Frequency of Nutritional Rickets in Children with Lower Respiratory Tract Infections under Five Years of Age

Objective: Rickets is a disease of growing bones which is secondary to the defect in mineralization at growth plate matrix.
Vitamin D deficiency remains the most common cause of rickets globally. Vitamin D is usually obtained from exposure to
sunlight and from diet like fish liver oil and egg yolk. Solar ultra violet B radiations penetrate the skin and initiate the process
of vitamin D formation. The objective is to determine the frequency of nutritional rickets in children with lower respiratory
tract infection
Materials and Methods: This cross sectional study was conducted in the Pediatric Department, Lady Reading Hospital,
Peshawar, from 6/2/2018 to 6/8/2018. Children were assessed by researcher through detailed history from the parents
followed by detailed clinical examination for the confirmation of lower respiratory tract infections. Blood sample was taken for
the children and were send to hospital laboratory for investigation of serum calcium, phosphorus and alkaline phosphatase
level and X-rays were performed. Diagnosis of nutritional rickets was done on the bases of all these factors. Data was
entered and analyzed by means of SPSS version 20 and was expressed in the form of tables and charts
Results: In this study 62% children were in age ranged 1-3 years and 38% children were in age range 4-5 years. Mean age was 2 years with SD ± 2.16. Fifty eight percent children were male and 42% children were females. More over 65% children had low serum calcium level < 2.12 mmol, 58% children had low serum phosphorus level < 0.87 mmol and 60% children had serum alkaline phosphatase > 280 units per liter on the bases of which the frequency of nutritional rickets among 151 children was 60% in our study.
Conclusion: study concludes that the frequency of nutritional rickets was 60% in children with lower respiratory tract infections under five years of age.
Key Words: nutritional rickets, children, lower respiratory tract infections.

Rickets is a disease of growing bones which is secondary to the defect in mineralization at growth plate matrix. Vitamin D deficiency remains the most common cause of rickets globally.1 Vitamin D is usually obtained from exposure to sunlight and from diet like fish, liver oil and egg yolk. Solar ultra violet B radiations penetrate the skin and initiate the process of vitamin D formation.2 Vitamin D helps in absorption of calcium from intestine. In the presence of vitamin D intestinal calcium absorption can be as high as 80% of the intake. Rickets usually presents with features like delayed fontanels closure, craniotabes, frontal bossing, enlargement of wrists, rachitic rosary, delayed teething, carious teeth and legs deformity like bowing of legs, kyphosis and narrowed pelvis.2


1.2,3 Assistant Professors, 4. Assistant Professor,Neuro Surgery,5.
Trainee Medical Officer,6 Associate Professor, Chairman, Department
of Pediatrics


Correspondence Dr. Samiullah Assistant Professor, Pediatric B
Unit, Lady Reading Hospital, Peshawar Mob: 0314-8109159
samiullah048@gmail.com samiullah048@gmail.com


Received: April’2019 Accepted: June’2019


The frequency of nutritional rickets was 60% in children with lower respiratory tract infections under five years of age.


Nutritional rickets caused by deficiency of vitamin D has been strongly associated with lower respiratory tract infections. Deformities in the chest like Harrison grove occurs from pulling of the softened ribs by diaphragm during inspiration. Softening of the ribs impairs air movement and predisposes patient to atelectasis and pneumonia. In addition, vitamin D deficiency which is the primary cause of nutritional rickets is also associated with an increased incidence of lower respiratory tract infections. Vitamin D has a role in innate immune system.3 Lower respiratory tract infections (like pneumonia and bronchiolitis) are the leading causes of mor-bidity and mortality in children under five years of age. Sub clinical vitamin D deficiencies were associated with severe lower respiratory tract infection, and clinical vitamin D deficiency was associated with a 13-fold-increased risk of pneumonia.4 The aim of this study is to find out the frequency of rickets in patients presenting with pneumonia in our set up. Pneumonia being one of the major killers among children is important to be studied in synergy with rickets as the combination is understandably fraught with more sinister outcomes. The results will add to the existing body of knowledge and would be useful for practitioners as well as planners and policy makers of health to devise meaningful interventions both at clinical and community levels. The frequency of nutritional rickets is 60% in children with lower respiratory tract infections under five years of age.

MATERIALS AND METHODS

This cross sectional study was conducted in the Pediatric Department of Lady Reading Hospital Peshawar from 6/2/2018 to 6/8/2018. Permission from hospital ethical committee was taken before start of study. All new cases with lower respiratory tract infections (as per operational definitions above) were enrolled in study. Informed written consent was taken from parents. Children were assessed by the researcher by taking detailed history from the parents followed by detailed clinical examination for the confirmation of lower respiratory tract infections. Blood sample was taken for the children and were send to hospital laboratory for investigation of serum calcium, phosphorus and alkaline phosphatase level. All the requisite investigations were done by expert pathologist and radiologist. Diagnosis of Nutritional rickets was done on the basis of all the factors mentioned in the operational definition. All the above mentioned information including name, age, gender and address were recorded in a pre-designed proforma. Strictly exclusion criteria had followed to control confounders and bias in the study results. Data was analyzed using SPSS version 20, and was expressed in the form of tables and charts.

