Abstract
The chapter reviews the role of low dietary calcium intakes in the pathogenesis of nutritional rickets in children. Calcium requirements in children are primarily determined by the skeletal demands for calcium during growth and the efficiency of intestinal calcium absorption to meet these demands. In large parts of the developing world, calcium intakes in children are considered to be low at approximately 300 mg/day. There is good evidence to indicate that children adapt to these low intakes by increasing fractional calcium absorption when the vitamin D status is adequate and by reducing renal calcium excretion. Nevertheless, despite these adaptive processes, calcium deficiency rickets has been described in children from a number of countries, such as South Africa, Nigeria, Bangladesh, and India. Calcium intakes in these children have been estimated to be approximately 200 mg/day. Biochemically, the hallmark is a marked elevation of serum 1,25-dihydroxyvitamin D [1,25(OH)2D] concentrations in association with hypocalcemia and elevated alkaline phosphatase concentrations. 25-Hydroxyvitamin D [25(OH)D] concentrations are lower than in non-rachitic children but generally above levels usually associated with vitamin D deficiency rickets. A number of studies have documented healing of the disease by the supplementation of dietary calcium alone. There is increasing evidence to suggest that vitamin D requirements in children are influenced by their calcium requirements and the calcium content of the diet. Thus nutritional rickets has a spectrum of causes with dietary calcium deficiency being at one end of the spectrum and pure vitamin D deficiency at the other. In between a combination of relative vitamin D insufficiency and low dietary calcium intakes combine to exacerbate the development of rickets.
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REFERENCES
Peacock M (1991) Calcium absorption efficiency and calcium requirements in children and adolescents. Am J Clin Nutr 54(1):261S–265S
Bailey DA, Martin AD, McKay HA, Whiting S, Mirwald R (2000) Calcium accretion in girls and boys during puberty: a longitudinal analysis. J Bone Miner Res 15:2245–2250
Zhu K, Greenfield H, Zhang Q, Du X, Ma G, Foo LH et al (2008) Growth and bone mineral accretion during puberty in Chinese girls: a five-year longitudinal study. J Bone Miner Res 23(2):167–172
Braun M, Palacios C, Wigertz K, Jackman LA, Bryant RJ, McCabe LD et al (2007) Racial differences in skeletal calcium retention in adolescent girls with varied controlled calcium intakes. Am J Clin Nutr 85(6):1657–1663
Joint FAO/WHO expert consultation (2004) Calcium, vitamin and mineral requirements in human nutrition, 2nd edn. WHO/FAO, Geneva, 59–93
Standing committee on the scientific evaluation of dietary reference intakes IoM (1997) Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. National Academy Press, Washington
Department of health (1998) Nutrition and bone health: with particular reference to calcium and vitamin D. Her Majesty’s Stationery Office, London
Heaney RP (2002) Ethnicity, bone status, and the calcium requirement. Nutrition Res 22(1–2):153–178
Weaver CM, McCabe LD, McCabe GP, Novotny R, Van Loan M, Going S et al (2007) Bone mineral and predictors of bone mass in White, Hispanic, and Asian early pubertal girls. Calcif Tissue Int 81(5):352–363
Gibson RS, Manger MS, Krittaphol W, Pongcharoen T, Gowachirapant S, Bailey KB et al (2007) Does zinc deficiency play a role in stunting among primary school children in NE Thailand? Br J Nutr 97(1):167–175
