In October 1999, the Georgia Department of Human Resources (GDHR)
was notified of two cases of severe malnutrition in toddlers. Both cases were
associated with the use of commercial alternative milk. In response, GDHR and CDC
reviewed Georgia hospital records to assess the frequency and cause of hospitalized cases
of rickets and protein energy malnutrition (PEM). The findings of this review
indicated that, although no new cases were associated with milk alternatives, three children
had PEM and six had vitamin D deficiency rickets. The children with rickets had been
breast fed for approximately 6 months while receiving no vitamin D supplementation.
Rickets is preventable through the adequate intake of vitamin D. The American Academy
of Pediatrics (AAP) is examining vitamin D supplementation among breast-fed infants.
For the purpose of this study, vitamin D deficient rickets was defined as having
an International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) (1) code of 268.0 (active rickets), 268.9 (unspecified vitamin D deficiency), or
268.2 (unspecified osteomalacia) combined with a low serum 25-hydroxy-vitamin-D
level (below laboratory reference range) and one or more of the following
radiographic changes: osteopenia, widening of growth plates, fraying and cupping of
the metaphysis, or craniomalacia. Severe PEM was defined as codes 260
(kwashiorkor), 261 (nutritional marasmus), or 262 (severe protein calorie malnutrition) combined
with one or more of the clinical signs: edema, nonspecific dermatitis, thinning and
streaking of hair, inadequate growth (below the fifth percentile weight-for-height), or weight loss.
To identify rickets and PEM cases among children aged 6 months--5 years,
GDHR and CDC reviewed hospital discharge records for January 1997--June 1999,
and confirmed cases by medical record review. Cases determined to have
nutritional causes were evaluated through telephone interviews with parents, guardians,
or attending physicians to assess the child's diet (e.g., use of alternative milk
beverages and vitamin supplements) and time spent outdoors. Among children aged 6
months--5 years residing in Georgia during January 1997--June 1999, case findings and
Georgia census data (2) suggest that five per one million children were hospitalized
with vitamin D deficient rickets and two per million were hospitalized with severe PEM.
Forty cases were identified; 11 were rickets and 29 were severe PEM. Five
rickets cases and 24 PEM cases were associated with metabolic disorders from
congenital (n=seven) or genetic (n=12) abnormalities, premature birth (n=seven), or
chronic diseases (n=three). Two children had disorders associated with chronic
infectious diseases. Six cases of rickets and three cases of PEM were associated with
primary nutritional deficiency. Interviews were conducted with a parent or guardian for three
the children with rickets and two with PEM. Of the remaining four cases, two
families declined an interview and two could not be located.
The six children with rickets were male and age 8--21 months. Three children
had skin complexions ranging from light to dark brown. The annual income level of
two families was $30,000--$49,999; two families' income level was $10,000--$29,999;
and the income level of two families was unknown. During this investigation, vitamin
D deficient rickets was reported in a child aged 17 months who drank a soy
beverage containing no vitamin D. This child also received a multivitamin supplement (30%
of the recommended dose) 1 month before hospital admission. Six children
received breast milk until age 8--20 months; none of the children received routine vitamin
D supplementation while breast feeding. Two children were exposed to six and 21
hours of sunlight per week, respectively, one child "did not receive much sunlight," and
two children received "minimal sunlight." Sun exposure was unknown for one child.
Three children with severe PEM and one child with kwashiorkor were age
6--22 months at diagnosis. The child with kwashiorkor drank a rice beverage with a
low protein content. One family reported $30,000--$49,999 annual income; the
income level of two families was unknown. Two children had eczema attributed to
food allergies. Concern about allergies led to diet restrictions and subsequent PEM.
Reported by: N Carvalho, MBChB, Scottish Rite Pediatric and Adolescent
Consultants, Children's Healthcare of Atlanta, Atlanta; K Tomashek, MD, U Parashar, MPH, K Powell,
MD, A Mellinger-Birdsong, MD, Epidemiology Br, Div of Public Health, Georgia Dept of
Human Resources. Maternal Child Nutrition Br, Div of Nutrition and Physical Activity,
National Center for Chronic Disease Prevention and Health Promotion; and an EIS Officer, CDC.
Rickets and severe PEM are rare in Georgia, and each can
be prevented through adequate nutritional intake. Rickets is caused by vitamin
D deficiency and severe PEM by severe protein and energy (caloric) deficiency
(3,4). Vitamin D is obtained from dietary sources or is synthesized in the skin by the
action of ultraviolet (UV) light on the cholesterol precursor 7-dehydrocholesterol
(7-DHC). Melanin in skin competes with 7-DHC for UV light, thus decreasing vitamin
D synthesis (3). The vitamin D content of human milk is low (approximately 22 IU/L)
(5). However, among most breast-fed infants, the combination of breast milk and
sunlight exposure provides sufficient vitamin D. AAP recommends 400 IU per day vitamin
D supplementation for breast-fed infants whose mothers are vitamin D deficient or
for those infants not exposed to adequate sunlight
(5,6). Skin complexion, environmental conditions, use of sunscreen, and the risk for developing skin cancer
(7,8) complicate the determination of adequate sunlight.
The findings in this study are subject to at least two limitations. First, the extent
of rickets in Georgia probably was underestimated because the study was limited
to hospitalized children. Rickets and PEM are not reportable diseases, and no
surveillance system or national rates exist for these conditions. ICD9CM codes alone do
not distinguish nutritional deficiencies from other causes of rickets. Second, the parents
of four of the nine children were not interviewed.
AAP is examining the recommendation for vitamin D supplementation
among breast-fed infants. In addition, efforts are under way to assess the frequency
of malnutrition associated with commercial or homemade alternative
beverages. Clinicians and state health departments should report such cases by accessing
the Food and Drug Administration's MedWatch program, http://www.fda.gov/medwatch/how.htm* or by calling MedWatch at (800) FDA-1088. Caretakers also
discuss a child's dietary intake and nutritional needs with their health-care provider
to ensure that these needs are met. Information on the nutritional requirements
of children is available from AAP, http://www.aap.org/pubserv*.
- Public Health Service and Health Care Financing Administration. International
classification of diseases, 9th revision, clinical modification. Washington, DC: Public Health
- US Bureau of the Census, Population Estimates Program, Population Division.
Population Estimate for the U.S. and states by single year: January 1997--June 1999. Available at
http://www.census.gov/population/estimates/state/stats/st9910.txt. Accessed March 2001.
- Hollick MF. Vitamin D. In: Shils ME, Olson JA, Shike M, Ross AC, eds. Modern nutrition
in health and diseases. Baltimore, Maryland: Williams and Wilkins, 1999:329--44.
- Torun B, Chew F. Protein-energy malnutrition. In: Shils ME, Olson JA, Shike M, Ross
AC, eds. Modern nutrition in health and diseases. Baltimore, Maryland: Williams and
- American Academy of Pediatrics. Vitamins: vitamin D. In: Kleinman RE, ed. Pediatric
nutrition handbook, 4th edition. Elk Grove Village, Illinois: American Academy of
- American Academy of Pediatrics Work Group on Breast-feeding. Breast-feeding and
the use of human milk. Pediatrics 1997;100:1035--9.
- Armstrong BK. Melanoma: childhood or lifelong sun exposure. In: Grob JJ, Stern
RS, Mackie RM, Weinstock WA, eds. Epidemiology, causes, and prevention of skin
diseases. Malden, Massachusetts: Blackwell Science, 1997:63--71.
- Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight exposure, pigmentation factors, and risk
of non-melanocytic skin cancer, I: basal cell carcinoma. Arch Dermatol 1995;131:157--63.