News outlets across the globe have been reporting a resurgence of rickets. The causes being cited are the increased popularity of breast feeding and doctor's failure to prescribe vitamin D supplements to infants. The issue is disproportionately on the rise in (although not limited to) dark-skinned children who cannot make enough vitamin D from their limited sun exposure.

There are no national rates for rickets in the US because it is not a reportable public health disease, and there are no surveillance systems that capture nation-wide information about it. In the UK, however, the Daily Mail cites 833 hospital admissions for rickets in 2012, four-fold the amount 10 years earlier.

What is rickets?

Rickets is a disorder characterized by softening and weakening of the bones resulting from a lack of vitamin D, calcium, or phosphate. Symptoms of rickets include bone pain or tenderness, decreased muscle tone, dental deformities, impaired growth, increased bone fractures, muscle cramps, short stature, and skeletal deformities such as the characteristic bowlegs.  

After being diagnosed with rickets, treatment is to replace the vitamin D, calcium and phosphorus that is lacking. If done during childhood, treatment usually eradicates all symptoms. Vitamin D levels of 20 ng/ml or higher will prevent most cases of rickets, so children diagnosed with rickets are generally severely vitamin D deficient.

Background on rickets

As late as the 1940s, rickets was a common childhood ailment, killing thousands of children annually until doctors learned that that vitamin D in milk and sunlight could largely prevent it. Since that time both infant formula and milk have been fortified with vitamin D and it almost eradicated the disease.  

Three prevalent positions spell trouble for infants

With the resurgence of breast feeding, more babies are off infant formula and are not getting vitamin D supplementation. This would be fine if the mother had a daily vitamin D intake (through sun exposure, food, or supplements) that resulted in 25(OH)D concentration of 40 ng/ml or higher. But most doctors do not know to tell breast feeding mothers this information, nor do they prescribe vitamin D supplementation to infants. In fact,

• the normal population has a vitamin D blood level of about 25 ng/ml (NHANES)

• AND... doctors are not recommending supplementation for infants or their mothers

• AND.... doctors are recommending that mothers and their infants stay out of the sun, cover up, or use sunscreen

The result is that most mothers and their babies are not getting enough vitamin D and rickets is re-emerging.

Lack of vitamin D supplementation in infants

Our panel of scientists recommend infants (< 1 year) take 400 IU vitamin D daily starting a few days after delivery. The easiest way for an infant to receive supplementation is by using drops (Google: 'vitamin D drops').

Carol Wagner, MD studied vitamin D in infants and found that with 400 IU/day the mean vitamin D level in her study group increased from 16 ng/ml (at 1 month) to 43 ng/ml (at 4 months) and 42 ng/ml (at 7 months).

How to get vitamin D in breast milk

Another way to provide vitamin D for an infant is to ensure that there is enough vitamin D in the breast milk. This is possible and has been demonstrated by Dr. Wagner. Wagner ran a lactation study that found women who are replete in vitamin D (> 40 ng/ml) can transfer vitamin D to their babies. She found that 6400 IU/day was necessary for the women to stay replete in vitamin D and that this would be equivalent to babies getting a 400 IU/day supplement.

Wagner's presentation on Vitamin D and Public Health: Integrating sunshine, supplement, and measurement for optimal health includes information from this lactation study (minutes 34:30 -> end).

In his blog Vitamin D and the nursing mother, Dr. Robert Heaney ends with a call to action that all mothers supplement with 5,000 - 6,000 IU/daily because doing so would provide the needed benefit for both the mother and baby, naturally. He also makes a very important point that supplementation needs to be daily:

"There is one important proviso for nursing mothers concerning the needed intake. Those who live in North America and have to rely on supplements should be certain that they take their supplements every day. While for other purposes it is possible to take vitamin D intermittently (e.g., once a week), that doesn't work for putting vitamin D into human milk. The residence time of vitamin D in the blood is so short that, if the mother stops taking her vitamin D supplement for a day or two, vitamin D in her milk will be low (or absent altogether) on the days she skips."

Rickets or Child Abuse?

Because rickets had been so rare, many doctors practicing just ten years ago had never seen a case in person and today many still don't recognize it when they do see it. There have been several cases where children have been pulled away from their families by child protective services (CPS) due to undiagnosed rickets. The children are brought into a medical facility for some treatment (sickness, disease) and broken bones or signs of healing bones are found and presumed to be a result of abuse. At this point CPS is contacted and sometimes the children taken away.

Recently Wagner consulted on such a case where twin 6 month old boys (and their 3 older brothers) were removed from their loving home because of a broken rib and threat of child abuse. The mother was severely vitamin D deficient during pregnancy, and after, and solely breast fed the twins. Vitamin D tests for the twins showed their levels to be < 10 ng/ml. After much work by Wagner and their lawyer the children are now back with their family - and hopefully the whole family is getting sun and supplementation.

Dr. John Cannell, of The Vitamin D Council, has also consulted on such cases. He describes two different, yet similar, cases on his web site.