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Matern Child Nutr. 2018 Jan;14(1). doi: 10.1111/mcn.12452. Epub 2017 May 3.

Vitamin D deficiency causes rickets in an urban informal settlement in Kenya and is associated with malnutrition.

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KEMRI-Wellcome Trust Research Programme, Kenya.
Section of Paediatrics and Centre for Global Health Research, Imperial College, London, UK.
MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK.
Department of Medicine, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK.
Baraka Health Centre, German Doctors Nairobi, Nairobi, Kenya.
MRC Keneba, The Gambia.
Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.


The commonest cause of rickets worldwide is vitamin D deficiency, but studies from sub-Saharan Africa describe an endemic vitamin D-independent form that responds to dietary calcium enrichment. The extent to which calcium-deficiency rickets is the dominant form across sub-Saharan Africa and in other low-latitude areas is unknown. We aimed to characterise the clinical and biochemical features of young children with rickets in a densely populated urban informal settlement in Kenya. Because malnutrition may mask the clinical features of rickets, we also looked for biochemical indices of risk in children with varying degrees of acute malnutrition. Twenty one children with rickets, aged 3 to 24 months, were identified on the basis of clinical and radiologic features, along with 22 community controls, and 41 children with either severe or moderate acute malnutrition. Most children with rickets had wrist widening (100%) and rachitic rosary (90%), as opposed to lower limb features (19%). Developmental delay (52%), acute malnutrition (71%), and stunting (62%) were common. Compared to controls, there were no differences in calcium intake, but most (71%) had serum 25-hydroxyvitamin D levels below 30 nmol/L. These results suggest that rickets in young children in urban Kenya is usually driven by vitamin D deficiency, and vitamin D supplementation is likely to be required for full recovery. Wasting was associated with lower calcium (p = .001), phosphate (p < .001), 25-hydroxyvitamin D (p = .049), and 1,25-dihydroxyvitamin D (p = 0.022) levels, the clinical significance of which remain unclear.


Africa; acute malnutrition; poverty; rickets; urbanization; vitamin D

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