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To the Editor: We describe two boys from well-off social strata who presented with rachitic fractures, representing child neglect and abuse by omission.
Case 1: A 13-y-old boy presented with sudden loss of consciousness. The history revealed difficulty in ambulation because of backache and knee pain for one month, with no seizure or fever. Child appeared unkempt, had florid rickets, and height and BMI were <-2 SDS. The household consisted of mother, maternal aunt, and maternal grandmother, who were all malnourished. The family lived in their ancestral home in a posh locality. The child’s parents had separated; and maternal grandfather, a government servant, had expired three years back. During the COVID-19 lockdown, his pension got interrupted. Despite being well-educated, the mother and aunt made no efforts to seek employment or restore pension. All three adults had psychological issues; they had withdrawn socially, stopped sending the child to school, and were surviving on meagre rations.
Child’s calcium was 3.5 mg/dL with severe vitamin D deficiency rickets, and fractures in left ulna and several vertebrae. Mother also had osteomalacia and vertebral fractures. Besides medical management, the family received psychological counselling. Our medical social services assisted in restoration of pension, and involvement of the child welfare committee to ensure child’s safeguard.
Case 2: A 10.5-y-old boy with cerebral palsy and epilepsy presented with spontaneous fractures in multiple long bones for 6 mo. At 5 y, he had a femoral fracture requiring internal fixation. His weight was 12.5 kg, and he had rachitic bony deformities confirmed on biochemistry and radiographs, along with displaced fractures of multiple long bones. With medical management; prompt improvement in irritability, seizure control, and tone was noted. Despite previous fractures, the recognition of precarious calcium and vitamin D status was delayed. Monitoring of bone health, optimization of dietary intake, and supplementation of calcium and vitamin D is recommended in all children with cerebral palsy [1, 2].
References
Seth A, Aneja S, Singh R, Majumdar R, Sharma N, Gopinath M. Effect of impaired ambulation and anti-epileptic drug intake on vitamin D status of children with cerebral palsy. Paediatr Int Child Health. 2017;37:193–8.
Ward LM. Part I: Which child with a chronic disease needs bone health monitoring? Curr Osteoporos Rep. 2021;19:278–88.
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Priyadarshini, S., Paul, P.G. & Jain, V. Rachitic Fractures and Severe Undernutrition: A Manifestation of Child Neglect. Indian J Pediatr (2024). https://doi.org/10.1007/s12098-024-05123-z
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DOI: https://doi.org/10.1007/s12098-024-05123-z