The Centers for Disease Control and Prevention (CDC) in collaboration with the Georgia Department of Human Resources, Division of Public Health, recently identified six cases of nutritional rickets and three cases of other nutritional deficiencies in young children, according to a report in the March 30, 2001, issue of Morbidity and Mortality Weekly Report (MMWR) published by CDC.
Nutritional rickets, a condition that causes weak or deformed bones in young
people, is rare in the United States since the introduction of vitamin-D fortified
milk and infant formula several decades ago. Health officials identified these cases
among children who were admitted to Georgia hospitals for malnutrition. The cases
occurred in infants who had been breast-fed for more than 6 months without receiving
"These cases underline how important it is for parents of infants and young
children to discuss diet with a child's pediatrician to ensure that their child's
nutritional needs are being met," said Dr. William Dietz, director of CDC's
nutrition and physical activity program. "Breast milk is the best source of
nutrition for infants but parents of breastfed infants should consult with their
pediatrician to determine if their infant needs vitamin-D supplementation."
Parents also need to ensure that children get enough vitamin-D after they are
weaned from breast milk or fortified infant formula. "Children obtain vitamin-D
from the diet primarily through vitamin-D fortified milk and breakfast cereals,"
said CDC Epidemiologist Dr. Shanna Nesby-O'Dell. "Infant cereals and other dairy
products such as cheese and yogurt do not contain vitamin-D. To prevent rickets,
parents who transition their children to milk at 12 months of age should use a milk
that is fortified with vitamin-D.
People also get vitamin-D through exposure to sunlight. Because the melanin in skin
filters sunlight, children with increased skin pigmentation require more sunlight
exposure to produce vitamin D. At least three of the Georgia children with nutritional
rickets had dark skin complexions. However, with increased concern about the long-term
harmful effects of sun exposure, dietary sources of vitamin-D may become more
important than sun exposure to meet the body's requirement for the vitamin.
Rickets is not always easy to recognize in infants and toddlers because its early
symptoms mimic other conditions. Infants often present with seizures and high fevers
associated with a secondary infection. If the child is treated for infection and no
blood is drawn, there will be no indication of low calcium levels, which would suggest
rickets. Toddlers with the condition may experience a delay in learning to walk,
low-height-for age, curvature of the spine, and bowing of the legs and arms.
There are no national rates for rickets because it is not a reportable public
health disease, and there are no surveillance systems that capture information about
it. The Georgia cases probably represent only part of the true prevalence of rickets,
as the study only reviewed cases of children who were hospitalized.
In addition to identifying children with nutritional rickets, doctors found three
children who had malnutrition associated with inadequate energy or protein in their
diet. The protein energy-deficient children had such clinical signs as swelling,
weight loss or inadequate growth, or thinning of hair. Two of the three children had a
skin condition attributed to food allergies. Concern about these allergies led to
inappropriate diet restrictions and subsequent protein energy malnutrition.
Dr. Norman Carvalho, a pediatrician at Children's Health Care of Atlanta, who
identified the first two cases, said, "Nutritional diseases are entirely
preventable. It is important for physicians to obtain a good diet history for the
children they see, and especially to inquire about use of milk alternatives, which
could be deficient in necessary nutrients."
Further insight into the Georgia cases is published in two Pediatrics articles : 1) "Nutritional
Rickets in Georgia" authored by CDC Epidemiologist Kay Tomashek, MD MPH et al.,
formerly of the Georgia Department of Human Resources, Division of Public Health; and
2) "Severe Nutritional Deficiencies in Toddlers Resulting form Health Food Milk
Alternative," authored by Norman Carvalho, MD et al.
As a result of the Georgia investigation, the Food and Drug Administration (FDA) is
now requesting that malnutrition associated with the use of alternative milk beverages
be reported to the FDA's Med watch system. Also, the American Academy of Pediatrics is
currently examining recommendations on the need for vitamin-D supplementation among