Materiały źródłowe

• #1 Rickets – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK562285/

  The prevalence of the disease has increased in both developed and developing countries. Yet, generally speaking, the prevalence of rickets is higher in developing counties than in developed countries. African, Middle Eastern, and Asian countries have a wide prevalence rate of 10% to 70%. Historically, the prevalence of rickets in the developed countries significantly decreased following the widespread introduction of dietary vitamin D supplementation, legislation to improve air quality, and recognition of the importance of vitamin D and bone health by the public. In the U.S., vitamin D milk fortification (100 IU/cup) was started in the 1930s. […] The worldwide incidence has been estimated differently per 100,000 in various countries as follows: in Canada, 2.9; in New Zealand, 10.5 among children less than three years while it is 2.2 in the older age group (3-15 years); in Australia, 4.9; in Turkey, 3.8; and in the United Kingdom, 7.5. In the U.S., specifically in Minnesota, there is a substantial increase in the incidence in the last 20 years. The reported incidences in the 1970s, 1980s, 1990s, and 2000s were 0, 2.2, 3.7, and 24.1, respectively. Restricted sunlight (UVB) exposure is one of the reasons for this increasing prevalence. Native Alaskan children are at considerable risk for developing rickets than other U.S. populations. The incidence of the rickets hospitalization rate is the highest in Alaska among all U.S. regions, 2.23/100,000 versus 1.23/ 100,000. The incidence of rickets in Alaska is significantly high because of higher latitudes.

• #1 Rickets in Children: An Update

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8301330/

  Rickets is still a common disease worldwide. Despite a global estimate of rickets, incidence is limited because of the paucity of basic data such as vitamin D dietary intake, especially among children in non-industrialized countries, and recent reports indicate an increase in its prevalence. […] Nutritional rickets remains the most common type globally, representing the most frequent cause of pediatric bone disease in the world. In the United States, incidence estimates of nutritional rickets in the early 2000s was 24.1 per 100,000 compared with 2.2 per 100,000 in the early 1980s. Today, case rate estimates of 2.927 per 100,000 individuals have been reported in the United States and Europe. However, nutritional rickets seems to be more common in low-and middle-income countries, especially the Indian subcontinent, Africa, and the Middle East.

• #1 Rickets in Children: An Update

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8301330/

  Although nutritional rickets continues to be an important global health problem, in the last years, the incidence of heritable forms of rickets has increased. This can be explained thanks to the improvement in molecular techniques that has made it possible to identify the genetic alterations of many of these rare forms of rickets. XLHR remains the most common heritable form, with an incidence of 3.9 per 100,000 live births and a prevalence of 1.7 per 100,000 children and a negative impact on patients quality of life.

• #2 Rickets in Children: An Update

  https://www.mdpi.com/2227-9059/9/7/738

  Rickets is still a common disease worldwide. Despite a global estimate of rickets, incidence is limited because of the paucity of basic data such as vitamin D dietary intake, especially among children in non-industrialized countries, and recent reports indicate an increase in its prevalence. […] Nutritional rickets remains the most common type globally, representing the most frequent cause of pediatric bone disease in the world. In the United States, incidence estimates of nutritional rickets in the early 2000s was 24.1 per 100,000 compared with 2.2 per 100,000 in the early 1980s. Today, case rate estimates of 2.9–27 per 100,000 individuals have been reported in the United States and Europe. However, nutritional rickets seems to be more common in low-and middle-income countries, especially the Indian subcontinent, Africa, and the Middle East. Studies from Asia continue to report high prevalence rates of nutritional rickets; in rural central Tibet, about 30% of children aged 0–5 years had at least one sign of nutritional rickets on clinical examination.

• #2 Rickets in Children: An Update

  https://www.mdpi.com/2227-9059/9/7/738

  Although nutritional rickets continues to be an important global health problem, in the last years, the incidence of heritable forms of rickets has increased. This can be explained thanks to the improvement in molecular techniques that has made it possible to identify the genetic alterations of many of these rare forms of rickets. XLHR remains the most common heritable form, with an incidence of 3.9 per 100,000 live births and a prevalence of 1.7 per 100,000 children and a negative impact on patients’ quality of life. Other heritable forms of rickets are extremely rare and few epidemiological data are available to date.

