Do you know what causes Nutritional Rickets in a child?

With a spell of cold wintery days, we look forward to the sun shining through to soak the warmth through its rays. As a little girl, I enjoyed sitting under the bright sun on cold days. Growing up in a hill station, winters would be long and harsh. However, it wouldn’t be long before my mom would call me back inside and if I wanted to hang around outside for a little longer, she would refuse citing the reason that I would tan and that there are other complications which could arise due to over exposure to sun and its Ultra Violet rays. Back then I did not care much about the benefits or dangers of the exposure to sun to one’s health. Forward to the winter of 2012-2013 and I am doing the same with my daughter. I let her play out in the sun for a considerable amount of time, after which I bring her back indoors. As the saying goes ‘everything is good but in moderation’, I now know how important sun exposure is to and also what damage it can do to a child’s health.

In this article, I would like to elaborate on a condition which is quite prevalent in temperate regions (which includes India). Nutritional Rickets or deficiency of Vitamin D is very common in warm regions where children spend more time indoors which leads to less or no exposure to Vitamin D. In developing nations like India, lack of essential nutrients such as calcium and vitamins in the diet of a child also leads to the weakening and softening of bones. 

What is Nutritional Rickets and what causes it?

Sunshine provides our bodies with Vitamin D. A certain amount of sun exposure is necessary to draw the benefits of this vitamin. Deficiency of Vitamin D in a child will lead to a bone disorder wherein the bones will soften and become prone to deformities and fractures. Lack of calcium, childhood kidney and liver diseases and complications which may result in low absorption of calcium or vitamin D may also result in rickets also known as Paediatric Osteomalacia.
Rickets usually affects children between the ages of 6 to 24 months as these are the years of rapid bone development. The factors, which contribute to onset of rickets at this age, include:
1. Exclusive breastfeeding: Breast milk is known to be low in Vitamin D. Vitamin Deficiency in the mother can also pass on to the baby through breast milk.
2. Children who do not drink enough Vitamin D fortified milk.
3. Lack of exposure to sunlight.
4. Poverty and Malnutrition. 

Symptoms and diagnosis:
The following are some of the signs and symptoms of rickets:
• Bone deformities such as bowed legs, knocked knees, abnormally shaped skull or ‘square headed’, outward projection of the chest bone.
• Pain and tenderness of the bones, particularly the hip bone.
• Brittle bones (bones breaking easily).
• Muscle spasms and weakness.
• Unusually short stature and delayed growth.
• Seizures.
• Widening of wrists.
The diagnoses of rickets involve the following tests:
• Blood and urine tests.
• X-ray.
• A biopsy of the bone may be done if the tests above are inconclusive. 

The Good News- Rickets is treatable and curable!
Rickets is basically a condition which results from the deficiency of Vitamin D. Supplementing or eating a diet rich in Vitamin D will reduce the chances of contracting this disease and also nourish the bones with the daily dose of vitamin D and calcium.
The daily recommendation for vitamin D is approximately 10 micrograms (400 IU) for infants, 15 micrograms (600 IU) for children and adults.

The following are way to prevent Rickets and to get that daily dose of Vitamin D for your child.

1. Supplements for infants: Infants who are exclusively breastfed need supplements of Vitamin D for the first year of life or until they are consuming whole milk. Infant formula is already fortified with Vitamin D. Nursing mother may also take supplements so as to pass on the same to her baby.
2. Milk, milk and more milk: Milk and milk products are one of the best sources of Vitamin D. Two glasses of milk provide with almost the daily requirement of vitamin D. Other products such as yogurt, cheese, butter may also be given if your child is not a big fan of milk.
3. Fish: Seafood such as salmon, tuna, sardines, shrimps and mackerel are some of the excellent source of Vitamin D.
4. Cereals for breakfast: Some of the breakfast cereals found on supermarket shelves provide with a good amount of vitamin to your diet. Packaged breakfast items such as porridge, cornflakes, wheat flakes, muesli, oats, rice crispies and the like may be given to your child with some milk or yogurt and fresh fruits. However, while buying such products, you may want to read the list of ingredients and nutritional information and avoid products with excess sugar and sodium.
5. Mushrooms: Surprisingly mushrooms contain the highest amount of vitamin D. Sun dried or Shiitake mushrooms are one of the best sources. They are commonly used in Chinese and Japanese cuisine.
6. An egg a day: Giving your child one egg a day will provide with 10% of the required dose of vitamin D.
7. Malted drinks such as Bournvita, Horlicks and Complan are also a good source and can be mixed with milk.
8. Get some fun in the sun: Exposure to the sun for 15-20 minutes, 2-3 times a week and preferably before 10 am is sufficient for the body to produce its own Vitamin D. When the weather permits, let your child play out in the sun and you may join them too to benefit from some Vitamin D. On hot days, you may apply some child friendly sun screen lotion on your the exposed parts of your child’s skin. It should have an SPF (Sun Protection Factor) of 15.
9. Healthy fats: Consuming fats such as seeds, nuts, pure ghee and olives help in better absorption of Vitamin D.
10. Supplements: Supplements such as Cod liver oil may be given to a child if sufficient Vitamin D is not taken through normal diet. It is always advisable to consult the paediatrician before starting your child on any form of supplement.

The treatment of rickets includes relieving the symptoms and correcting the underlying cause to prevent it from reoccurring. If the diagnosis is made and the skeletal deformities are corrected while the child is still growing, then the deformities gradually disappear with age. A couple of ways of dealing with the deformities are maintaining a good posture and bracing. However, some skeletal deformities can only be corrected by performing a surgery. Since rickets is a curable condition, if left untreated, a child with rickets is prone to frequent fractures. Severe and prolonged rickets may lead to permanent bone deformities.

Does more mean better?
Excess Vitamin D is not healthy for the body. Vitamin D is fat soluble and any excess amount can get stored as fat in tissues. This may result in toxicity, although the occurrence of it is quite rare. Signs of overdose or toxicity include nausea, vomiting, poor appetite, weakness, frequent urination and may also lead to kidney problems. Discontinuing with consumption of excess Vitamin D will immediately reduce the toxicity in the body.

Let us help our children know and understand the importance of eating smart- making healthy food choices. The food choices children make during the crucial years of development can influence their future health risk and can also influence food habits in later life.