Docstoc

NUTRITIONAL RICKETS ABDUS SATTAR KHAN

Document Sample
NUTRITIONAL RICKETS ABDUS SATTAR KHAN Powered By Docstoc
					                                                 SUPPLEMENT                                                MEDICAL
                                                                                                           CHANNEL
     Vol. 15, No. 4
                                               BIOCHEMISTRY
                                                                                                           OCTOBER-DECEMBER 2009
ORIGINAL PAPER




                                         NUTRITIONAL RICKETS AMONG CHILDREN IN
                                         PESHAWAR, NWFP, PAKISTAN


1.   ABDUS SATTAR KHAN                   ABSTRACT
     MSc. PhD (UK).
2.   TANVEER H SHAH                      OBJECTIVE: The comparison of biochemical and radiological changes in children with
     MSc.                                nutritional rickets belonging to rural and urban areas of Peshawar, NWFP, Pakistan has
3.   MUDASSIR AHMAD KHAN                 been taken.
     MBBS, MPhil, PhD.                   MATERIALS AND METHODS: Serum Calcium, Phosphate, Alkaline Phosphatase
                                         levels, and radiological examination of wrist of 164 children suffering from rickets and
                                         41 healthy controls up-to 4 years of age from both sexes were examined.
                                         RESULTS: Majority of (60%) children receiving weaning diet and exposed to sunlight
                                         suffering from rickets were from urban area. Children deprived exposure to sunlight but
                                         kept on weaning diet only also developed rickets and 70% of them were from urban areas
                                         residing in multistory buildings, where sunlight could not reach. Amongst 29% of
                                         children deprived of exposure to sunlight and weaning diet but breast-fed were mostly
                                         from rural areas. It is observed that normal biochemical values are affected by taking
                                         the weaning diet. Similarly the radiological symptoms like the biochemical values are also
                                         affected.
                                         CONCLUSION: Children with rickets can have alterations in both biochemical parameters
                                         and the radiological findings. These changes can be attributed to poor socio-economic
                                         background, inadequate dietary intake in both mother and children, prolong breast
                                         feedings, pre-maturity, limited sun exposure and type of residence.

                                         KEY WORDS: Rickets, Calcium, Phosphate, Alkaline Phosphatase, Radiological
                                         Examination.

                                         INTRODUCTION
                                         The prevalence of nutritional rickets in different populations depends upon different
                                         dietary intake, socio-economic position and their geographical distribution and other
                                         cofactors maternal diet, climatic conditions, feeding patterns, dietary intake and pre-
                                         maturity. In rural north Yemen 1 and Libyan children rickets has been associated with
                                         traditional cultural habits that limit sunshine exposure of mothers and infants and with
                                         breast feedings 2, 3 Results of series of studies have attributed rickets to vitamin D
                                         deficiency and correlated with sunlight 4. Vitamin D supplementation of 400 IU per day
                                         in all infants, children advisable to prevent rickets 3, 5, 6. The incidence of nutritional
                                         rickets has declined in America and European countries due to introduction of vitamin
     Department of Chemistry,            D in milk and cereals as prophylactic treatment 7. Long periods of ultraviolet rays may
     University of Peshawar and *        produce harmful effects on the human body 8, 9 such as development of vitamin D
     Department of Biochemistry,         deficiency and rickets in children due to disturbance in phosphorus and calcium metabolism
     Khyber Medical College, Peshawar.   3
                                           . Poor socio-economic background, inadequate dietary intake in both mother and children,
                                         prolong breast feedings, pre-maturity, limited sun exposure and type of residence has
                                         been ascribed as the possible cause of rickets in Sudanees children 3, 10. Rickets is still
                                         a clinically important nutritional disorder among the inhabitants living in extremely
Address for Correspondence:              northern latitudes in the developed countries 11, 12, 13.
    DR. ABDUS SATTAR KHAN
    HOUSE NO. 287, SECTOR H-1,           MATERIAL AND METHODS
    STREET NO. 7, PHASE – 2,             Selection of Patients:
    HAYATABAD, PESHAWAR.                 A total of 164 children suffering from rickets and 41 healthy controls up-to 4 years of
    Phone: 0300 9321580                  age from both sexes were included in this study. Patients and controls were selected from
    Email: drsattar@brain.net.pk         the children ward and OPD of Khyber Teaching Hospital, Peshawar, Pakistan. The