• #3 Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota | Health & Environmental Research Online (HERO) | US EPA

  https://hero.epa.gov/hero/index.cfm/reference/details/reference_id/2752672

  Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota […] To determine temporal trends in incidence and risk factors of nutritional rickets in a community-based population. […] The main outcome measure was radiographic evidence of rickets without identifiable inherited, genetic, or nonnutritional causes. […] The incidence of nutritional rickets in children younger than 3 years was 0, 2.2, 3.7, and 24.1 per 100,000 for the decades beginning in 1970, 1980, 1990, and 2000, respectively (P=.003 for incidence trend). […] Nutritional rickets remains rare, but its incidence has dramatically increased since 2000.

• #4 Nutritional rickets under 16 years: UK surveillance results | Archives of Disease in Childhood

  https://adc.bmj.com/content/105/6/587

  The UK national incidence of nutritional rickets is unknown. We aimed to describe the incidence, presentation and clinical management of children under 16 years with nutritional rickets in the UK presenting to secondary care. […] 125 cases met the case definition, an annual incidence of 0.48 (95% CI 0.37 to 0.62) per 100000 children under 16 years. […] The incidence of nutritional rickets in the UK is lower than expected. Serious complications and unexpected deaths, particularly in Black and South Asian children under 5years, occurred. Both vitamin D deficiency and dietary calcium deficiency are role players in pathogenesis. Uptake of vitamin D supplementation remains low.

• #5 Rickets and Vitamin D Deficiency in Alaska Native Children

  https://stacks.cdc.gov/view/cdc/36852

  Background Rickets and vitamin D deficiency appeared to increase in Alaskan children, starting in the 1990s. […] We evaluated the epidemiology of rickets and vitamin D deficiency in Alaska Native (AN) children in 2001-2010. […] AN children annual rickets-associated hospitalization rate (2.23/100,000 children/year) was higher than general U.S. rate (1.23; 95% CI 1.08-1.39). […] Rickets incidence increased with latitude. […] Rickets/vitamin D deficiency cases were more likely to have malnutrition (OR 38.1; 95% CI 4.9-294), had similar breastfeeding prevalence, and were less likely to have received vitamin D supplementation (OR 0.23; 95% CI 0.1-0.87), than controls. […] Our findings highlight the importance of latitude, malnutrition and lack of vitamin D supplementation as risk factors for rickets.

• #6 Rickets | Vitamin D Deficiency, Bone Development & Calcium | Britannica

  https://www.britannica.com/science/rickets

  As a result of therapeutic developments in the 20th century, the prevalence of rickets decreased, particularly in developed countries such as the United States, the United Kingdom, and Australia, where it eventually became rare. […] Today the distribution and prevalence of rickets are aligned primarily with risk factors. Hence, it is most prevalent in peoples who are dark-skinned and in developing countries where access to vitamin D-fortified foods is lacking. Africa, the Middle East, and parts of Asia rank among the worlds most heavily affected regions.

• #7

  https://link.springer.com/article/10.1007/s11914-017-0383-y

  Nutritional rickets and osteomalacia are common in dark-skinned and migrant populations. Their global incidence is rising due to changing population demographics, failing prevention policies and missing implementation strategies. […] The global rickets consensus recognises the equal contribution of vitamin D and dietary calcium in the causation of calcium deprivation and provides a three stage categorisation for sufficiency, insufficiency and deficiency. For rickets prevention, 400 IU daily is recommended for all infants from birth and 600 IU in pregnancy, alongside monitoring in antenatal and child health surveillance programmes. […] Public health research has identified traditional diets low in calcium, dark skin and cultural full body clothing, as the predominant causes of rickets and osteomalacia in sunny parts of the world such as the Indian subcontinent, the Middle East and Africa. In high Northern or Southern latitudes (more than approximately 34), it is the seasonal lack of the ultraviolet-B (UV-B) spectrum of sunlight that causes seasonal vitamin D deficiency (also called vitamin D winter). In high latitude countries, the dark-skinned immigrant and resident population is at greatest risk.

