Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

Abstract

Background: Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication.

Evidence: A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence.

Process: Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus.

Results: This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts.

Conclusion: Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.

Figure 1.

Biochemical disturbances in rickets pathogenesis based on a three-stage classification of vitamin D status (symbolized by the sun) and calcium intake (symbolized by a glass of milk). [Modified from Högler W. Complications of vitamin D deficiency from the foetus to the infant: One cause, one prevention, but who's responsibility? Best Pract Res Clin Endocrinol Metab. 2015;29(3):385–398.(246), with permission. © 2015 Elsevier.]

Figure 2.

Double-blind RCTs have shown that maternal intakes of 1000–6400 IU/d of vitamin D are associated with increased breast milk vitamin D concentrations (156, 168, 169, 171). Lines of similar color represent the same study, and the legend provides the vitamin D supplementation dose (IU/d unless otherwise stated). Oberhelman et al (171) reported milk concentrations of cholecalciferol only.

Figure 3.

Double-blind RCTs have shown that maternal serum 25OHD concentrations are increased with vitamin D supplementation (169, 171, 174, 182). Most trials began supplementation shortly after birth. Markers of similar color represent the same study, and the legend provides the vitamin D supplementation dose in IU/d unless otherwise stated. 1 ng/mL ≈ 2.5 nmol/L. Wtr, winter; Sum, summer.

Figure 4.

Infant serum 25OHD concentrations by age in RCTs where either the mother was supplemented with vitamin D (A) or the infant was supplemented (B) (,–182). Markers of similar color represent the same study, and the legend provides the vitamin D supplementation dose in IU/d unless otherwise stated. 1 ng/mL ≈ 2.5 nmol/L. Wtr, winter; Sum, summer.