much stronger and although not walking, she is now pulling herself to standing position and climbing on and off furniture with ease. The consultant is confident she’ll be walking fairly soon without surgical intervention. I too have recently been diagnosed with vitamin D deficiency and have begun a course of supplements as supplied by my GP.

I would like to extend my personal thanks to Dr Ben Lloyd, Consultant Paediatrician and his colleagues at the Child Health Team at the Royal Free Hospital whose quick diagnosis and efficiency have single-handedly restored my faith in the quality of service provision within the NHS.