• #7

  https://link.springer.com/article/10.1007/s11914-017-0383-y

  In developed countries, the prevalence of NR is several hundred-fold higher in dark-skinned immigrants compared to native populations. This means conditions that are rare in the host country are common in ethnic minorities. […] The mounting evidence on endemic calcium deprivation and NR in risk groups precludes the need for routine 25OHD measurement in asymptomatic individuals; the consensus group therefore recommends lifelong supplementation in high-risk groups. […] NR and osteomalacia are fully preventable. Universal supplementation of infants, supplementing pregnant women, promoting vitamin uptake and also food fortification with vitamin D and calcium to prevent fractures in elderly have been proven cost-effective.

• #8 Rickets – OrthoInfo – American Academy of Orthopaedic Surgeons

  https://orthoinfo.aaos.org/en/diseases–conditions/rickets

  Rickets is a bone disease in children that causes weak bones, bowed legs, and other bone deformities. Children with rickets do not get enough calcium, phosphorus, or Vitamin D all of which are important for healthy growing bones. […] Although considered a disease of the past, rickets has not been eliminated in the world, and it seems to be getting more common in the United States. […] A number of factors decrease the amount of vitamin D a person can make, and therefore contribute to the risk of developing nutritional rickets: […] The key to preventing rickets is to make sure your child is getting enough Vitamin D and calcium. […] Rickets remains a serious nutritional disorder that results from calcium or Vitamin D deficiency. Prevention of rickets is important. Playing outside in the sun for safe amounts of time and eating dairy products and other calcium-rich foods are key to preventing rickets. Vitamin D should be supplemented for most children. […] Rickets is treated with calcium and vitamin D and has a good outlook after treatment.

• #9 Azthena logo with the word Azthena

  https://www.news-medical.net/health/What-is-Rickets.aspx

  Rickets represents an important health issue not only in developing countries but also in the developed world. The prominent contributing factors include limited sunlight exposure, increased skin pigmentation, geographical location and decreased dietary intake. […] The Centers for Disease Control and Prevention (CDC) estimation is that 5 of every million children between 6 months and 5 years of age have rickets, with a peak prevalence of vitamin D-deficient rickets between 6 and 18 months of age. The majority of affected children are black or breastfed. […] In North America, rickets is most commonly found in children with relatively more pigmented skin, who are exclusively breastfed. In Europe and Australia, rickets is typically identified in immigrant populations from the Indian subcontinent and the Middle East.

• #9 Azthena logo with the word Azthena

  https://www.news-medical.net/health/What-is-Rickets.aspx

  In the United States, nutritional rickets was eradicated in the 1930s after discovering that vitamin D possessed antirachitic properties. However, the disease has made an unfortunate comeback, primarily due to a lack of appreciation that human milk contains very little vitamin D to satisfy the infants requirement. […] Of the genetic causes, X-linked hypophosphatemic rickets is most commonly encountered, with a prevalence of 1 in 20 thousand children. Other genetic causes (such as autosomal dominant and autosomal recessive, or mutations in vitamin D 25-hydroxylase or 1-alpha-hydroxylase enzymes) are exceptionally rare.

• #10 Rickets: Practice Essentials, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/985510-overview

  In the United States, vitamin D deficiency rickets does not generally occur in infants fed proprietary infant formulas, because both formula and cow milk sold in the United States contain 400 IU of vitamin D per liter. Accordingly, except in pediatric patients with chronic malabsorption syndromes or end-stage renal disease, nearly all cases of rickets occur in breastfed infants who have dark skin and receive no vitamin D supplementation. […] The incidence of rickets in Europe is similar to that in the United States. In sunny areas, such as in the Middle East, rickets may occur when infants are bundled in clothing and are not exposed to sunlight. In some parts of Africa, deficiency of calcium, phosphorus, or both in the diet may also lead to rickets, especially in societies where corn is predominant in the diet.

