Management Of Nutritional Rickets Research Articles

Parathyroid hormone-vitamin D dynamics vary according to the definition of vitamin D deficiency in newborn infants.

Parathyroid hormone (PTH) is an indirect functional indicator of vitamin D status. Risk of vitamin D deficiency, assessed using circulating 25-hydroxyvitamin D (25(OH)D), is defined as <30nmol/L by the National Academy of Medicine and alternatively <25nmol/L in the global consensus recommendation on prevention and management of nutritional rickets. To test PTH concentrations and the odds for elevated values according to vitamin D deficiency cut-points (<30nmol/L, or <25nmol/L) in newborn infants. Healthy term-born infants (n=858) were recruited from Montreal, Canada (2016-2019). Obstetric data were obtained from medical records, and demographic factors surveyed. Immunoassays were used to measure newborn (24-36h) serum PTH and 25(OH)D; 25(OH)D was standardized to National Institute of Standards and Technology (NIST) standard reference materials. Serum PTH was log-transformed before comparing serum 25(OH)D groups (<30 vs. ≥30; or <25 vs. ≥25nmol/L) using ANCOVA adjusted for infant sex, type of delivery, parity, race, and family income. The odds of elevated PTH (>71.48pg/mL) were tested using logistic regression, adjusted for the same covariates. Infants (50.2% female) were 39.6±1.0weeks gestational age (mean±SD), and 3.41±0.38kg. Median serum 25(OH)D was 45.4 (IQR 23.2) nmol/L; 20.5% had serum 25(OH)D<30nmol/L, and 12.4% <25nmol/L. Median serum PTH was 30.72 (IQR 33.90) pg/mL, elevated in 12.7% overall, and higher in infants born with serum 25(OH)D<25 vs. ≥25nmol/L (35.96 (IQR 39.20) vs. 30.36 (IQR 32.93) pg/mL, p=0.0158). The odds of elevated PTH were higher when serum 25(OH)D was <25nmol/L (ORadj 2.13, 95% CI: 1.23, 3.69). PTH concentration and the odds of being elevated did not differ according to the 30nmol/L cut-point. Based on this study, the definition of vitamin D deficiency relative to bone health as set by the National Academy of Medicine (<30nmol/L) exceeds the threshold at which PTH is elevated in newborn infants.

Vitamin D testing in children and adolescents in Victoria, Australia: are testing practices in line with global recommendations?

ObjectiveTo describe changing primary care ordering of serum 25-hydroxyvitamin D (25OHD) tests in Australian children.DesignLongitudinal, population-based descriptive study of 25OHD testing using a large administrative dataset of pathology orders and...

Approach to nutritional rickets.

Rickets is the disease of a growing skeleton and results from impaired apoptosis of hypertrophic chondrocytes and mineralization of the growth plate. Nutritionally induced rickets, secondary to vitamin D and/or calcium deficiency, remains a major global problem. In this review, we discuss pathogenesis, clinical signs, investigation and management of nutritional rickets.

P121: PREVALENCE OF VERTEBRAL COMPRESSION FRACTURE AND HYPOVITAMINOSIS D IN CHILDREN WITH THALASSEMIA MAJOR

Background: Thalassemia major has various complications that can increase morbidity and mortality. Osteoporosis is a common complication in thalassemia major and has a multifactorial pathogenesis. Osteoporosis can cause vertebral compression fractures and lead to disability. In TIF recommendation, a DEXA-scan is used to measure bone density in thalassemia patients. However, most patients in Indonesia could not afford the DEXA-scan examination because it is not covered by insurance. The 2019 ISCD Pediatric Positions Task Forces stated that the diagnosis of pediatric osteoporosis included the presence of a nontraumatic vertebral compression fracture (VF), without the need for BMD criteria. In Indonesia, there has been no study for the prevalence of hypovitaminosis D and vertebral compression fractures in children with thalassemia major and its correlation. Objective: To describe the prevalence of VF and hypovitaminosis D in children with thalassemia major. Methods: A cross-sectional study design was conducted in children with thalassemia major aged 7–18 years at the Thalassemia Center at Cipto Mangunkusumo National Hospital. Detection and evaluation techniques for vertebral fractures were using plain radiograph from Siemens Healthineers – Ysio Max – X-ray. The classification is based on Global Consensus Recommendations on Prevention and Management of Nutritional Rickets, whereas <30 nmol/L or <12 ng/mL are deficient, 30–50 nmol/L or 12–20 ng/mL are insufficient. Results: This study obtained 165 subjects (50,1% boys, 66% homozygous beta-thalassemia). Fifty-two subjects (31,5%) have VF, and three of them have both thoracal and lumbar fractures. The most common sites of VF were lumbar five and thoracic 11–12. The youngest subject who has VF is seven years old. Osteopenia was found in 67,3% of patients. There were no subjects with fractures who had complaints of pain or a history of previous trauma. Vitamin D levels [25(OH)D] were measured in 122 subjects, and hypovitaminosis D occurred in 77,9% of the subject (32,8% deficiency, 45,1% insufficiency). Our study found no significant relationship between vitamin D levels on the incidence of vertebral compression fractures (p>0,05). Conclusion: To our knowledge, this is the highest prevalence of VF among various studies that have been conducted. Vertebral X-ray is beneficial to detect bone density from osteopenia to fracture in children with thalassemia major. Hypovitaminosis D is common in thalassemia, requiring regular vitamin D administration. Further research is needed to consider the other contributing factors.

