Doctors Say Rickets Is Back

By Melissa Schorr
B O S T O N, Aug. 10

An exclusive diet of breast milk could be putting some babies at risk for vitamin D deficiency and thus at risk for rickets, a bone-weakening disorder that has been virtually nonexistent in the United States for decades.

Doctors nationwide are reporting a small spike in the number of breast-fed babies developing nutritional rickets, Rickets is caused by a lack of vitamin D, which is crucial for strong bone development. It can result in stunted growth, broken bones and bow legs in children.

Breast milk, though an excellent source of nutrition overall, provides little vitamin D. Babies can get the vitamin instead from a splash of sunlight or from a daily supplement.

But rickets may be on the rise, researchers believe, because of the renewed popularity of breast-feeding, along with doctors’ failure to properly prescribe vitamin D supplements to breast-feeding moms.

Dark Skin, High Risk At special risk are dark-skinned babies, whose pigmentation prevents them from using sunlight to produce the necessary vitamin D.

But babies of any race who aren’t getting enough vitamin D from their diet and aren’t getting a daily dose of sunlight are potentially at risk of developing rickets, researchers say.

Doctors at two medical centers in North Carolina report in this month’s issue of the Journal of Pediatrics that they saw 30 cases of rickets in breast-fed black infants from 1990 though 1999, with more than half of the cases occurring in the last 18 months alone.

This June, researchers at the University of Texas Southwestern Medical Center in Dallas published a report in the journal Texas Medicine about a recent outbreak of rickets among dark-skinned infants who were breast fed, despite the presence of abundant sunlight in the state.

Statewide Surge Cases of rickets have been popping up around the country, from New York to Florida, notes Dr. Robert P. Schwartz, an endocrinologist at Wake Forest University School of Medicine in Winston-Salem, N.C., lead author of the study.

Schwartz decided to study the issue along with his colleagues, Dr. Shelley Kreiter, a pediatrician at Wake Forest, and Dr. Henry Kirkman of the University of North Carolina School of Medicine in Chapel Hill.

Because of growing concerns, the Centers for Disease Control will be putting out a bulletin on rickets this fall, a spokesman says.

“This is a disease that was here 100 years ago,” Schwartz says. “It’s back.”

History of Rickets

As late as the 1940s, rickets was a common childhood ailment, killing thousands of children annually until doctors learned that that vitamin D in milk and sunlight could largely prevent it.

Today, fortified milk and prepared baby formula both contain vitamin D, largely eliminating the problem.

But because breast milk contains much lower levels of vitamin D, babies exclusively fed on it may be at risk, especially if they have darker skin that blocks out sunlight; live in northern climates and receive less light or have moms with vitamin D deficiencies themselves.

The number of African-American women who are breast-feeding has been on the rise in the past decade, from about 5 to 22 percent, the Pediatrics study reports.

“We’re glad to see that more minority women are breast-feeding, and we don’t want them scared away because they hear their breast milk is not sufficient,” says Carol Huotari, manager for the Center for Breastfeeding Information at La Leche League International, a Schaumburg, Ill.-based group that promotes breast-feeding. “It’s a simple thing to provide vitamin D supplements.”

“We don’t want to come across as against breast-feeding,” Schwartz concurs. “But we think all infants should be supplemented with vitamins.”

Since January, Schwartz’ group has provided supplements to more than 700 women in North Carolina who are exclusively breast-feeding. The supplements are paid for by the federal Health Resources and Services Administration’s Maternal and Child Health Block Grant program.

“Proving supplements to every baby seems like overkill,” says Huotari, “when it’s just a selected group of babies that would benefit.”

But Schwartz says many infants are potentially at risk and the cost has been minimal so far: about $1.50 per infant per month — far less than hospitalizing infants for fractures and broken bones.

Doctors Fail to Warn Besides the increase in breast-feeding contributing to this rise in rickets, pediatricians also may not be telling mothers to supplement the breast milk with vitamin D.

The Journal of Pediatrics study surveyed 400 North Carolina pediatricians and found that 16 percent weren’t prescribing vitamin supplements at all. Younger doctors, who may have never seen a case of rickets, were less likely to prescribe vitamin D than older ones.

“Doctors have not been led to believe it is essential,” Schwartz explains.

Schwartz says the American Academy of Pediatricians hasn’t established clear enough guidelines on supplementation.

In 1998, the academy recommended vitamin D supplements be used for breast-fed infants with dark skin or inadequate exposure to sunlight, but other earlier policy statements still in effect haven’t provided a clear mandate for vitamin use.

“The nice thing is, this disease doesn’t have to occur at all,” Schwartz says. “This is 100 percent preventable.”

http://abcnews.go.com/Health/story?id=118054&page=1#.T36eC6tSSj_

Dr. David Ayoub

David Ayoub, MD

David Ayoub, MD is a board certified diagnostic radiologist practicing in Springfield Illinois as a senior partner in a large, multispecialty private practice group, Clinical Radiologist, SC. He is a volunteer faculty member at Southern Illinois University School of Medicine where he teaches radiology residents and medical students. His areas of interest are metabolic bone disease, including rickets, pediatric skeletal trauma and vaccine injuries. In the last two years he has reviewed over 75 cases of alleged child abuse presenting with multiple fractures. He is currently preparing several research papers on the subject of infantile rickets misdiagnosed as child abuse and a review paper on the limitations of the Classic Metaphyseal Lesion (CML). He is a member of the Society of Skeletal Radiology and the International Bone and Mineral Society.