• #10 Rickets: Practice Essentials, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/985510-overview

  The frequency of rickets has been increasing internationally. Possible reasons include recommendations for children to wear sunscreen while outdoors and a tendency for children to spend more time indoors, watching television or playing electronic games, instead of playing outdoors. […] Sodri et al reported the case of a 22-month-old girl in Malaysia with nutritional rickets, who presented with abnormal gait and bowing of the legs during the coronavirus disease 2019 (COVID-19) pandemic. Because of lockdowns related to COVID, she had minimal exposure to sunlight. In addition, her calcium intake was poor.

• #11 Nutritional rickets under 16 years: UK surveillance results | Archives of Disease in Childhood

  https://adc.bmj.com/content/105/6/587.responses

  Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to white. As the proportion of ethnic minority in the UK continues to rise (14% in 2011 census) those at highest risk of VDD are failed most by inadequate prevention strategies. […] Shockingly, 77% of reported cases were not on the Department of Health recommended vitamin D supplements demonstrating lack of policy implementation.

• #11 Nutritional rickets under 16 years: UK surveillance results | Archives of Disease in Childhood

  https://adc.bmj.com/content/105/6/587.responses

  Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population. […] In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate. Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty. As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded. The true disease burden is unravelled when family members of affected children are investigated.

• #12 Rickets | Better Health Channel

  https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/rickets

  Rickets is a preventable bone disease that causes soft and weakened bones in infants and young children. […] Although rare, rickets is on the increase among Australian children. Most cases of rickets in Australia occur due to low levels of vitamin D. […] In Australia, rickets occurs most frequently in recently arrived migrant, asylum seeker and refugee children, as well as in those whose parents migrated to Australia. […] Rickets can often be prevented through preventing or treating low vitamin D levels, in addition to maintaining sufficient dietary intake of calcium and phosphate. […] Bones that are poorly mineralised generally respond very quickly to dietary supplementation with calcium and vitamin D. Improvements may be seen on x-ray after only a few days of treatment. If rickets is treated when the child is young, there is a good chance that the skeletal deformities will disappear as the child matures. However, the deformities and reduced height will be permanent if the child goes through puberty without treatment.

• #13 Incidence of vitamin D deficiency rickets among Australian children: an Australian Paediatric Surveillance Unit study | The Medical Journal of Australia

  https://www.mja.com.au/journal/2012/196/7/incidence-vitamin-d-deficiency-rickets-among-australian-children-australian

  Objective: To determine the incidence of and factors associated with vitamin D deficiency rickets in Australian children. […] The overall incidence in children 15 years of age in Australia was 4.9/100 000/year. […] Vitamin D deficiency rickets is a significant problem in Australia among known high-risk groups. Public health campaigns to prevent, identify and treat vitamin D deficiency, especially in high-risk groups, are essential. […] Our study aimed to assess vitamin D deficiency with rickets, rather than vitamin D deficiency alone. […] The estimated national annual incidence of vitamin D deficiency rickets among children was 4.9/100 000 children (95% CI, 4.45.4/100 000). […] This is the first study to assess the incidence of vitamin D deficiency rickets in Australian children.

• #13 Incidence of vitamin D deficiency rickets among Australian children: an Australian Paediatric Surveillance Unit study | The Medical Journal of Australia

  https://www.mja.com.au/journal/2012/196/7/incidence-vitamin-d-deficiency-rickets-among-australian-children-australian

  Although our study provides the first national estimate of vitamin D deficiency rickets, it is likely that there was underreporting of cases leading to an underestimate of the true incidence of vitamin D deficiency rickets. […] Further public health campaigns are also needed to increase awareness of vitamin D deficiency in at-risk groups.

• #14 Rickets: Symptoms, Diagnosis, and Treatments

  https://www.healthline.com/health/rickets

  Rickets is most common in children who are between 6 and 36 months old. […] Rickets is rare in the United States. Rickets used to be more common, but it mostly disappeared in developed countries during the 1940s due to the introduction of fortified foods, such as cereals with added vitamin D. […] Risk factors for rickets include the following: […] One form of rickets can be inherited. This means that the disorder is passed down through your genes. This type of rickets, called hereditary rickets, prevents your kidneys from absorbing phosphate. […] Rickets can also be prevented with moderate sun exposure. According to the National Health Service of England (NHS), you only need to expose your hands and face to sunlight a few times a week during the spring and summer months to prevent rickets.

