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ORIGINAL ARTICLES
 
Nutritional rickets and osteomalacia in school children and adolescents
 
  Nasir A Al-Jurayyan,  Mahmoude E El-Desoukit,  Abdullah S Al-Herbisht,  Abdullah S Al-Mazyad,  Mahao M Al-Qhtani
 
ABSTRACT
 

Objectives: To review experiences of nutritional rickets and osteomalacia in school children and adolescents at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia.
 
Methods: Records of children and adolescents aged 6-18 years, seen at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, during the period January 1994 through to December 1999, who were diagnosed to have rickets or osteomalacia were reviewed. The diagnosis was based on clinical, biochemical and radiological data. Data extracted and analyzed included age, sex, presenting symptoms and signs, dietary history and sun exposure, blood count, bone profiles, renal and liver profile, and 25-hydroxy vitamin D3 and 1, 25 dihydroxy vitamin D3. Hand and wrist x-rays were carried out for all patients while bone density of lumbar spine and 3 femoral sites and bone scan were performed on the majority of patients.
 
Results: Forty-two children and adolescents (25 females and 17 males) were diagnosed. Their age ranged between 6-18 years with a mean of 13.5. Non specific symptoms, such as bone pain and fatigue were the most presenting symptoms, while skeletal deformities and fractures were the presenting symptoms in only 5 and 3 patients. Lack of direct sun exposure and poor calcium intake was evident. Bone profiles at the time of diagnosis revealed mean serum calcium of 2.1 mmol/L, range 1.5–2.3 (Normal=2.2-2.7), phosphorus 1.1 mmol/L, range 0.7–1.9 (Normal=1.4–2.1) and alkaline phosphatase activities of 1,480 U/L, range 834 – 2,590 (N=<600). Serum concentrations of 25-hydroxy Vitamin D were low (<10 mg/L) while that of 1, 25 Dihydroxy Vitamin D varied between low to normal (<10-45 ng/L). Bone density of the lumbar spine and 3 femoral sites were performed in 26 patients and showed markedly reduced values, while bone scan demonstrated a high uptake of tracer throughout the skeleton "super scan". Multiple stress fractures were evident in 8 children.
 
Conclusions: Although a community-based study to assess the magnitude of the problem is needed, it seems that rickets and osteomalacia of nutritional origin are not that uncommon and deserves special attention from all pediatricians and practicing physicians. They also suggested that further studies are needed to help understand the pathophysiology, and identify the contributing factors for the development of the disorder.

 
 
Saudi Medical Journal 2002; Vol.  (2): 182-185 doi: http://dx.doi.org/
 

 

Rickets and osteomalacia are anatomically distinct conditions arising from the common event of mineral insufficiency. Rickets is often referred to as failure of mineralization of a growing bone, whereas osteomalacia indicates failure of a mature bone to mineralize.1-7 In developing countries, nutritional rickets is still being seen in infants and toddlers in such a magnitude as to be considered a community health problem.5,8—23 In older children and adolescents it is also reported with increasing frequency.8,19, 24-25 In sunny Saudi Arabia, there is no precise clinical data on the magnitude of the disease in older children and adolescents. However, there is an impression fostered by the clinical experience that this is not uncommon. This article reviews our clinical experience with nutritional rickets and osteomalacia in school children and adolescents (6-18 years) at the King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia over a 6 year period January, 1994 through to December 1999.P> FONT>

Methods.FONT> FONT>Children and adolescents aged 6-18 years who were seen at the KKUH during the period January 1994 through to December 1999, and confirmed to have nutritional rickets or osteomalacia were included. In this study, KKUH is the major teaching hospital of the King Saud University, Riyadh, Kingdom of Saudi Arabia (KSA) and provides primary, secondary and tertiary health care services to the local population and also receives patients referred from all over the country. The diagnosis was based on clinical, biochemical, and radiological data. Rickets and osteomalacia associated with Vitamin D dependency, renal or liver disorders malabsorption and drug therapies such as steroid or anti-convulsant medications were excluded by appropriate clinical and laboratory investigations.P>

The records of all patients were reviewed and data extracted for analysis included age, sex, presenting symptoms and signs, dietary history, sun exposure and medication intake as well as detailed physical examination. Laboratory investigations included complete blood count, renal, liver and bone profiles. Serum concentrations of 25 hydroxy Vitamin D (25 Hydroxy (OH) D) and, 1, 25 dihydroxy Vitamin D (1,25 (OH) 2 D) were measured commercially by Bio-Scientia Laboratory, Germany. Parathyroid hormone (PTH) level was carried out if indicated. Hand and wrist x-rays were carried out for all patients while other x-rays were carried out when appropriate. Bone density of the lumbar spine and 3 femoral sites and bone scans were performed in 26 patients as described before.26 All patients were treated with oral Vitamin D preparations, ± calcium supplement with proper sun exposure.P> FONT>

Results.FONT> FONT>During the period January 1994 through to December 1999, 42 children and adolescents (25 females and 17 males) were diagnosed to have nutritional rickets or osteomalacia. Their ages ranged between 6 and 18 years with a mean of 13.5 years. Non-specific symptoms, such as bone pain and fatigue were the most presenting symptoms in 27 (64.3%) patients. Short stature in 6 (14.3%), while skeletal deformities and pathological fractures were the presenting symptoms in 5 (11.9%), and 3 (7.1%) patients. Only one patient presented with hypocalcemic tetany (2.4%). The dietary calcium intake was estimated to be as low as 100-300 mg/day. Milk consumption was generally low, with increased consumption of fast food and soft drinks. Sun exposure was negligible and the majority of activities were indoors. Bone profiles at the time of diagnosis revealed mean serum calcium of 2.1 mmol/L, range 1.5—2.3 (N=2.2-2.7), phosphorous 1.1 mmol/L, range 0.7—1.9 (N=1.4-2.1), and alkaline phosphatase activities of 1480

 

From the Department of Pediatrics (Al-Jurayyan, Al-Herbish, Al-Mazyad & Al-Qhtani), Department of Nuclear Medicine (El-Desouki), College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Received 15th May 2001. Accepted for publication in final form 30th September 2001.

Address correspondence and reprint request to: Dr. Nasir A. Al-Jurayyan, Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, Riyadh 11461, Kingdom of Saudi Arabia. Tel. +966 (1) 4671503. Fax. +966 (1) 4679463. E-mail: jurayyanna@yahoo.com

 

Acknowledgment.FONT> FONT>The authors would like to thank Ms. Cecile S. Sael and Ms. Loida D. Manalo for their secretarial assistance.P>FONT>


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