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Nutritional rickets under 16 years: UK surveillance results
  1. Priscilla Julies1,
  2. Richard M Lynn2,3,
  3. Karina Pall4,
  4. Marina Leoni4,
  5. Alistair Calder5,
  6. Zulf Mughal6,
  7. Nick Shaw7,8,
  8. Ciara McDonnell9,
  9. Helen McDevitt10,11,
  10. Mitch Blair12
  1. 1Child Health, Royal Free London NHS Foundation Trust, London, UK
  2. 2Institute of Child Health, University College London Research Department of Epidemiology and Public Health, London, UK
  3. 3BPSU, Royal College of Paedaitrics, London, UK
  4. 4BPSU, Royal College of Paediatrics and Child Health, London, UK
  5. 5Department of Radiology, Great Ormond Street Hospital, London, UK
  6. 6Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
  7. 7Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, West Midlands, UK
  8. 8Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, West Midlands, UK
  9. 9Endocrinology Department, Children's University Hospital, Temple Street, Dublin, Ireland
  10. 10Paediatric Bone and Endocrinology, Royal Hospital for Children Glasgow, Glasgow, UK
  11. 11Neonatology, Royal Hospital for Children Glasgow, Glasgow, UK
  12. 12Paediatrics, Imperial College London, Harrow, UK
  1. Correspondence to Dr Priscilla Julies, Child Health, Royal Free London NHS Foundation Trust, London NW3 2QG, UK; p.julies{at}nhs.net

Abstract

Objective The UK national incidence of nutritional rickets is unknown. We aimed to describe the incidence, presentation and clinical management of children under 16 years with nutritional rickets in the UK presenting to secondary care.

Methods Prospective data were collected monthly between March 2015 and March 2017 from 3500 consultant paediatricians using British Paediatric Surveillance Unit methodology. Clinicians completed online clinical questionnaires for cases fitting the surveillance case definition.

Results 125 cases met the case definition, an annual incidence of 0.48 (95% CI 0.37 to 0.62) per 100 000 children under 16 years. 116 children were under 5 years (annual incidence of 1.39 (95% CI 1.05 to 1.81) per 100 000. Boys (70%) were significantly more affected than girls (30%) (OR 2.17, 95% CI 1.25 to 3.78). The majority were of Black (43%) or South Asian (38%) ethnicity. 77.6% of children were not taking vitamin D supplements despite being eligible. Complications included delayed gross motor development (26.4%), fractures (9.6%), hypocalcaemic seizures (8%) and dilated cardiomyopathy (3%). Two children died (1.6%). In eight cases, rickets was confirmed radiologically and biochemically [raised serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) levels ] but were excluded from the incidence analysis for not meeting the case definition of 25-hydroxyvitamin D of <25 nmol/L.

Conclusion The incidence of nutritional rickets in the UK is lower than expected. Serious complications and unexpected deaths, particularly in Black and South Asian children under 5 years, occurred. Both vitamin D deficiency and dietary calcium deficiency are role players in pathogenesis. Uptake of vitamin D supplementation remains low.

  • paediatric practice
  • nutrition
  • bone disease
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  • Contributors PJ: design of the project, review and analysis of data, main author, review of the manuscript. RML: original conception of the project idea; design of the project; collection, recording and statistical analysis of the data; contribution to the write-up of the final manuscript; review of the manuscript. KP: design of the project; collection, recording and statistical analysis of the data; review of the manuscript. ML: collection, recording and statistical analysis of the data; review of the manuscript. AC: design of the project, assessment of cases by an expert panel, review and analysis of the data, contribution to the write-up of the final manuscript, review of the manuscript. ZM: design of the project, assessment of cases by an expert panel, review and analysis of data, review of the manuscript. NS: design of the project, assessment of cases by an expert panel, review of the manuscript. CM: review of the manuscript. HM: assessment of cases by an expert panel, review of the manuscript. MB: original conception of project idea, design of the project, assessment of cases by an expert panel, review of the manuscript, supervision of the main author.

  • Funding An educational grant from the Royal National Orthopaedic Hospital research committee supported by a Vitamin D Nutricia Early Life Nutrition Research grant.

  • Competing interests MB receives funding from the National Institute for Health Research under the Collaborations for Leadership in Applied Health Research and Care programme for North West London. ZM has received honoraria from Internis Pharmaceuticals Ltd.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by NRES Committee London, West London & GTAC (REC reference: 14/LO/2221, IRAS ID: 144785) and was granted Section 251 HRA-CAG permission (CAG reference: 14/CAG/1042).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article. As patient data was obtained from reporting clinicians and the National Research Ethics Service approval obtained only for the purposes of the specified activity, the data cannot be made publicly available for other purposes.

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