Rickets: Emerging from Obscurity
Am Fam Physician. 2006 Aug 15;74(4):561-562.
The review,1 “Rickets: Not a Disease of the Past,” by Nield and colleagues in this issue of American Family Physician is an important reminder that changes in lifestyle can cause the reappearance of disease states that were thought to have been eradicated. In one study more than 80 years ago, one teaspoon of cod liver oil given daily to children was found to prevent and, in many cases, reverse nutritional rickets2; this finding was a major scientific discovery that is still relevant today. The advent of modern-day laboratory techniques that allow isolation and measurement of vitamin D compounds3 has shown that one teaspoon of cod liver oil provides 400 IU of vitamin D3, which appears to be an adequate amount for infants and young children.4
During the past two decades, the lifestyles and dietary habits of Americans have changed considerably. The average American spends 93 percent of his or her time indoors5—more time spent in front of the television, the video game console, or the computer. Children with lighter pigment who are encouraged to play outdoors often are covered with sunscreen during the summer months, preventing the synthesis of previtamin D3 in their skin 6 and making them more susceptible to vitamin D deficiency during winter months, especially in northern climates. Children with darker pigment require much greater sunlight exposure to attain the same levels of vitamin D3.7
Intake of foods enriched with vitamin D, such as vitamin D–fortified cow’s milk and yogurt, provides relatively small amounts of vitamin D. One cup of milk provides 100 IU of vitamin D3, whereas 10 minutes of full-body sunlight exposure during summer months provides 10,000 to 20,000 IU of vitamin D3 within 24 hours3 The American Academy of Pediatrics (AAP), however, does not recommend sun exposure before six months of age and advises parents to apply sunscreen to infants when exposed to the sun to avoid skin damage. As a result, the AAP recognizes that using sunlight as the main source of vitamin D for infants is not a viable option.
An issue with breastfeeding is that when the mother is deficient in vitamin D, her milk has limited transfer of vitamin D and its metabolites. Consequently, unless her infant receives ultraviolet exposure from sunlight or receives supplements, the infant will be vitamin D deficient.3 The AAP recommends that all infants, including those who are exclusively breastfed, receive a minimum of 200 IU of vitamin D per day, starting within the first two months of life. This recommendation ensures that the breastfed infant will have adequate vitamin D status8 but does not address the reason the breast milk is deficient.
The effectiveness of high-dose vitamin D supplementation in lactating women has been studied in two pilot clinical trials.9,10 Both studies demonstrate that if the mother has substantial circulating levels of vitamin D3 and 25(OH)D3, her breast milk will have consistently higher antirachitic activity, and her infant will achieve optimal vitamin D status. Before this therapy can be recommended for all breastfeeding mothers and infants, larger studies need to be completed.
Only recently have liquid forms of vitamin D3 (cholecalciferol) become available commercially. Vitamin D3 is the more bio- available form of vitamin D; vitamin D2 is less potent than vitamin D311 As noted by Nield and colleagues,1 all infants should receive a dietary source of vitamin D3 that equals at least 200 IU per day, through a supplement if breastfeeding or through formula for those not breastfeeding.
The long-term implications of vitamin D deficiency are not restricted to bone disease because multiple disorders have been linked with vitamin D deficiency. For example, patients with cystic fibrosis experience the sequelae of vitamin D deficiency because of their malabsorption of fats and fat-soluble vitamins. In December 2005, the Cystic Fibrosis Foundation released a consensus statement12 calling for all physicians who have patients with cystic fibrosis to measure their vitamin D levels and recommend supplementation for those who are deficient to help normalize bone mineral density. Vitamin D deficiency is common in persons with cystic fibrosis irrespective of season or latitude. What was once thought to be rare is, in fact, common.
For this and other reasons, optimization of vitamin D levels is viewed as an important factor in long-term health. Through enhanced awareness, it is eminently possible to prevent rickets and other conditions caused by vitamin D deficiency in the 21st century.
1. Nield LS, Mahajan P, Joshi A, Kamat D. Rickets: not a disease of the past. Am Fam Physician. 2006;74:619–26.
2. McCollum EV, Simmonds N, Becker JE, Shipley PG. Studies on experimental rickets. XXI. An experimental demonstration of the existence of a vitamin which promotes calcium deposition. J Biol Chem. 1922;53:293–312.
3. Hollis BW, Wagner CL. Assessment of dietary vitamin D requirements during pregnancy and lactation. Am J Clin Nutr. 2004;79:717–26.
4. Pittard WB III, Geddes KM, Hulsey TC, Hollis BW. How much vitamin D for neonates?. Am J Dis Child. 1991;145:1147–9.
5. Report to Congress on indoor air quality. Vol. 2. Assessment and control of indoor air pollution. Washington, D.C.: U.S. Environmental Protection Agency, 1989:4–14.
6. Matsuoka LY, Wortsman J, Hollis BW. Use of topical sunscreen for the evaluation of regional synthesis ofvitamin D3. J Am Acad Dermatol. 1990;22(5 pt 1):772–5.
7. Matsuoka LY, Wortsman J, Haddad JG, Kolm P, Hollis BW. Racial pigmentation and the cutaneous synthesis of vitamin D. Arch Dermatol. 1991;127:536–8.
8. Gartner LM, Greer FR. for the Section on Breastfeeding and Committee on Nutrition, American Academy of Pediatrics Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics. 2003;111(4 pt 1):908–10.
9. Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D in both the mother and the nursing infant. Am J Clin Nutr. 2004;80(6 suppl):1752S–8S.
10. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month intervention study. Breastfeeding Medicine. [In press].
11. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89:5387–91.
12. Aris RM, Merkel PA, Bachrach LK, Borowitz DS, Boyle MP, Elkin SL, et al. Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab. 2005;90:1888–96.
Copyright © 2006 by the American Academy of Family Physicians.
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