Dahifar H, Faraji A, Ghorbani A, Yassobi S (2006) Impact of dietary and lifestyle on vitamin D in healthy student girls aged 11–15 years. J Med Invest 53(3–4):204–208
Marwaha RK, Tandon N, Reddy DRH, Aggarwal R, Singh R, Sawhney RC et al (2005) Vitamin D and bone mineral density status of healthy schoolchildren in northern India. Am J Clin Nutr 82(2):477–482
Winzenberg T, Shaw K, Fryer J, Jones G (2006) Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials. BMJ 333(7572):775–780
Greer FR, Krebs NF (2006) Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics 117(2):578–585
Kerstetter JE, O’Brien KO, Insogna KL (2003) Low protein intake: the impact on calcium and bone homeostasis in humans. J Nutr 133(3):855S–861
Hansen KE, Jones AN, Lindstrom MJ, Davis LA, Engelke JA, Shafer MM (2008) Vitamin D insufficiency: disease or no disease? J Bone Miner Res 23(7):1052–1060
Rafferty K, Heaney RP (2008) Nutrient effects on the calcium economy: emphasizing the potassium controversy. J Nutr 138(1):166S–171S
Bass JK, Chan GM (2006) Calcium nutrition and metabolism during infancy. Nutrition 22(10):1057–1066
Lynch MF, Griffin IJ, Hawthorne KM, Chen Z, Hamzo M, Abrams SA (2007) Calcium balance in 1–4-yr-old children. Am J Clin Nutr 85(3):750–754
Lee WT, Leung SS, Fairweather-Tait SJ, Leung DM, Tsang HS, Eagles J et al (1994) True fractional calcium absorption in Chinese children measured with stable isotopes (42Ca and 44Ca). Br J Nutr 72(6):883–897
Abrams SA, Griffin IJ, Hawthorne KM, Gunn SK, Gundberg CM, Carpenter TO (2005) Relationships among vitamin D levels, parathyroid hormone, and calcium absorption in young adolescents. J Clin Endocrinol Metab 90(10):5576–5581
Braun M, Martin BR, Kern M, McCabe GP, Peacock M, Jiang Z et al (2006) Calcium retention in adolescent boys on a range of controlled calcium intakes. Am J Clin Nutr 84(2):414–418
Abrams SA, Griffin IJ, Hicks PD, Gunn SK (2004) Pubertal girls only partially adapt to low dietary calcium intakes. J Bone Miner Res 19(5):759–763
Bell NH, Yergey AL, Vieira NE, Oexmann MJ, Shary JR (1993) Demonstration of a difference in urinary calcium, not calcium absorption, in black and white adolescents. J Bone Miner Res 8:1111–1115
Weaver CM (1994) Age related calcium requirements due to changes in absorption and utilization. J Nutr 124(8_Suppl):1418S–1425S
Abrams SA, Strewler GJ (2007) Adolescence: how do we increase intestinal calcium absorption to allow for bone mineral mass accumulation? BoneKEy-Osteovision 4(5):147–157
Lanou AJ, Berkow SE, Barnard ND (2005) Calcium, dairy products, and bone health in children and young adults: a reevaluation of the evidence. Pediatrics 115(3):736–743
Winzenberg T, Jones G (2008) recommended calcium intakes in children: have we set the bar too high? IBMS BoneKEy 5(2):59–68
Maltz HE, Fish MB, Holliday MA (1970) Calcium deficiency rickets and the renal response to calcium infusion. Pediatrics 46:865–870
Kooh SW, Fraser D, Reilly BJ, Hamilton JR, Gall D, Bell L (1977) Rickets due to calcium deficiency. N Engl J Med 297:1264–1266
Walker ARP (1972) The human requirement of calcium: should low intakes be supplemented? Am J Clin Nutr 25:518–530
Thacher TD, Fischer PR, Strand MA, Pettifor JM (2006) Nutritional rickets around the world: causes and future directions. Ann Trop Paediatr 26(1):1–16
Pettifor JM, Ross P, Wang J, Moodley G, Couper-Smith J (1978) Rickets in children of rural origin in South Africa: is low dietary calcium a factor? J Pediatr 92:320–324