                                                             135
                                                             Table -1
                     General and Anthropometric Data of Control and Children with Rickets.
                 NUMBER           AGE
                   (n)           (Years)              AREA                     GENDER                         HEIGHT            WEIGHT
                                                    R             U            M       F                       (meters)          (Kg)
                                                   (%)           (%)          (%)     (%)
CONTROL              41          2.40 ± 0.19        19            22           25               16
                                                   (46)          (54)         (61)             (39)           0.90 ± 0.02      12.95 ± 0.74
CHILDREN            164          2.28 ± 0.11     52 (32)     112 (68)       101 (62)         63 (38)          0.76 ± 0.01      10.26 ± 0.19
WITH RICKETS

Note: R = Rural, U = Urban, M = Male, F = Female
                                                             Table -2
                   Biochemical and Radiological Findings in Control and Children with Rickets.
                                           BIOCHEMICAL                                                 RADIOLOGICAL
                     Calcium                Phosphate              ALP                  F                S     F,S,C                 S,C
                     (mg/dl)                 (mg/dl)               (U/l)               (%)              (%)     (%)                  (%)
CONTROL            9.09 ± 0.05             4.70 ± 0.05        332 ± 15.37               -                 -               -           -
(n = 41)
CHILDREN           9.06 ± 0.05             2.90 ± 0.06        953 ± 21.64            38 (28)           36 (26)       48 (35)       15 (11)
WITH RICKETS
(n = 164)

Note: ALP = Alkaline Phosphatase, F = Fraying, S = Splaying, C = Cupping
                                                             Table -3
  General and Anthropometric Data of Children with Rickets on basis of Biochemical and Radiological Findings.

FINDINGS                   n          AGE                 AREA                 GENDER                    HEIGHT                 WEIGHT
                          (%)        (Years)                                                             (meters)                (Kg)
                                                      R             U          M             F
                                                     (%)           (%)        (%)           (%)
BIOCHEMICAL &             122      1.70 ± 0.09     44 (36)       78 (64)    74 (61)    48 (39)          0.73 ± 0.01            9.74 ± 0.19
RADIOLOGICAL              (74)
BIOCHEMICAL                27      0.60 ± 0.00     06 (22)       21 (78)    18 (67)    09 (33)          0.59 ± 0.01            5.00 ± 0.29
                          (17)
RADIOLOGICAL               15      1.29 ± 0.00     02 (13)       13 (87)    09 (60)    06 (40)          0.73 ± 0.02            9.49 ± 0.43
                          (09)

Note: R = Rural, U = Urban, M = Male, F = Female
                                                             Table – 4
           Laboratory Data in Children with Rickets on basis of Biochemical and Radiological Findings.
                                           BIOCHEMICAL                                                 RADIOLOGICAL
                      Calcium                Phosphate              ALP                 F                S     F,S,C                 S,C
                      (mg/dl)                 (mg/dl)               (U/l)              (%)              (%)     (%)                  (%)

BIOCHEMICAL &        8.90 ± 0.06            2.60 ± 0.05          1027 ± 21.06          31                30               39         —-
RADIOLOGICAL
(n=122)
BIOCHEMICAL          9.40 ± 0.07            3.60 ± 0.05          666 ± 16.90           —-               —-             —-            —-
(n=27)
RADIOLOGICAL         9.60 ± 0.05            4.50 ± 0.12          531 ± 21.32           —-               —-             —-             15
(n=15)

Note: ALP = Alkaline Phosphatase, F = Fraying, S = Splaying, C = Cupping


                                                                 136
                                                                   Table – 5
                            Gender and Laboratory Data in Group I, II and III Children with Rickets.
  GROUP               M/F              R/U                           BIOCHEMICAL                              RADIOLOGICAL
                      (%)              (%)            Calcium         Phosphate             ALP             F     S   F,S,C             S,C
                                                      (mg/dl)          (mg/dl)              (U/l)          (%)   (%)   (%)              (%)
  I                   29/11           16/24                                                                 05       07        17        09
  (n=40)            (73)/(27)        (40)/(60)      9.10 ± 0.10       3.01 ± 0.11       913 ± 35.86        (13)      (18)      (45)      (24)
  II                 43/34            23/54                                                                21        22        28        05
  (n=77)            (56)/(44)        (30)/(70)      8.90 ± 0.07       2.70 ± 0.09      1030 ± 27.86        (28)      (29)      (37)      (06)
  III                29/18            37/10                                                                12        07        03        01
  (n=47)            (62)/(38)        (79)/(21)      9.16 ± 0.08       3.30 ± 0.09       752 ± 32.10        (52)     (30)       (13)      (05)

