I16 Nutritional rickets presenting to secondary care in children (<16 years) – a uk surveillance study

Abstract

AimsRickets is a disease of growing children with serious short and long-term complications. Although the prevalence of rickets has been reported widely to be increasing the actual national incidence of nutritional rickets (NR) in the United Kingdom (UK) is unknown. This study aims to describe the incidence, presentation, and clinical management of children with NR in the UK and ROI.MethodsData was collected prospectively monthly between March 2015-March 2017 from 3500 paediatricians using British Paediatric Surveillance Unit reporting methodology with the following definition (table 1):Abstract I16 Table 1 Clinical rickets with any of the following:• Leg deformity/Swollen wrists or knees or ribs AND 250 hour vitamin D<25 nmol/L with one or more abnormalities of serum calcium, alkaline phosphatase, phosphate, parathyroid hormone OR Radiological rickets with:• Widening, cupping, splaying of metaphysis (of any long bone) AND 25OHVitamin D<25 nmol/L Results130 cases met the case definition with an overall annual incidence of 5.04 cases per million children under 16 years.London, East Midlands, West Midlands and Scotland had estimated incidences above the national incidence. Boys (91/130; 70%) were significantly more affected than girls (39/130; 30%) and the majority were of Black (44.6%) and South Asian (36.2%) ethnicity with a median age of 18 months. The commonest clinical presentations were bowed legs, swollen wrists and radiological rickets. Comorbidities included fractures (15/130; 11.5%) hypocalcaemic seizures (11/130; 8.5%;), and dilated cardiomyopathy (4/130; 3%) Two children died of dilated cardiomyopathy from vitamin D deficiency. The commonest associated conditions were cows milk protein allergy (19/51; 19%; ) iron deficiency (8/51; 7%) and eczema (8/51; 7%) At the time of diagnosis 77% of children were not receiving vitamin D supplements. 19 children had rickets despite being reported to be receiving appropriate supplementation. All confirmed radiological cases had either high parathyroid hormone and/or low phosphate. Following diagnosis, most clinicians initially prescribed treatment themselves, with huge variation in duration of prescriptions. In a further 10 cases, rickets was confirmed but excluded in the incidence analysis, for not meeting the case definition (specifically Vitamin D<25 OHnmol/L), suggesting both dietary calcium deficiency and vitamin D insufficiency as role-players in the presentation of NR in the UK.ConclusionsNR continues to affect children in the UK with serious sequelae. Uptake of vitamin D supplementation remains low and constitutes a failure of current public health policy. A UK national policy focusing on vitamin D and calcium supplementation and adherence is required to eliminate this entirely preventable condition.

The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales

“…While both supplements and fortified foods are important sources of vitamin D for the UK population, evidence suggests supplementation polices are not working (7,17) and the mean daily vitamin D intake is still below the Reference Nutritional Intake (RNI) of 400 IU per day (2,18). Therefore, rickets and hypocalcemic complications remain a serious health issue and cause of death in infants, particularly in the BAME group (4,7,19,20). Evidence shows that vitamin D status, which is measured through the blood concentration of a Vitamin D metabolite, the 25-hydroxyvitamin D [25(OH)D], is suboptimal in 13% of the European population (21).…”