RESULTS:

In this study age distribution among 151 children were analyzed, and 94(62%) children in the age ranged 1-3 years while 57(38%) children were in age range 4-5 years. Mean age was 2 years with SD ± 2.16. Gender distribution among 151 children was analyzed as 88(58%) children were male while 63(42%) children were females. Among 151 children analyzed on weight, 68(45%) children had weight ≤12 Kg, while 83(55%) children had weight >12 Kg. Mean weight was 12 Kg with SD ± 5.713. 62(41%) children had duration of sun exposure ≤30 minutes while 89(59%) children had duration of sun exposure >30 minutes. Radiological findings in these patients showed that 59(39%) children had open fontanelle, 91(60%) children had frontal bossing, 110(73%) children had splaying, 118(78%) children had rachitic rosary, 113(75%) children had bow legs as these are shown in the table 1.





Fifty three (35%) children had normal serum calcium > 2.12 mmol, while 98(65%) children had low serum calcium level < 2.12 mmol. Sixty three (42%) children had normal serum Phosphorus > 0.87 mmol, while 88(58%) children had low serum phosphorus level < 0.87 mmol, Sixty (40%) children had normal serum alkaline phosphatase < 280 units per liter while 91(60%) children had serum alkaline phosphatase > 280 units per liter. 91(60%) children had rickets while 60(40%) children didn’t had rickets. (as shown in table

DISCUSSION

Rickets is a disease of growing bones which is secondary to the defect in mineralization at growth plate matrix. Vitamin D deficiency remains the most common cause of rickets globally.1 Vitamin D is usually obtained from exposure to sunlight and from diet like fish, liver oil and egg yolk. Solar ultra violet B radiations penetrate the skin and initiate the process of vitamin D formation.2 Vitamin D helps in absorption of calcium from intestine. In the presence of vitamin D intestinal calcium absorption can be as high as 80% of the intake. Rickets usually presents with features like delayed fontanels closure, craniotabes, frontal bossing, enlargement of wrists, rachitic rosary, delayed teething, carious teeth, and legs deformity like bowing of legs, kyphosis and narrowed pelvis.2 Our study shows that 62% children were in age ranged 1-3 years and 38% children were in age range 4-5 years. Mean age was 2 years with SD ± 2.16. In one study 14(23.33%) children were below 6 months of age while 38(68.33%) children were below 13 months. Poor maternal vitamin D status during pregnancy, in addition to other factors, may be important risk factor in these babies.5 Thick dark veils and habit of indoor staying contributes to vitamin D deficiency in pregnant and lactating mothers.6 Fifty eight percent children were male and 42% children were females. In a study carried out by Siddiqui et al6 there was high male predominance with male to female ratio of 3.71:1(78% vs 21%). In another study from Turkey male to female ratio was 2.9:1.15 Same results were reported in a study from Peshawar by Khattak et al7 with male to female ratio of 1.77:1.9 While in a very large study from Denmark, Beck-Nielson et al observed no difference in gender distribution.8 More over 65% children had low serum calcium level < 2.12 mmol, 58% children had low serum phosphorus level <0.87 mmol and 60% children had serum alkaline phosphatase >280 units per liter on the bases of which the frequency of nutritional rickets among 151 children was 60% in our study. Similar findings were observed in other studies as: In a study conducted in slum areas of Karachi 99% of the children with nutritional rickets were malnourished.9 In another study 24(40%) children were underweight according to Gomez classification of malnutrition. Malnutrition has been reported in literature as a contributing factor for nutritional rickets.10 The clinical signs of the rickets (widened wrists, rickety rosary of costochondral junctions, and bowing of the legs) were present in 40 (66.66%) children in our study, while Hameed et al9 have reported these clinical signs in 70% of the children with nutritional rickets. In another study 51(85%) children had radiological findings of rickets, while these findings were detected in 73.84% 11, 38.09% 12, and 100% 13 in different studies. Highest incidence of rickets was found in age between 2 to 12 months that is 79.8%. Even in studies from other cities of Pakistan same fact was enhanced like in studies from Abbotabad and Peshawar, 90% patients were below 2 years while from Lahore 76% were under 2 years consistent with this study.6,7,11 In this study rickets was more common in breast fed infants that is 85.3%. In a study from United States, 96% of children who developed rickets were breast fed while in a Canadian study 94% rachitic children were breast fed.14 For this reason it has been recommended by American Academy of Pediatrics that breastfed and partially breastfed infants should be supplemented with 400 IU/day of vitamin D beginning in the first few days of life. Supplementation should be continued unless the infant is weaned to 1 L/day or 1 qt/day of with rickets had none or minimal exposure to sun light.16vitamin D-fortified or whole milk.15 Rickets in this study was found to be more common in children who were not exposed to sunlight i.e.,98.3%. In a study from Sydney 89% of children in Karachi city there is an increased trend of living in multistoried apartments where there is no or minimal sunlight exposure. Other possible reasons could be living indoors due to hot climate and wearing fully covered clothes with most of the women covering their head and few their faces as well.17 There was an increased incidence of rickets in patients admitted with severe pneumonia i-e 74 % (101/137) in this study.18 A similar study from Jordan has shown 85% patients having rickets presented with respiratory tract infections.19 While in other studies chest infections were the second most common presentation. 9

CONCLUSION;

Our study concludes that the frequency of nutritional rickets was 60% in children with lower respiratory tract infections under five years of age.

