Nutritional rickets under 16 years: UK surveillance results

Abstract

ObjectiveThe UK national incidence of nutritional rickets is unknown. We aimed to describe the incidence, presentation and clinical management of children under 16 years with nutritional rickets in the UK presenting to secondary care.MethodsProspective data were collected monthly between March 2015 and March 2017 from 3500 consultant paediatricians using British Paediatric Surveillance Unit methodology. Clinicians completed online clinical questionnaires for cases fitting the surveillance case definition.Results125 cases met the case definition, an annual incidence of 0.48 (95% CI 0.37 to 0.62) per 100 000 children under 16 years. 116 children were under 5 years (annual incidence of 1.39 (95% CI 1.05 to 1.81) per 100 000. Boys (70%) were significantly more affected than girls (30%) (OR 2.17, 95% CI 1.25 to 3.78). The majority were of Black (43%) or South Asian (38%) ethnicity. 77.6% of children were not taking vitamin D supplements despite being eligible. Complications included delayed gross motor development (26.4%), fractures (9.6%), hypocalcaemic seizures (8%) and dilated cardiomyopathy (3%). Two children died (1.6%). In eight cases, rickets was confirmed radiologically and biochemically [raised serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) levels ] but were excluded from the incidence analysis for not meeting the case definition of 25-hydroxyvitamin D of <25 nmol/L.ConclusionThe incidence of nutritional rickets in the UK is lower than expected. Serious complications and unexpected deaths, particularly in Black and South Asian children under 5 years, occurred. Both vitamin D deficiency and dietary calcium deficiency are role players in pathogenesis. Uptake of vitamin D supplementation remains low.

Vitamin D supplementation and testing in the UK: costly but ineffective?

“…18 In the second survey, 125 cases of rickets that met a standard, predefined definition were reported over 2 years between 2015 and 2017. 19 These figures may be underestimates because rickets may be under-recognised or non-skeletal complications, such as hypocalcaemic seizures or cardiomyopathy, may not be attributed to vitamin D deficiency. [19][20][21] Nevertheless, the findings from these three reports are consistent with the hospital statistics, and collectively show that neither rickets nor osteomalacia admissions have decreased substantially.…”

“…24 Rickets and osteomalacia are preventable and others have argued that the UK should be able to prevent these conditions through public health policy. 18,19,24 Box shows five possible broad strategies and their advantages and disadvantages. The public health strategy that is most likely to be effective is food fortification.…”

Interventions to improve vitamin D status in at-risk ethnic groups during pregnancy and early childhood: a systematic review

“…Vitamin D is an essential nutrient that contributes to bone health, and deficiency status increases the risk of rickets, osteomalacia and osteoporosis (2)(3)(4) . Pregnant women and their breastfed neonates as well as older children are at particular risk for vitamin D deficiency, as are Black and ethnic minority groups (1) .…”

“…Short-term implications include lower neonate birth weight, length and head circumference (6,(8)(9)(10) and skeletal outcomes such as muscle pain and fractures (11) . Hypocalcaemic seizures, rickets and cardiomyopathy have been reported in children under 5 years (2,12) . Deficiency in childhood is associated with obesity and metabolic syndrome (13) , and is a significant risk factor for dental caries (10,14,15) .…”

“…In women of childbearing-age, supplementation rates range between 12-27% (17) , and data indicates 63% women of reproductive age are vitamin D deficient (18) . The Royal College of Paediatrics and Child Health and the British Paediatric Surveillance Unit recently ascertained the national incidence of nutritional rickets in children under age 16 years (2) . Black and South Asian children had a 10-fold and 5-fold greater incidence of nutritional rickets respectively, compared with other ethnic groups under 5 years.…”