SAT-275 “Nutritional Rickets: Still A Problem In The 21(St)Century”

Background:  Nutritional rickets is common despite educational efforts and prenatal counseling with recent resurgence in the developed world. Possible reasons are parental lack of knowledge about need for supplementation and complex socio-economic factors. Vitamin D and Calcium (Ca) deficiency are the commonest etiologies. The presentation is varied, ranging from being asymptomatic to bony changes, weakness, and seizures. Objective:  We aimed to evaluate the presentation, patient characteristics, management and recovery of inner city children presenting with Rickets. Methods: We reviewed medical records of 14 patients between ages 0-3 years, seen at our center with a diagnosis of active rickets between 2013 and 2017. Data are reported as mean ± SD. Results: 14 patients were included in the study. The patients were aged 3-18 months [8.7 ± 4.0mo], weight SDS -1.35±1.29, length SDS -2.07±1.62, weight-for-length SDS -0.06 ±1.9. Most of the patients were male [93.8%] with 57% Arabic and 28% African-American. Most patients (58 %) presented with unrelated symptoms and were found to have rickets by exam and/or with lab work; 21% presented with seizures and 21% with musculoskeletal symptoms. Mean age of exclusive breast-feeding was 7.8± 4.4mo. Only one of the 14 patients was on vitamin D supplementation. Labs at presentation showed hypocalcemia (mean Ca level of 6.65±1.61mg/dl), hypophosphatemia (3.92±1.06mg/dl), hypomagnesemia (1.87±0.29mg/dl), elevated alkaline phosphatase (1234±764 U/L), low 25OH-vitamin D (8.25±2.82ng/ml) and elevated PTH (90-742pg/ml). Most of the children had X-ray changes in the knee and wrists with metaphyseal flaring and widening being the most common findings. In addition to the usual management with Calcium and Ergocalciferol, Calcitriol was used in 5 out of 14 patients (35%) to help normalize calcium levels. Time to normalize total calcium levels ranged from 1-22 days [7.44±6.98 days], time to achieve 25OH-vitaminD level of >20 ng/ml ranged between 7 and 285 days. Labs at first clinic follow-up showed improvement with calcium of 9.3±1.0mg/dl, Phosphorus of 4.4±1.4mg/dl, 25OH-vitamin D level of 26±13ng/ml. PTH level was still elevated in two patients at follow-up. Conclusion:  Nutritional rickets is still a prevalent problem especially among infants of Arabic and African-American ethnicity. At least 42% of the patients present with significant morbidity including seizures and musculoskeletal abnormalities. Treatment with vitamin D and calcium (for a short period to avert hungry bone syndrome) improves vitamin D status and decreases the risk of hypocalcemia. Adequate counseling of mothers in Prenatal and Pediatric clinics regarding vitamin D supplementation needs to be a priority. Consideration may need to be given to screening for vitamin D deficiency in mothers with risk factors like ethnicity, nutritional restrictions or other contributing factors.