Seasonal variations in 25-hydroxy vitamin D3, parathormone and alkaline phosphatase in school-aged children

The main role of Vitamin D is to regulate calcium metabolism, whose main source is vitamin D3 ob tained mostly from the action of ultraviolet (UV) light on the skin. To evaluate the seaso nal differences in the concentrations of 25-hydroxy-vitamin D3 (25OHVitD3), parathyroid hormone (PTH), alkaline phosphatase (ALP), and calcium in school-age children. The concentrations of 25OHVitD3, PTH, ALP, and calcium were measured in children from Santiago, Chile (latitude -33.4372), aged 5 to 8 years, without Vitamin D supplementation, in different seasons of the year. VitD status was defined as sufficient with concentrations of 25OHVitD3 >20 ng/mL (50 nmol/L), insufficient 12-20 ng/mL (30-50 nmol/L) and deficient <12 ng/mL (30 nmol/L) based on the recommendations of the expert group of the "Global Consensus for the Prevention and Mana gement of Nutritional Rickets". 133 children participated (89 preterms under or equal to 32 weeks), 41 during summer, 28 in fall, 35 in winter, and 29 in spring. The difference of means between summer and winter was 9.6 ng/mL for 25OHVitD3 (p <0.0001), -11.1 pg/mL for PTH (p <0.0001), and -47.5 IU/mL for ALP (p= 0.01). There were no differences in calcium concentrations. In sum mer, 97.6% of the subjects were classified with sufficiency status (> 20 ng/mL), which decreased significantly in winter to 54.3% (p <0.0001). In winter, 25OHVitD3 concentrations decreased in approximately half of the children, which was associated with an increase in PTH and ALP, and normal calcium concentrations. According to our results, children may need VitD supple mentation during fall and winter.

Global consensus on nutritional rickets: Implications for Australia.

In 2016, a global consensus on the prevention, diagnosis and management of nutritional rickets was published. The bone and mineral working group of the Australasian Paediatric Endocrine Group provides a summary and highlights differences to previous Australian and New Zealand (ANZ) guidelines on vitamin D deficiency and their implications for clinicians. Key points are: (i) The International Consensus document is focused on nutritional rickets, whereas the ANZ guidelines were focused on vitamin D deficiency. (ii) Definitions for the interpretation of 25-hydroxy vitamin D (25OHD) levels do not differ between statements. (iii) The global consensus recommends that routine 25OHD screening should not be performed in healthy children and recommendations for vitamin D supplementation are not based solely on 25OHD levels. The Australasian Paediatric Endocrine Group bone and mineral working group supports that screening for vitamin D deficiency should be restricted to populations at risk. (iv) Recommendations from the global consensus for vitamin D dosages for the therapy of nutritional rickets (diagnosed based on history, physical examination, biochemical testing and a confirmation by X-rays) are higher than in ANZ publications. (v) The global consensus recommends the implementation of public health strategies such as universal supplementation with vitamin D from birth to 1 year of age and food fortification. We conclude that updated global recommendations for therapy of nutritional rickets complement previously published position statements for Australia and New Zealand. Screening, management and the implementation of public health strategies need to be further explored for Australia.

A Brief History of Nutritional Rickets.