• #15 Rickets | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/rickets?lang=us

  Rickets is seen in a number of distinct populations. […] The onset and presentation of rickets depend on the etiology and degree of deficiency. Typically, in severe cases, rickets becomes apparent in the second year of life.

• #16 Rickets | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/rickets?embed_domain=hackmd.io%252525252F%2525252540yIPUAFeCSL2JsU8smR5nJQ%252525252Fbnjhjgjghjghjgh&lang=us

  Rickets is seen in a number of distinct populations. The onset and presentation of rickets depend on the etiology and degree of deficiency. Typically, in severe cases, rickets becomes apparent in the second year of life. […] Rickets, less commonly known as rachitis, refers to deficient mineralization of the growth plate in the pediatric population.

• #17 Hypophosphatemic Rickets: Practice Essentials, Etiology, Epidemiology

  https://emedicine.medscape.com/article/922305-overview

  Although serum phosphate levels are similarly depressed in affected males and females, the degree of bone involvement is substantially less severe in heterozygous females. […] As in all genetic disorders, hypophosphatemic rickets is present from conception. Infant birth weight is generally normal, but early growth may be slower than normal. The author’s experience indicates abnormalities are common at birth, including cranial synostosis and increased bone density. […] A study by Endo et al found the estimated incidence of X-linked hypophosphatemic rickets in Japan to be approximately 1 case in 20,000, with this condition being the most prevalent genetic FGF-23 related hypophosphatemic disease in the country. […] A study by Beck-Nielsen et al determined hereditary rickets to be the prevalent form of rickets in ethnic Danish children in southern Denmark, although among all young children in that region, nutritional rickets was found to be the most common type. […] A study by Rafaelsen et al reported that in Norwegian children, the prevalence of X-liked dominant hypophosphatemic rickets is about 1 in 60,000.

• #18 Rickets: Not a Disease of the Past | AAFP

  https://www.aafp.org/pubs/afp/issues/2006/0815/p619.html

  Rickets is not a reportable disease in the United States, national data are unavailable. […] Unlike developing countries, the United States saw the eradication of nutritional rickets in the 1930s following the discovery that vitamin D possessed antirachitic properties. […] Today, in the absence of ongoing national surveillance, it is difficult to know how likely it is that a child with rickets will present to the primary care physicians office. […] In one study, the prevalence of nutritional rickets was estimated to be nine cases per 1 million children, whereas the Centers for Disease Control and Prevention places this rate at five cases per 1 million children six months to five years of age. […] Of note, in multiple studies, most affected children were black.

• #19 Fraying of Metaphysis in Rickets in an Adolescent Girl in: The American Journal of Tropical Medicine and Hygiene Volume 107 Issue 5 (2022)

  https://www.ajtmh.org/view/journals/tpmd/107/5/article-p957.xml

  Rickets is a metabolic bone disease seen in children. It occurs due to the deficiency of calcium and/or phosphate, required for mineralization of the bones. Vitamin D deficiency is a common cause of nutritional rickets in tropical countries. Rickets is more common in younger children (mean age 1.4 years in a study from New Zealand). Various skeletal deformities are seen due to suboptimal bone strength. Abnormal ossification of the growth plate in growing children is the hallmark of the disease. The finding is more commonly seen in younger children and is unusual at the age of our patient. […] Reduced outdoor exposure to sunlight due to the prevailing COVID-19 pandemic perhaps resulted in severe vitamin D deficiency. Moreover, fortification of foodstuff with vitamin D is lacking in India.

