Purpose In the last few decades, there has been an increase in the reports of nutritional rickets due to deficient intake of vitamin D in the United States and other developed countries, particularly among vulnerable population of children. We call the attention over the reemergence of a nutritional problem that should have been eradicated.
Methods and Results We have seen in the last 10 years several patients with nutritional rickets and have selected 4 representative cases from our clinics that presented with tetany, bony deformities such as bowed legs, widening of wrists and ankles, and rachitic rosary, ages 0.3 to 3.3 years, three African American and one Arabic. They all had been breast-fed with no vitamin D supplementation and after weaning from breast milk had negligible intake of vitamin D-fortified milk or dairy products, with very limited exposure to UV solar radiation. All had low serum total calcium between 6.1 and 7.8 mg/dL (8.7-10.3 mg/dL) and ionized calcium between 2.2 and 4.3 mg/dL (4.3-5.9 mg/dL), relatively low normal serum phosphorus between 4.3 and 6.1 mg/dL (4.0-9.5 mg/dL), and elevated alkaline phosphatase between 391 and 1,158 U/L (70-250 U/L). All had low serum 25(OH) vitamin D between 5.0 and 21 ng/mL (20-60 ng/mL) and high PTH between 25 and 454 pg/mL (10-60 pg/mL) and relatively high 1,25(OH)2 vitamin D between 93 and 195 pg/mL (15-90 pg/mL). Renal and liver functions were normal. All had complete or near-complete resolution of their medical problems with appropriate therapeutic doses of calcium, ergocalciferol, or calcitriol.
Conclusions Nutritional rickets due to vitamin D deficiency and not associated with other organic or metabolic problem resolves easily with the administration of intravenous calcium followed by oral calcium supplementation and therapeutic doses of ergocalciferol or calcitriol. The risk factors for vitamin D deficiency in these children were not timely anticipated. Recommendations from the Committee on Nutrition of the American Academy of Pediatrics 2003 (adequate UV light solar exposure and supplementation of 200 IU vitamin D if taking fortified formula or 400 IU vitamin D if breast-fed exclusively) had not been followed. Health care providers should be aware that nutritional rickets due to vitamin D deficiency is still prevalent and is preventable.
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