  Note:      ALP = Alkaline Phosphatase, F = Fraying, S = Splaying, C = Cupping
             I. Exposed to sunlight and weaning diet (> 1 year and < 5 year)
             II. Kept on weaning diet no exposure to sunlight (2 years)
             III. Breast fed only (< 1 year)



controls were healthy and not suffering           Radiological Examination:                         exposed to sun light. They were two years
from rickets or any other disease.                Radiological examination of children was          of age. Group III (47) consisted of those
                                                  done by performing an x-ray of the antereo-       children who were only on breast feeding.
Weight Measurement:                               posterior aspect of the wrist.                    This group had children of less than one
Weight of the children above 03 years of                                                            year of age (Table-5).
age were measured by using standard weight        RESULTS                                           Group I had 38 children, Group II had 76
machine (Japan), on the other hand for            Out of total 164 children suffering from          children whereas Group III had 23 children
weight of children below 03 years of age,         rickets 62% were male and 38% were female.        having radiological changes. Group I and
infant weight machine (Japan) was used.           Amongst these, 32% were residing in the           Group II comprised of 60% and 70% children
                                                  rural while 68% in the urban areas (Table-        respectively from the urban areas, whereas
Height or Length Measurement:                     1). Serum calcium and phosphorus were             Group III consisted of more children i.e.,
Height of children who were more than 3           found to be significantly lower (P < 0.01),       79% from the rural areas. All the three
years of age and were able to stand was           whereas serum alkaline phosphatase levels         radiological changes together i.e., fraying,
recorded. They were asked to stand straight       were significantly higher (P < 0.001) in          splaying, and cupping were found in greater
with the scale, both feet together; knees         children with rickets as compared to control      percentage in children from Group I (45%)
extended and head touching the scale.             healthy children (Table-2). Amongst the           and Group II (37%), whereas in Group III
Whereas children who were of less than 03         radiological abnormalities in children with       52% of the children were having fraying
years of age, unable to stand were made to        rickets those with all the three findings i.e.,   alone than the rest of the radiological changes.
lye down with their knees fully extended          fraying, splaying and cupping were higher         (Table - 5).
and feet making 90o angle with the legs,          (35%) than fraying (28%) or splaying (26%)
and then their length was measured.               alone or splaying and cupping which was           DISSCUSSION
                                                  11%, the lowest of all (Table-2).                 The breast milk is the ideal form of nutrition
Blood Collection:                                 Children with rickets having both                 for infants but the amount of vitamin D in
Blood sample (5ml) was drawn from the             biochemical and radiological changes were         breast milk depends on the vitamin D status
veins in the dorsum of head of infants and        122 (74%). Of them 61% were males and             of the mother14. Breast-fed infants who
from cubital vein in case of children was         39% females; 36% were living in rural while       receive no vitamin D supplementation also
collected in a tube. It was allowed to clot       64% in urban areas (Table-3). Children with       are at risk. In sunny areas, such as in the
and was centrifuged at 3000 rpm and serum         radiological changes fraying, splaying and        Middle East, rickets may occur when infants
separated.                                        cupping altogether were higher (39) than          are bundled in clothing and are not exposed
                                                  fraying (31), or splaying alone (30) (Table       to sunlight. In some parts of Africa, deficiency
Biochemical Examination:                          - 4). Children having rickets with only           of calcium and / or phosphorus in the diet
Serum Calcium was determined by using             alterations in biochemical parameters (17%)       may lead to rickets3. Data showed that
MTB colorimetric kit supplied by Clonital,        had male to female ratio of 18:9, whereas         (47%) the children deprived exposure to
Italy. Serum Phosphate and serum alkaline         those children with rickets having only           sunlight but kept on weaning diet only also
phosphatase were analyzed by using                radiological changes (09%) had male to female     developed rickets (Group II). Most of them
Merkotest kit and Ecoline 2S, kit respectively,   ratio of 9:6 (Table-3).                           (70%) were from urban areas residing in
both supplied by Merck, Germany. Quality          Children with rickets were divided into three     multistory buildings, where sunlight could
Control Serum N (Human) was used to               groups. Group I (40) comprised of children        not reach. The remaining (30%) rickets
monitor accuracy and precision. The serum         who were on weaning diet and exposed to           children were from rural areas where the
assays were done on Spectrophotometer             sun light. The age ranged from greater than       cultural practice of keeping the babies in
4010, Roche.                                      one year to less than five years. Group II        heavy clothes prevented exposure to sunlight.
                                                  (77) had children on weaning diet but not         Thus biochemical and radiological changes


