Document Sample
					                                                 SUPPLEMENT                                                MEDICAL
     Vol. 15, No. 4
                                                                                                           OCTOBER-DECEMBER 2009

                                         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
                                         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

                                         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.
    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:         the children ward and OPD of Khyber Teaching Hospital, Peshawar, Pakistan. The

                                                             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

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)
(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
RADIOLOGICAL               15      1.29 ± 0.00     02 (13)       13 (87)    09 (60)    06 (40)          0.73 ± 0.02            9.49 ± 0.43

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         —-
BIOCHEMICAL          9.40 ± 0.07            3.60 ± 0.05          666 ± 16.90           —-               —-             —-            —-
RADIOLOGICAL         9.60 ± 0.05            4.50 ± 0.12          531 ± 21.32           —-               —-             —-             15

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

                                                                   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

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
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