Vitamin D via sun or fortified formula is called essential

By Erin Allday, Taken from The San Francisco Chronicle, Monday, August 28, 2006

Rickets is a disease caused by vitamin D deficiency that causes bowed legs, fractured bones and poor overall growth, and it is resurging among very young children in the United States. The vast majority of cases are among dark-skinned children who have a more difficult time absorbing sunlight, which stimulates vitamin D production in the body, and in babies who are breast-fed exclusively and don't get vitamin-fortified formula.

Rickets is still rare -- at Children's Hospital, one of the few hospitals in the country that has tracked rickets, there have been 59 cases since 2000 -- but pediatricians fear that only the most serious conditions are drawing attention and that there may be many more babies who are vitamin D-deficient but not symptomatic.

"Vitamin D deficiency is probably under-recognized, and rickets is just the most severe form," said Laura Bachrach, a pediatrics professor at Stanford University School of Medicine. "There is concern that vitamin D deficiency early on in life can have long-term effects on bone density and bone strength."
The irony is that it's mothers who are doing everything right whose babies have the highest risk for developing rickets: By feeding their infants only breast milk and keeping them out of the sun, they're taking away babies' two best sources of vitamin D.

In the past three decades, the percent of mothers who breast-feed their babies for at least the first six months has more than quadrupled, from 7.5 percent in 1973 to 33 percent in 2003, according to the Ross Laboratories Mothers' Survey, a national survey conducted every year since 1955.

Pediatricians are quick to insist that feeding babies only breast milk from birth to 6 months is ideal. But after a handful of rickets reports in several states and anecdotal evidence from doctors, the American Academy of Pediatricians in 2003 recommended that all babies who are fed exclusively breast milk also receive a daily vitamin D supplement. The multi-vitamin supplement can be bought over the counter at most drugstores for about $5 to $15 a month.

The problem is that the supplement recommendation hasn't yet reached the majority of mothers.
"Breast-feeding is the best thing to do for feeding a baby. We have to be careful that breast-feeding moms do not see this as something negative about breast milk," said Kelley Scanlon, an epidemiologist at the Centers for Disease Control and Prevention. "But I would also recommend following the AAP recommendation that the child receive supplements of vitamin D."

The body uses vitamin D to absorb calcium in bones. Without enough vitamin D, the body doesn't know how to use the calcium correctly, and bones become weak and are more prone to fractures.

Vitamin D deficiency and rickets were common a hundred years ago, when children increasingly were living in big cities with poor diets and not enough sunlight. It was especially common in places with long, cold winters where children couldn't play outside for months at a time.

Vitamin D does not occur naturally in many foods, but rickets mostly disappeared around the 1920s when the dairy industry started fortifying milk with vitamin D. Today, most people get vitamin D from both sun exposure and fortified foods.

In addition to poor growth and weakened bones, symptoms of rickets in children include thickening at the wrists, delayed walking and soft spots in the skull that take a long time to close. The bow-legged appearance generally doesn't occur until fairly late stages.

In the vast majority of cases, rickets is easily treated with dietary supplements and symptoms disappear fairly quickly. Rarely does rickets lead to long-term developmental problems.

Almost three quarters of the 59 rickets cases at Children's Hospital Oakland were in black children, and 90 percent were in children who were fed only breast milk. Two of the youngest cases were in babies whose Muslim mothers wore clothing that covered their entire bodies, thus limiting their own ability to absorb enough sunlight to build up vitamin D stores.

Six of the rickets cases were in babies younger than 3 months, who were almost definitely born vitamin D-deficient because their mothers were not getting enough sunlight or taking prenatal vitamins.
At other Bay Area hospitals that don't track rickets cases, doctors said the disease is unusual, but not unheard of -- and they've seen it more often in the past five or so years.

Dr. Catherine Albin, chief of pediatrics at Kaiser Permanente Santa Clara Medical Center, said she suspects South Bay cases may be arising in the region's growing Muslim community, with more mothers who cover their own skin and their babies and who may not be familiar with importance of taking prenatal vitamins.

Bachrach said she hears of two to four cases of rickets each year at Stanford. She saw one case several years ago where a 3-year-old boy was so vitamin D-deficient that he could barely walk and required surgery to repair his legs.

"His family did not allow him to play outside very much," Bachrach said. "He suffered from rickets for probably at least a year before it was finally picked up, and it may be that nobody thought about it because they thought rickets doesn't happen anymore."

Bhatia said her most memorable case was in 2002, when a mother brought in her son after he suffered a fractured femur. Pediatricians feared the worse -- child abuse. The mother was distraught.

"She was very upset that anybody would think of her as an abusive mom," Bhatia said. "Then he had all the symptoms of rickets. The mom was very articulate and if she'd known this was going on, she would have given him vitamin D."