                                                                       137
were observed and the percentage of                 D supplementation for all breast fed infants      CONCLUSION:
radiological disorders was maximum (99%),           is safe, low cost and reasonable option 14,       Children with rickets can have alterations
                                                    29, 30, 31
which seems to be the effect of the weaning                    .                                      in both biochemical parameters and the
diet plus no curative effect of sunlight            Vitamin D is synthesized in the skin after        radiological findings. These changes can be
(Table-3).                                          exposure to UV-?-radiation from the sun.          attributed to poor socio-economic
Large variations in the clinical and radiological   For any given infant/or child, however the        background, inadequate dietary intake in
spectrum of disease depend upon age,                amount of sun light exposure needed to            both mother and children, prolong breast
duration and severity of vitamin D deficiency       prevent vitamin D deficiency and rickets is       feedings, pre-maturity, limited sun exposure
15, 16
       . Moreover, calcium malnutrition and         difficult to determine; this is greatly           and type of residence.
not the degree of vitamin D deficiency has          influenced by environment, including weather
been the cause of rickets in Nigerian               conditions, air pollution, time of year, degree   REFERENCES
children 17. Most severe biochemical                of latitude exposure32. There is a growing        1.    Underwood P, Margretts B. High level
abnormalities lead to radiological findings         concern regarding UV- ?-light exposure in               of childhood rickets in rural North Yemen.
of fraying, splaying and cupping and were           childhood and its relation ship to skin cancer          Soc Sci Med 1987;24:37-41.
                                                                                                      2.    Elzouki AY, Markestad T, Elgarrah M,
affecting height and weight of children (Table-     in last years 9. A positive co-relation exists
                                                                                                            et al. Serum concentration of vitamin
2 and 3). The biochemical abnormality was           between the occurrence of malignant                     D metabolites in rachitic Libyan children.
preliminary to radiological finding, thus           melanoma among adults and the degree of                 J Pediatr Gastroenterol Nutr 1989;4:507-
27(16%) rickets of early age in which               sun light exposure in childhood 32, 33 .                12.
biochemical levels were abnormal but no             American Academy of pediatrics and                3.    Greer FR. Issues on establishing vitamin
radiological defects were observed (Table -         American Cancer Society has launched a                  D recommendations for infants and
4).                                                 major public health campaign urging people              children.     Am       J      Clin    Nutr
Present study shows that majority of (60%)          to limit exposure to UV light and to use                2004;80(6suppl):1759S-62S.
                                                                                                      4.    Joiner TA, Foster, C. Shop, The many
children receiving weaning diet and exposed         screens. The committee Environmental Health
                                                                                                            faces of vitamin D deficiency Rickets.
to sunlight suffering from rickets (Group I)        of AP recommended that infants less than                PediatricRev 2000;21:296-302.
were from urban area. It is observed that           (<) 6 months of age be kept out of direct         5.    Saggese G, Baroncelli GI. Vitamin D
normal biochemical values are affected by           sunlight, and use protective clothing and               prophylaxis In childhood. Minerva
taking the weaning diet. Similarly the              screens at all times 34.                                Pediatr           1992;44(11):S33-49.
radiological symptoms like the biochemical          Vitamin D supplementation is crucially            6.    Speaker BL, Ho ML, Oestreich A, et al.
values are also affected. Among this group          important for infants living in an inner city           Prospective study of vitamin D
the percentage of radiological changes was          area and those with increase skin                       supplementation in China. J Peditr
                                                                                                            1992;120:732.
95%. The possible reason for this seems to          pigmentation 3, 13, 34, 35. The supplement
                                                                                                      7.    Jocobus CH, Holick MF, Shao Q, et al.
be the maximum deteriorating effect of the          should prevent vitamin D deficiency for all             Hyper vitamin D associated with milk.