Since first described almost a century ago, vitamin D preparations have been successfully used as a public health intervention to prevent nutritional rickets. In this manuscript, we document the periods in history when nutritional rickets was described, examine early efforts to understand its etiology and the steps taken to treat and prevent it. We will also highlight that despite the wealth of historical data and multiple preventative strategies, nutritional rickets remains a significant public health disorder. Nutritional rickets has both skeletal and extraskeletal manifestations. While the skeletal manifestations are the most recognized features, it is the extraskeletal complications, hypocalcaemic seizure and cardiomyopathy that are the most devastating features and result in reported fatalities. Reviewing this history provides an opportunity to further promote recent global consensus recommendations for the prevention and management of nutritional rickets, as well as gain a greater understanding of the well-known public health measures that can be used to manage this entirely preventable disease.

RICKETS, VITAMIN D DEFICIENCY, AND GLOBAL CONSENSUS RECOMMENDATIONS ON PREVENTION AND MANAGEMENT OF NUTRITIONAL RICKETS: RUSSIAN PEDIATRICIANS’ OPINION

The article focuses on Global Consensus recommendations on prevention and management of nutritional rickets (2016), created by 33 foreign experts, representing 11 pediatric communities from 18 countries. Positive and negative aspects of these Consensus recommendations are reviewed and carped when necessary. The need for the development of Russian national consensus on rickets prevention and management is noted.

Rickets/Osteomalacia. Consensus on Vitamin D Deficiency and Insufficiency in Children.

Vitamin D deficiency is usually manifested as rickets in children. Since vitamin D deficiency/insufficiency is common worldwide, global consensus has been formulated on prevention, diagnosis and treatment of nutritional rickets represented by vitamin D-deficient rickets. This consensus has defined vitamin D insufficiency as the status with serum 25-hydroxyvitamin D(25OHD)level between 12 and 20 ng/mL and vitamin D deficiency as the status with serum 25OHD level below 12 ng/mL. Generally low dietary calcium(Ca)intake coexists with vitamin D deficiency/insufficiency in patients with rickets, and it is important to ensure sufficient Ca intake ensure in the management of nutritional rickets.

Interpretation for the global consensus recommendations on prevention and management of nutritional rickets

Interpretation for the global consensus recommendations on prevention and management of nutritional rickets

Prevention and management of nutritional rickets; a 21st century approach

Prevention and management of nutritional rickets; a 21st century approach

A global consensus on the prevention and management of nutritional rickets: How does this change policy in South Africa?

Globally, rickets secondary to vitamin D deficiency and/or low dietary calcium intake remains a significant public health problem, not only in resource-poor countries but also in those that are better resourced, despite effective means being available for its prevention and treatment. The disease may have both short- and long-term consequences for the affected child, the latter frequently persisting into adulthood.

Global Consensus Recommendations on Prevention and Management of Nutritional Rickets.

Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence. Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.

Management of Nutritional Rickets in Indian Children: A Randomized Controlled Trial

Rickets is usually attributed to vitamin D deficiency. However, recent studies have implicated dietary calcium deficiency in its etiology. Information on relative efficacy of calcium, vitamin D or both together in healing of rickets is limited. To study effect of treatment with calcium, vitamin D or a combination of these two on healing of nutritional rickets in young children. Randomized controlled trial. Sixty-seven cases of nutritional rickets in the age group of 6 months to 5 years were randomly allocated to receive vitamin D (600 000 IU single intramuscular dose), calcium (75 mg/kg/day elemental calcium orally) or a combination of the above two for a period of 12 weeks. The demographic parameters, nutritional status, dietary calcium and phytate intake were assessed for all. Radiographs (wrist and knee) and biochemical parameters (serum calcium, inorganic phosphate, alkaline phosphatase, 25-hydroxycholecalciferol and parathyroid hormone) were evaluated at baseline, 6 and 12 weeks for evidence of healing. Mean dietary intake of calcium in all cases was low (204 ± 129 mg/day). Mean serum 25-hydroxycholecalciferol D level was 15.9 ± 12.4 ng/ml, and 82.1% of patients had serum vitamin D levels <20 ng/ml, indicative of vitamin D deficiency. After 6 and 12 weeks of treatment, radiological and biochemical evidence of healing rickets was observed in all treatment groups, albeit to a variable extent. The combined end point of normal serum alkaline phosphatase and complete radiological healing at 12 weeks was observed in 50% subjects on combination therapy as compared with 15.7% subjects on vitamin D alone and 11.7% on calcium alone. Children with rickets had a low serum vitamin D level and a low dietary calcium intake. The best therapeutic response was seen with a combination of vitamin D and calcium than either of them given alone. CTRI/2010/091/000448.