• #20

  https://journals.lww.com/sjkd/fulltext/2009/20020/epidemiology_of_nutritional_rickets_in_children.15.aspx

  In most developing countries, nutritional rickets is a major health problem. The aim of this study was to explore the magnitude of nutritional rickets among Saudi infants, and the various clinical presentations, as well as to address the possible operating risk factors behind the disease. […] In most developing regions worldwide, nutritional rickets is a prominent health problem probably because the risk factors still operate. […] In the Kingdom of Saudi Arabia, despite having economic affluence and adequate sunlight all year round, vitamin D deficiency is fairly common in infants, children, adolescents, as well as pregnant and lactating Saudi women. […] The aim of this study was to explore the magnitude of nutritional rickets among Saudi infants, and the various clinical presentations, as well as to address the possible operating risk factors behind the disease and identify recommendations to prevent its occurrence.

• #20

  https://journals.lww.com/sjkd/fulltext/2009/20020/epidemiology_of_nutritional_rickets_in_children.15.aspx

  Nutritional rickets is still prevalent in Saudi Arabia with the primary etiology being vitamin D deficiency. […] The prolongation of exclusive breast-feeding until the age of one year without vitamin D supplement is an important factor leading to the development of rickets in the rapid growth period of infancy; in addition, none of our infants were exposed to direct sunlight. […] Therefore the pediatrician needs to screen the infant with active nutritional rickets for the possibility of co-existence IDA. […] The lack of a formal policy from health professionals recommending routine vitamin D supplementation for all breastfed infants is also a concern. […] Routine supplementary vitamin D 400 IU/day in breast-fed infants has been proven adequate to prevent rickets caused by vitamin D deficiency.

• #21 Preventing symptomatic vitamin D deficiency and rickets among Indigenous infants and children in Canada | Canadian Paediatric Society

  https://cps.ca/documents/position/vitamin-d-deficiency-and-rickets-among-indigenous-infants-and-children

  FNFNES evidence clearly shows that the VitD intake of Canadian Indigenous populations is higher when traditional foods are consumed. […] The Canadian Consensus on Female Nutrition stressed the importance of balanced dietary intake for all women, but indicated that FN pregnant women are at particularly high risk for VitDD. […] Recommendations for all pregnant women living in Alaska are for 1000 IU/day plus a daily prenatal vitamin containing 400 IU of VitD. […] Adherence to supplementation is the most significant barrier to effective VitDD prevention in Canada. […] The strategies found to most improve adherence are habit-based and focus on behaviour, such as linking medication-taking with existing routines. […] Health care professional (HCP, including pharmacist) awareness and promotion of VitD at each health visit improve adherence rates. […] During routine prenatal, infant, and child care visits, health care providers (HCPs) should take three steps: Assess mother and child for VitDD risk, Determine appropriate dosage for VitD supplements, and Support and monitor adherence to dietary and supplementation recommendations.

• #22 Multiple Diagnoses of Nutritional Rickets in An Inner-City Pediatric Population: A Case Series

  https://www.orthojournal.org/articles/multiple-diagnoses-of-nutritional-rickets-in-an-inner-city-pediatric-population-a-case-series.html

  This case series details seven pediatric cases of nutritional rickets in an inner-city population of New Jersey. […] The aim of this case series is to emphasize the importance of surveillance and high clinical suspicion for nutritional rickets, particularly in children with darker skin complexions and who were exclusively breast-fed during infancy. Rapid diagnosis and intervention may delay or negate the need for orthopedic surgical intervention. […] The global incidence of nutritional rickets is rising, even in the United States and other high-income countries. […] Nutritional rickets had largely disappeared from industrialized countries when food fortifications programs were introduced, but there has been a re-emergence over the past two decades. […] In the US alone, the prevalence of rickets has increased from 0 per 100,000 in 1970 to 3.7 per 100,000 in 1990, and further up to 24.1 per 100,000 in 2000.

• #22 Multiple Diagnoses of Nutritional Rickets in An Inner-City Pediatric Population: A Case Series

  https://www.orthojournal.org/articles/multiple-diagnoses-of-nutritional-rickets-in-an-inner-city-pediatric-population-a-case-series.html

  Early intervention with therapeutic dosing of calcium and vitamin D is key and can help to avoid preventable orthopedic surgeries. […] In order to prevent nutritional rickets, it is recommended that physicians and public health workers promote vitamin D supplementation of mother and infant in the short term, and food fortification in the long term.

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