weaning diet on the curative effect of sunlight.    infants and children, including those with              N Engl J Med 1992;326:S 1173-7.
Sun exposure is necessary for the synthesis         chronic disease, who may have decreased           8.    Ohnaka T. Health effects of ultraviolet
of vitamin D in the skin 18. Rickets in             vitamin D absorption. No ethnic group or                radiation. Ann Physiol Anthrapol Japan
infants has been attributed to inadequate           minority should be singled out. For breast              1993;12(1):1-10.
vitamin D intake and decreased exposure             fed infants, supplement should be started         9.    Marks R, Jolley D, Lectsas S, et al. The
to sunlight 19, 20, 21, 22. High prevalence of      in early infancy and continued until there              role of child-hood exposure to sunlight
                                                                                                            in the development of solar keratosis
rickets in infants on macrobiotic diets than        is an intake of 200 IU/day. The vitamin D
                                                                                                            and non-molanocytic skin cancer. Med
omnivorous diet 23 and despite of ample             status of mother during pregnancy and                   J 1990;152:62-66.
sunlight nutritional rickets is still prevalent     lactation should be taken into consideration      10.   Hag AL, Karrar ZA. Nutritional vitamin
in many tropical countries 24.                      36
                                                       .                                                    D deficiency rickets in Sudanese children.
Infants who are breast-fed but not receive          Dietary calcium intake may play a                       Ann Trop Paediatr 1995;15(1):69-76.
supplemental vitamin D or adequate sunlight         contributory role in the development of           11.   Barness LA. Rickets: The chiken or
exposure or living in climates with abundant        rickets 37 as oral intake of calcium has                the egg. J Pediatr 1996;129(6):941-2.
sunshine are at increased risk of developing        progressively healed radiological and reversed    12.   Gessener BD, Deschweinitiz E, Paterson
                                                                                                            KM, et al. Nutritional rickets among
vitamin D deficiency or rickets 25, 26, 27.         biochemical features of nutritional rickets
                                                    38
                                                                                                            breast fed black and Alaskan native
Our study shows rickets children, (29%)                . Vitamin deficiency is not the only,                children. Alaska Med 1997;39(3):72-74
deprived exposure to sunlight and weaning           nutritional calcium deficiency is also an               and 87.
diet but breast-fed were mostly from rural          important factor of rickets 39. The time of       13.   Ward, LM. Vitamin D deficiency in 21st
areas (Group III). They also had altered            introduction of weaning food as well as the             century: a persistent problem among
biochemical values but radiological changes         types of the weaning diet also play important           Canadian infants and mothers. Can Med
were much less (49%) than those children            factor bearing on the occurrence of rickets.            Assoc J. 2005;172:769-70.
having rickets in other groups (Table-3)            Since most of our traditional food that contain   14.   Rockvillie       MD.        Vitamin     D
                                                                                                            supplementation to prevent Rickets in
On the other hand ultra violet radiations           phytic acid, this may result in lowering the
                                                                                                            breast fed babies. In: Agency for health
have been found to correct biochemical              amount of available calcium and phosphorus              care research and quality. Fact sheet
abnormalities and have improved the                 for absorption 40. Children living at high              AHRQ. Publication No.2. 1980:1-34.
condition of the children suffering from            altitudes often have delayed growth, but          15.   Chesney RW. Requirement and upper
rickets28, The amount of sun exposure an            whether growth retardation is related to                limits of vitamin D intake in the term
infant need to prevent rickets depends on           altitude or to other factors is not known.              nonates,infants and older chidren. J
skin pigmentation, the amount of clothing           Severe stunting due to malnutrition occurs              Peadiatr 1990;116:159-66.
worn, latitude, time of day, season of the          early in life and morbidity is high 41, 42.       16.   Francis H, Glorieux FH. Common Vitamin
                                                                                                            deficiency rickets.Nestle In: Nutrition
year, amount of smog and so on. Vitamin