Pettifor JM, Ross FP, Travers R, Glorieux FH, DeLuca HF (1981) Dietary calcium deficiency: a syndrome associated with bone deformities and elevated serum 1,25-dihydroxyvitamin D concentrations. Metab Bone Rel Res 2:301–305
Pettifor JM (1991) Dietary calcium deficiency. In: Glorieux FH (ed) Rickets. Nestec, Vevey; Raven Press, New York, 123–143
Bhimma R, Pettifor JM, Coovadia HM, Moodley M, Adhikari M (1995) Rickets in black children beyond infancy in Natal. S Afr Med J 85:668–672
Marie PJ, Pettifor JM, Ross FP, Glorieux FH (1982) Histological osteomalacia due to dietary calcium deficiency in children. N Engl J Med 307:584–588
Eyberg C, Pettifor JM, Moodley G (1986) Dietary calcium intake in rural black South African children. The relationship between calcium intake and calcium nutritional status. Hum Nutr Clin Nutr 40C:69–74
Pettifor JM, Ross FP, Moodley GP, Shuenyane E (1981) The effect of dietary calcium supplementation on serum calcium, phosphorus and alkaline phosphatase concentrations in a rural black population. Am J Clin Nutr 34:2187–2191
Okonofua F, Gill DS, Alabi ZO, Thomas M, Bell JL, Dandona P (1991) Rickets in Nigerian children: a consequence of calcium malnutrition. Metabolism 40:209–213
Oginni LM, Worsfold M, Oyelami OA, Sharp CA, Powell DE, Davie MW (1996) Etiology of rickets in Nigerian children. J Pediatr 128(5 Pt 1):692–694
Thacher TD, Ighogboja SI, Fischer PR (1997) Rickets without vitamin D deficiency in Nigerian children. Ambulatory Child Health 3:56–64
Akpede GO, Solomon EA, Jalo I, Addy EO, Banwo AI, Omotara BA (2001) Nutritional rickets in young Nigerian children in the Sahel savanna. East Afr Med J 78(11):568–575
Ekanem EE, Bassey DE, Eyong M (1995) Nutritional rickets in Calabar, Nigeria. Ann Trop Paediatr 15(4):303–306
Thacher T, Glew RH, Isichei C, Lawson JO, Scariano JK, Hollis BW et al (1999) Rickets in Nigerian children: response to calcium supplementation. J Trop Pediatr 45(4):202–207, [Erratum, J Trop Pediatr 2000; 46:62.]
Thacher TD, Fischer PR, Pettifor JM, Lawson JO, Isichei C, Chan GM (2000) Case-control study of factors associated with nutritional rickets in Nigerian children. J Pediatr 137:367–373
Fischer PR, Rahman A, Cimma JP, Kyaw-Myint TO, Kabir AR, Talukder K et al (1999) Nutritional rickets without vitamin D deficiency in Bangladesh. J Trop Pediatr 45(5):291–293
Arnaud J, Pettifor JM, Cimma JP, Fischer PR, Craviari T, Meisner C et al (2007) Clinical and radiographic improvement of rickets in Bangladeshi children as a result of nutritional advice. Ann Trop Paediatr 27(3):185–191
Kabir ML, Rahman M, Talukder K, Rahman A, Hossain Q, Mostafa G et al (2004) Rickets among children of a coastal area of Bangladesh. Mymensingh Med J 13(1):53–58
Balasubramanian K, Rajeswari J, Gulab GYC, Agarwal AK, Kumar A et al (2003) Varying role of vitamin D deficiency in the etiology of rickets in young children vs. adolescents in northern India. J Trop Pediatr 49(4):201–206
DeLucia MC, Mitnick ME, Carpenter TO (2003) Nutritional rickets with normal circulating 25-hydroxyvitamin D: a call for reexamining the role of dietary calcium intake in North American infants. J Clin Endocrinol Metab 88(8):3539–3545
Legius E, Proesmans W, Eggermont E, Vandamme-Lobaerts R, Bouillon R, Smet M (1989) Rickets due to dietary calcium deficiency. Eur J Pediatr 148(8):784–785
Dagnelie PC, Vergote FJVRA, van Staveren WA, van den Berg H, Dingjan PG, Hautvast JGAJ (1990) High prevalence of rickets in infants on macrobiotic diets. Am J Clin Nutr 51:202–208
Thacher TD, Fischer PR, Pettifor JM, Lawson JO, Isichei CO, Reading JC et al (1999) A comparison of calcium, vitamin D, or both for nutritional rickets in Nigerian children. N Engl J Med 341(8):563–568