DAVID. M. AYOUB, M.D.
Diagnostic Radiology Curriculum Vitae
Last updated February 25, 2011

EDUCATION

Peoria High School, Peoria, Illinois, 1977

University of Illinois at Urbana-Champaign, Illinois 1981, B.S.

University of Illinois College of Medicine, Peoria, Illinois 1985, M.D.

POSTGRADUATE MEDICAL TRAINING

Internship, Weiss Memorial Hospital, Chicago, IL 1985-1986

Diagnostic Radiology Residency, Southern Illinois University
Affiliated Hospitals, Springfield, IL 1986-1990

Fellowship, Cardiovascular and Interventional
Radiology, University of Iowa, Iowa City, IA 1990-
1991

Active Medical License

State of Illinois
State of Iowa
State of Missouri

Medical Certification

American Board of Radiology, 1990

American Board of Radiology, subspecialty certification in
Vascular and Interventional Radiology, 1995

Titles

Chief Resident, Diagnostic Radiology, Southern Illinois University, 1989-1990
Section Head, Interventional Radiology, Memorial Medical Center, Springfield, IL
1993-1998
Section Head, Division of Cardiovascular and Interventional Radiology, Rush-
Presbyterian St.
Luke’s Medical Center, Chicago, IL 1998-1999
Fellowship Director, Cardiovascular and Interventional Radiology, Rush-Presbyterian

St. Luke’s
Medical Center, Chicago, IL 1999-2000
Treasurer, Board of Directors, Affiliated Radiologists, S.C., 1999-2000
Treasurer, Chicago Vascular and Interventional Radiological Society, 1999-2001

Employment / Appointments

Clinical Radiologists, S.C., Springfield, IL, July 1991-May 1998

Affiliated Radiologists, S.C., Chicago Il, July 1998 –July 2000

Clinical Radiologists, S.C., Springfield, Illinois July 2000-present

Clinical Associate Professor (Volunteer), Southern Illinois University School of Medicine,
July 1991 through May 1998; July 2004 - current

Active Professional Memberships

Radiological Society of North America

Illinois State Medical Society

Sangamon County Medical Society

Central Illinois Radiologic Society

Society of Nuclear Medicine

American College of Radiology

Society of Skeletal Radiology

International Bone and Mineral Society

American Society for Bone and Mineral Research

Recent Publications – Letters to editor

Ayoub D, Plunkett J, Keller KA, Barnes PD. Are Paterson's critics too biased
to recognize rickets? Acta Paediatr. 2010 Sep;99(9):1282-3.

Response to Taylot et al: Comments on Making the Diagnosis of Rickets in
Asymptomatic Young Children. Hyman CJ, Ayoub D, Miller ME. Clin Pediatr

(Phila). 2010 Dec 2. Epub 2010 Dec 21.

Response to Vinchon. Hyman CJ, Ayoub D, Miller M. Childs Nerv Syst. 2011
Feb;27(2):201

Poster Presentations:

Barnes, PD, Keller, KA, Ayoub D and Ophoven, J. Dating the CML: a radiologic-
pathologic case report and review of the literature. Presented at the 53rd Annual Meeting
of the Society of Pediatric Radiology Boston, MA. April 14-17, 2010.

Ayoub D, Hyman C and Miller M. Metabolic bone disease in young infants with multiple
unexplained fractures: Multifactorial in etiology and often confused for child abuse.
Gordon Conference on Biomineralization, Colby-Sawyer College, New London, NH.
August 15-20, 2010.

Ayoub D, Miller and Hyman, C. Evidence of metabolic bone disease in young infants
with multiple fractures misdiagnosed as child abuse. American Society for Bone and
Mineral Research 32nd Annual Meeting. Toronto, Ontario, Canada. October 15 - 19,
2010.

Annual Society Meeting Scientific Presentations

Ayoub D, Miller M and Hyman C. The forgotten signs of healing rickets in early infantile
Hypovitaminosis D. Radiology Society of North America Annual Meeting. Chicago,
Illinois. December 3, 2010.

Grand Rounds

Infantile rickets vs. child abuse. Southern Illinois University Radiology Staff Grand
Rounds. June 25, 2010. Room A132 Memorial Medical Center, Springfield, Illinois.

Invited Presentations:

Classic metaphyseal lesions or classic metabolic lesions? National Child Abuse Defense
& Resource Center (NCADRC) Annual Conference, Las Vegas, Nevada, August 26,
2010.

Congenital Rickets and Misdiagnosed Child Abuse. Third International Pediatric Abusive
Head Trauma: Medical, Forensic, & Scientific Advances & Prevention Sir Francis Drake
Hotel, San Francisco, California July 7-8, 2011.