                                                                         138
      Workshop Series Vol: 21, New York            26. Daaboul J, Sanderson S, Kristensen K,              on Environ Health, UV Light: a hazard
      1991;109-113.                                    et al. Vitamin D deficiency in pregnant            to children. Pediatr 1999;104:328 -33.
17.   Okonofua F, Gills DS, Alabi ZO, et al.           and breast-feeding women and their           35.   Tangpricha V, Kontika P, Rieke SM, et
      Rickets in Nigerian children: A                  infants. J Perinatol 1997;17:10-14.                al. Fortification of orange juice with
      consequence of calcium malnutrition.         27. Shaikh U, Alpert MSN. Practices of                 vitamin D: A novel approach for
      1991;40(2):209-13.                               vitamin D recommendations in Las Vegas,            enhancing Vitamin D Nutritional Health.
18.   Holick MF. Vitamin D, New horizons               Nevada. J Hum Lact 2004;20(1):56-61.               Am J Clin Nutr 2003:77:1478-83.
      for the 21 st century. Am J Clin Nutr        28. Kooh SW, Roberts EA, Fraser D, et al.        36.   Greer FR. Vitamin D and Health in the
      1994;60(4):619-30.                               Ultraviolet radiation for hepatic rickets.         21 st Century: Bone and beyond. Am J
19.   Kreiter SR, Schwartz RP, Kirkman HN,             Arch Dis Child 1989;64(4):617-9.                   Clin Nutr 2004;80(6):1759S-62S.
      et al. Nutritional rickets in African        29. Lo CW, Paris PW, Holick MF. Indian           37.   Delucia MC, Mitnick NE, Carpenter TO.
      American breast-fed infants. J Peadiatr          and Pakistani immigrants have the same             Nutritional     rickets    with    normal
      2000; 137:153-7.                                 capacity as Caucassians to produce                 circulating 25-hydroxyvitamin D:A call
20.   Pugliese MF, Blumberg DL, Hludzinski             vitamin D in response to ultraviolet               for reexamining the role of dietary
      J, et al. Nutritional rickets in suburbia.       irradiation. Am J Clin Nutr 1986;44:683-           calcium intake in North American infants.
      J Am Coll Nutr 1998;17:637-41.                   85.                                                J      Clin       Endocrinol        Metab
21.   Sills IN, Skuza KAA, Horlick MN, et al.      30. Kriester SR, Schwartz RP, Kirkman HN,              2003;88(8):3539-45.
      Vitamin D deficiency rickets.Reports of          et al. Nutritional Rickets in African        38.   Oginni LM, Sharp CA, Badru OS, et al.
      its demise are exaggerated. Clin Peditr          American Breast-fed infants. J Pediatr             Radiological and biochemical resolution
      (Phila) 1994;33:491-93.                          2000;137(2):153-57.                                of nutritional rickets with calcium. Arch
22.   Pitt MJ. Rickets and osteomalacia are        31. Welch TR, Bregstorm WH, Tsang RC.                  Disease Childhood 2003;88:812-17.
      still around. Radiol Clin North Am               Vitamin D Deficient Rickets: The re-         39.   Allgrove J. Is nutritional rickets
      1991;29(10):97-118.                              emergence of a once conquered disease.             returning? Arch. Disease Childhood.
23.   Dagnelie PC, Vergote FJ, vanStaveren             J Pediatr 2000:143-45.                             2004;89:699-701.
      WA, et al. High prevalence of rickets        32. Antier P, Dore JF. Influence of sun-         40.   Sanders TA, Reddy S. Vegetarian diet
      in infants on macrobiotic diets. Am J            exposure during child hood and adult               and children. Am J Clin Nutr 1994;59(5
      Clin Nut 1990;51:20-6.                           hood a      melanoma risk: EPIMEL &                Suppl):1176-81.
24.   Thacher TD, Fisher PR, Pettifor JM,              EORTC Melanoma Cooperative Group.            41.   Harris NH, Crawford PB, Yesh Yangzom
      et al. A comparison of calcium,vitamin           Int J Cancer 1998;77:533-37.                       PH, et al. Nutrition and Health Status
      D,or both for nutritional rickets in         3 3 National Coalition for Skin Cancer                 of Tibitan Children Living at High
      Nigerian children. New Engl J Med                Prevention: The National Forum for                 Altitudes. N Engl J Med 2001;344(5):341-
      1999:341(8):563-68.                              Skin Cancer Prevention in Health,                  47.
25.   Binet A, Kooh SW. Persistence of vitamin         Physical Education, Recreation and Youth     42.   Pettifer JM. Nutritional Rickets:
      D deficiency rickets in Toronto in the           Sports. Reston VA. Am Assoc for Health             Deficiency of Vitamin D, Calcium or
      1990s. Can J Public Health 1996;87:227-          Educ 1998:45-73.                                   both? Am J Clin Nutr 2004; 80:1725S-
      30.                                          34. Am. Academy for Pediatric, Committee               29S.




                                                                        139

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:24
posted:3/5/2011
language:English
pages:5