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Reports of Rickets a Worrying Turn

Posted on: Wednesday, 23 July 2008, 06:00 CDT

Over the last three years, pediatricians in Philadelphia have identified more than 150 cases of rickets, the childhood scourge that was virtually eliminated from early 20th-century America by milk fortified with Vitamin D.

Unlike infectious diseases such as tuberculosis, rickets is not tracked by the government, so it is difficult to know if it is increasing. But the new statistic, culled from billing records at three children's hospitals, almost certainly represents just part of the total.

"For a disease that's 100 percent preventable, one is too many," said pediatrician Dan Taylor, who last week was examining Khamani Thompson, age 14 months, whose growth has been stunted by rickets.

The disease generally leaves no lasting effects if treated early, as Khamani's was. But it can lead to serious developmental problems in the rare cases when it is not.

While childhood rickets is perhaps the most serious manifestation of Vitamin D deficiency, new research suggests that the nutrient is so integral to human metabolism that low levels in adults may raise the risk of heart disease, hypertension, diabetes, depression, multiple sclerosis, and several types of cancer.

Some surveys show that half or more of the population fails to get enough of the "sunshine vitamin" to meet federal guidelines. And many doctors believe that current recommendations are too low.

The American Academy of Pediatrics this fall will publish new guidelines that double the amount of Vitamin D that the government recommends. This will be the pediatric group's third set of guidelines in six years.

Taylor saw his first case of rickets -- a 1-year-old boy with bowed legs -- two years ago, and another a couple of months later. When colleagues told him they had seen similar patients, he checked records at St. Christopher's Hospital for Children (73 cases), Temple Children's Medical Center (11) and Children's Hospital of Philadelphia (67).

Most were African American and many were Muslim -- groups that researchers say are at high risk for reasons that include religious and cultural practices.

Vitamin D is crucial to the absorption of phosphorus and calcium, the body's most abundant mineral, which in turn is required for skeletal development, muscle contraction and nerve conduction.

The vitamin is most critical during spurts of bone-building: pregnancy, infancy and adolescence.

Deficiency is a side effect of modern civilization. While some Vitamin D occurs naturally in fatty fish such as salmon, most of what we need is made in skin exposed to ultraviolet radiation in sunlight.

For a species that evolved in Africa, latitudes more distant from the equator do not provide optimum sun. The advent of clothing further reduced exposure, and more recent trends -- industrialization, air pollution, even video games and sunscreen -- cut it further. Skin that is dark in pigment or thin from old age also makes less Vitamin D.

Before store-bought milk was fortified in the 1930s, rickets was common among poor children. Short stature, delayed tooth development and misshapen skeletons were seen on the street.

That is no longer true. So why should a disease that every medical student has known how to prevent for nearly a century be here at all?

Taylor, who is also an assistant professor at the Drexel University College of Medicine, has formed a task force at St. Christopher to ponder these questions.

Perhaps, he says, the covering worn by practicing Muslims could be diminishing their ability to produce Vitamin D.

Maybe, he says, some doctors weren't stressing Vitamin D enough -- and that the one downside of nursing is that babies miss out on the "fortified" vitamin added to all infant formula and cow's milk.

This is what he says he didn't do with Regina Thompson until her son's low weight gain stared him in the face.

"I always was taught that breast milk was the healthiest thing," said Thompson, 29, of Northeast Philadelphia, who has exclusively breast-fed all five of her children.

Taylor diagnosed Khamani with rickets four months ago. It turned out his mother had used the vitamin drops Taylor recommended for only one child, and all of Khamani's siblings were healthy.

"It took for him to be on my head about this -- 'This is important!' -- to get me to do it," Thompson said last week at the clinic, where she had taken Khamani for an ear infection.

Massive amounts of Vitamin D and calcium returned his levels to normal. Thompson worries about his weight: just 15 pounds, which is average for a 4-month-old. Khamani is 10 months older.

Anne Merewood, an assistant professor of pediatrics at Boston University School of Medicine, knows the pattern.

Preliminary data from her new study of 433 mothers and 376 newborns at Boston Medical Center showed that a mother's skin color alone put black babies at 21/2 times greater risk for severe Vitamin D deficiency compared with white babies -- 10 percent vs. 28 percent in her sample -- at birth.

Muslims who cover themselves are at further risk, she said. So are immigrants who come from Islamic countries with more sun.

"And the Quran says you should breast-feed for the first two years of life," Merewood said. If the breast-feeding mother doesn't give vitamin drops to her infant, the risk goes still higher.

More than 42,000 Muslims live in Philadelphia, making up nearly 3 percent of the population, according to population estimates.

Some Muslims may skip Vitamin D supplements fearing that they don't meet the dietary restrictions known as halal, said Zain Abdullah, an assistant professor of religion, race and ethnicity at Temple University.

Traditions can also play a role in deciding whether to follow a doctor's advice on Vitamin D drops, said nurse specialist Diane Spatz, an expert in the use of human milk in vulnerable populations.

"I think it really comes down to how you explain it or how you educate someone," said Spatz, director of lactation programs for Children's Hospital of Philadelphia.

One of the first detailed descriptions of rickets in a largely non-immigrant Muslim population was published in the journal Pediatrics by doctors at Children's Hospital of Philadelphia in 1979. They identified 24 cases, all in African Americans; 16 were Muslim.

Is rickets on the rise?

Steven Bachrach, who coauthored that study during his residency and now is chief of general pediatrics at Alfred I. Du Pont Hospital for Children in Wilmington, believes that rickets has occurred steadily at least since then in specific populations; he published a paper a few years ago about rickets in U.S. children adopted from Russia.

The recent revelations about possible links between Vitamin D and conditions that have nothing to do with bones -- from cancers to depression -- have led to more screening, which doctors say may be finding more rickets.

The majority of people with deficiencies don't show symptoms, said Francesco De Luca, chief of endocrinology at St. Christopher and a consultant to the rickets task force.

"Vitamin D is important to prevent many other different problems," he said. "This is beyond rickets."

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Changing World of Vitamin D

New findings about the vitamin's benefits come as surveys show that many Americans fail to get enough, and proper amounts vary among different groups.

Healthy levels may protect against:

Heart disease.

Various cancers.

Immune system disorders such as multiple sclerosis and rheumatoid arthritis.

Infectious diseases like tuberculosis and the flu.

Mental illness including depression and schizophrenia.

Severe deficiencies may make*:

* Besides the long-known risk of rickets.

Men more likely to have heart attacks.

Colon and breast cancer victims less likely to survive.

Children more likely to develop diabetes.

At greater risk are people who:

Are exposed to less sun because they have dark skin, which blocks UV rays; live in northern latitudes; wear clothing that covers virtually all of their skin; stay indoors; or apply sunscreen liberally.

Are elderly, when thinning skin reduces production.

Don't get supplemental Vitamin D, which is intended to make up for insufficient sun exposure. Most people get this from Vitamin D-fortified milk or infant formula; breast-fed babies need Vitamin D drops.

More information about recent research, and links to detailed recommendations: http://go.philly.com/health

Source: The Philadelphia Inquirer

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