Nutritional Vitamin D deficiency rickets in children – Challenges in diagnosis, management, and prevention

Nutritional rickets are characterized by under mineralization of the skeleton that leads to bone deformities and poor growth. The balance between Vitamin D and calcium intake is critical for the maintenance of bone health. A few risk factors that contribute to a high prevalence of rickets in India include poor maternal nutrition, poor dietary calcium, and Vitamin D intake and poor sunshine practices. Early features of rickets may be asymptomatic and may be missed without biochemical and radiological investigations. Severe rickets may be the first manifestation of an underlying non-nutritional rickets that may be misdiagnosed in the absence of a complete workup. The treatment of rickets requires Vitamin D therapy with adequate calcium supplementation. The schedule of treatment with Vitamin D is not standardized, but daily therapy is preferable compared to weekly/monthly stoss therapy. Both cholecalciferol and ergocalciferol may be used for treatment as they are efficacious and cost-effective instead of active Vitamin D preparations. Periodic monitoring for the resolution of biochemical deficiency and improvement in skeletal changes should be emphasized. Prolonged treatment with Vitamin D and calcium should be avoided for the risk of Vitamin D toxicity and nephrocalcinosis. An impetus is required toward the prevention of Vitamin D deficiency. At present, nutritional strategies should focus on a life-cycle approach during the antenatal period, early infancy, and childhood and adolescence. Food fortification is likely to be an effective option, but the efficacy and logistics of this in the Indian setting will require further research.