Weaver CM, Proulx WR, Heaney R (1999) Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr 70(suppl):543S–548S
Sly MR, van der Walt WH, Du Bruyn D, Pettifor JM, Marie PJ (1984) Exacerbation of rickets and osteomalacia by maize: a study of bone histomorphometry and composition in young baboons. Calcif Tissue Int 36:370–379
Weaver CM (2007) Vitamin D, calcium homeostasis, and skeleton accretion in children. J Bone Miner Res 22(s2):V45–V49
Graff M, Thacher TD, Fischer PR, Stadler D, Pam SD, Pettifor JM et al (2004) Calcium absorption in Nigerian children with rickets. Am J Clin Nutr 80:1415–1421
Thacher TD, Fischer PR, Isichei CO, Pettifor JM (2006) Early response to vitamin D2 in children with calcium deficiency rickets. J Pediatr 149(6):840–844
Docio S, Riancho JA, Perez A, Olmos JM, Amado JA, Gonzales-Macias J (1998) Seasonal deficiency of vitamin D in children: a potential target for osteoporosis-preventing strategies? J Bone Miner Res 13(4):544–548
Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M (2008) On behalf of the drug and therapeutics committee of the Lawson Wilkins pediatric endocrine society. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics 122(2):398–417
Clements MR, Johnson L, Fraser DR (1987) A new mechanism for induced vitamin D deficiency in calcium deprivation. Nature 325:62–65
Clements MR, Davies M, Hayes ME, Hickey CD, Lumb GA, Mawer EB et al (1992) The role of 1,25-dihydroxyvitamin D in the mechanism of acquired vitamin D deficiency. Clin Endocrinol 37:17–27
Batchelor AJ, Watson G, Compston JE (1982) Changes in plasma half-life and clearance of [3H]-25-hydroxyvitamin D3 in patients with intestinal malabsorption. Gut 23:1068–1071
Fischer PR, Thacher TD, Pettifor JM, Jorde LB, Eccleshall TR, Feldman D (2000) Vitamin D receptor polymorphisms and nutritional rickets in Nigerian children. J Bone Miner Res 15:2206–2210
Baroncelli GI, Bereket A, El Kholy M, Audi L, Cesur Y, Ozkan B et al (2008) Rickets in the Middle East: role of environment and genetic predisposition. J Clin Endocrinol Metab 93:1743–1750
Thacher TD, Pettifor JM, Fischer PR, Okolo SN, Prentice A (2006) Case-control study of breast milk calcium in mothers of children with and without nutritional rickets. Acta Paediatr 95(7):826–832
Prentice A, Jarjou LMA, Cole TJ, Stirling DM, Dibba B, Fairweather-Tait S (1995) Calcium requirements of lactating Gambian mothers: effects of a calcium supplement on breast-milk calcium concentration, maternal bone mineral content, and urinary calcium excretion. Am J Clin Nutr 62(1):58–67
Prentice A, Yan L, Jarjou LM, Dibba B, Laskey MA, Stirling DM et al (1997) Vitamin D status does not influence the breast-milk calcium concentration of lactating mothers accustomed to a low calcium intake. Acta Paediatr 86(9):1006–1008
Levine MA, Dang A, Ding C, Fischer PR, Singh R, Thacher T (2007) Tropical rickets in Nigeria: Mutations of the CYP2R1 gene encoding vitamin D 25-hydroxylase as a cause of vitamin D dependent rickets. Bone 40(suppl):S22–S89
Pettifor JM (1994) Privational rickets: a modern perspective. J Roy Soc Med 87:723–725
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Pettifor, J.M., Fischer, P.R., Thacher, T.D. (2010). Dietary Calcium Deficiency and Rickets. In: Holick, M. (eds) Vitamin D. Nutrition and Health. Humana Press. https://doi.org/10.1007/978-1-60327-303-9_34
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DOI: https://doi.org/10.1007/978-1-60327-303-9_34
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