1. Greenbaum LA. Rickets and hypervitamonosis D. In: Kliegman RM, Stanton BF, Schor NF, St.Geme III JW, Behman RE, editors. Nelson text book of pediatrics,19th Ed. Philadelphia: Saunders Elsevier, 2011:200-9.
2. Hollick MF. Vitamin D deficiency. N Eng J Med 2007;357:266-81.
3. Özkan B. Nutritional rickets. J Clin Res Pediatr 2010;2:137- 43.
4. Roth DE, Caulfield LE, Ezzati M, Black RE. Acute lower respiratory tract infections in childhood: opportunities for reducing the global burden through nutritional interventions. Bull World Health Org 2008;86:321-416.
5. Serenius F, Elidrissy AT, Dandona P. VitaminD nutrition in pregnant women at term and in new born babies in Saudi Arabia. J Clin Pathol 1984;37(4): 444-7.
6. Siddiqui TS, Rai MI. Presentation and predisposing factors of nutritional rickets in children of Hazara division. J Ayub Med Coll Abbotabad 2005; 17: 29-32.
7. Khattak AA, Rehman G, Shah FU, Khan MK. Study of Rickets in admitted patients at Lady Reading Hospital, Peshawar. J Postgrad Med Inst. 2004; 18: 52-8.
8. Beck-Nielsen SS, Jensen TK, Gram J, Brixen K, Brock- Jacobsen B.Nutritional rickets in Denmark: a retrospective review of children’s medical records from 1985 to 2005. Eur J Pediatr 2009; 168: 941-9.
9. Hameed A, Ahmad S, Rehman S, Urakzai AA, Gandapoor AJ.A study of rickets-Morbidity and aetiology of a Low Profile Disorder. J Post Med Inst 1998;12(2):14-21
10. Salimpur R. Rickets in Tehran. Study of 200 cases. Arch Dis Child 1975; 500:63-6
11. Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Archives of disease in childhood 2004; 89:781-84
12. Dawodu A, Wagner CL. Vitamin D Mother-child vitamin D deficiency: an international perspective. Arch Dis Child 2007; 92: 737-40.
13. Ozkan B, Doneray H, Karacan M, Vancelik S, Yildirim ZK, Ozkan A, et al. Prevalance of vitamin D deficiency rickets in the eastern part of Turkey. Eur J Pediatr 2009; 168: 95-100.
14. Weiseberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in United States: review of cases reported between 1986 and 2003. Am J Clin Nutr 2004; 80: S1697-1705.
15. Ward LM, Gaboury I, Ladhani M, Zlotkin S. Vitamin D-deficiency rickets among children in Canada. CMAJ 2007; 177: 161-6.
16. Gartner LM, Greer FR; Section on Breast Feeding and Committee on Nutrition. American Academy of Paediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003; 111: 908-10.
17. Najada AS, Habashneh MS, Khader M. The frequency of nutritional rickets among hospitalized infants and its relation to respiratory diseases. J Trop Pediatr 2004; 50: 364-8.
18. Khan HI, Abdullah A, Kazi MY, Afzal MF. Hypocalcemia and nutritional rickets in children: common etiological factors. Ann King Edward Med Coll 2006; 12: 29-32.
19. Robinson PD, Hogler W, Craig ME, Verge CF, Walker JL, Piper AC, et al. The re-emerging burden of rickets: a decade of experience from Sydney. Arch Dis Child 2006; 91: 564-8.

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Thrombotic thrombocytopenic purpura 

A young man presented with a 2-day history of abdominal pain, headache, and brown urine. He was well oriented. He had no purpura or petechiae. Laboratory evaluation revealed a hemoglobin level of 8.6 g per deciliter and a platelet count of 6000 per cubic millimeter. Levels of indirect bilirubin and lactate dehydrogenase were elevated, haptoglobin was undetectable, and the serum creatinine level was 1 mg per deciliter. Test results for infection with the human immune-deficiency virus were negative. A peripheral-blood smear showed numerous schistocytes.

Differential Diagnosis: Idiopathic thrombocytopenic purpura, Thrombotic thrombocytopenic purpura, Pseudothrombocytopenia, Hemolytic uremic syndrome, Excessive splenic platelet sequestration. Curtsey: NEJM