Rickets Marion Kelly 04.09.97
Re: rickets Michael H.N.Golden 04.09.97
rickets (fwd) Marion Kelly 04.09.97
Rickets Patricia Haggerty 04.09.97
Re: rickets George Fuchs 05.09.97
Rickets André Briend 08.09.97
Rickets Michael H.N.Golden 08.09.97
Rickets in Iraq Ariane Curdy 09.09.97
Re: Rickets in Iraq David Alnwick 09.09.97
FW: Rickets in Iraq Florence Egal 09.09.97

Thu, 4 Sep 1997 14:17:50 +0100 (BST)

From: m-kellyatdfid.gtnet.gov.uk

Subject: rickets


Dear Mike,

Hello, I hope you're well. I know there is meant to be an e-mail group for ad hoc advice on nutrition questions; in fact, I received instructions on how to join it but couldn't seem to make them work.

I'd like to pick your brains about rickets, in view of reports I'm seeing which say that this has become common in children in Iraq. This doesn't seem plausible to me; I wonder whether some other condition is being misdiagnosed?

Also, if rickets really is a problem, would it be appropriate to treat by calciferol injection?

Grateful for any advice you can offer.

best wishes,


Marion Kelly

Thu, 4 Sep 1997 18:38:27 +0100 (BST)

Subject: Re: rickets

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>


Dear Marion,

Rickets is not an uncommon problem in countries such as Iraq, Indeed, rickets is endemic in most countries in a band going from Morocco to Pakistan and even occurs as far south as Ethiopia. It was one of the main concerns addressed at the GERM meeting some years ago, and there was a meeting in Saudi Arabia on this problem.

The reasons for the occurance of rickets in these countries seems to be:

1) The diet is very low in preformed vitamin D; and is also very high in phytic acid (the bread is unleavened).

2) The atmospheric dust in these desert areas is a very good filter of UV-light. One study from Saudi Arabia measured the incident UV on the roof of the Military Hospital in Riyadh. There was no recorded UV until about 1100h and none after about 1300h - so it was only when the sun was directly overhead for two hours per day that sunlight exposure would give rise to dermal vitamin D synthesis.

3) Nearly everyone is indoors around noon, the hottest part of the day, and the construction of the houses is such that there is very little direct sunlight exposure..

4) It is the practice in most of these countries to cover the body very extensively with clothes - including the infants.

So, I would not be at all surprised by reports of rickets from Iraq.

One note of caution though. Swelling of the ends of the ribs ("ricketty roseary") is very common in severe malnutrition in all areas of the world, and the unwary could diagnose rickets on the basis of this sign alone. The cause of this "costro-chondral bossing" elsewhere is not due to rickets but to deficiencies of vitamin C, phosphorus, or rarely copper. I do not know the extent to which physicians in Iraq would make the diagnosis on the basis of this sign alone.

The treatment is with oral vitamin D, it is not usually necessary to give parenteral doses with rickets that is due to simple dietary deficiency or lack of exposure to sunlight (parenteral vitamin D is used when rickets is secondary to malabsorption syndromes and in some uncommon congenital forms of the disease).

Appropriate daily doses for treatment of children are:

1-4 years, 40 to 80 micrograms (1500-3000 international units) calciferol. 4-13 year, 80 to 160 micrograms (3000 - 6000 international units) Treatment is generally continued for about 2 weeks.

If there is concern about compliance then a single large dose can be given. The doseage recommendations seem to vary quite considerably from one text-book to another. I would be grateful if list members would indicate the regime that they use for management of rickets.

Best wishes,


Prof. Michael H.N.Golden

Thu Sep 4 18:38 BST 1997

Subject: rickets (fwd)


Dear Mike,

I'm seeing reports which say that rickets has become common in children in Iraq. This doesn't seem plausible to me; I wonder whether some other condition is being misdiagnosed?

Also, if rickets really is a problem, would it be appropriate to treat by calciferol injection?

best wishes,


Marion Kelly

Thu, 4 Sep 1997 19:30:56 +0100 (BST)

From: Patricia Haggerty haggertyatmacroint.com

Subject: rickets


There may be a number of reasons for rickets in this part of the world, and they apparently differ depending on the location. In northern Iraq, Eastern Turkey, northern Iran... in general where the Kurdish population is high... the climate is usually cold, the altitude high (this is near Mt. Ararat), the sky very overcast, the terrain rugged. In the mountainous areas children are kept indoors most of the day because it is cold (and it is the custom). Swaddling of infants (wrapping the body, mostly the legs, very tightly, almost mummy-like) is very common, partly because of the cold, partly because it is believed this will help the infants legs to grow straight. Ironically, it has the opposite effect.


Patricia Haggerty

DHS/Macro International

Date: Fri, 05 Sep 1997 09:16:07 +0600

From: George Fuchs <gfuchsatcitechco.net>

Subject: Re: rickets (fwd)


Attention Marion Kelly

We have a population of children in southern Bangladesh who we are fairly sure has hypocalcemic rickets, although as yet for poorly defined reasons. There are a few other reports of this from other tropical/"sunny" countries. Although apparently uncommon, something you might also consider.


Mon, 8 Sep 1997 10:16:12 +0200 (METDST)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: rickets


Dear NGOnut's

Yes, rickets may occur in a mediterranean climate. I saw historical cases of rickets in Algeria (some 20+ years ago, I am afraid) in rural places where prophylaxis was not working. It disappeared by introduction of mass prophylaxis in northern Africa and with the use of vitamin D fortified diets (and a change in life style in some places). I would not be not surprised if in a disrupted country like Irak rickets is back.

MSF faced rickets problems in different part of former USSR. They invited an expert (Michele Garabedian) to examine the problem. She wrote on how to prevent/treat rickets in emergency setting. I advise those interested to read her report (Medical News, Jan 1997, p27). By the way, Michele was the key speaker at the Germ meeting Mike refers to.

Her recommendations are based on use of massive (non toxic) doses of vitamin D (200 000IU), most appropriate in difficult settings. She recommends in some cases to add Ca to the treatment. Risk of hypocalcemia+++ at the beginning of tt. Difficult to abstract this document in a short E mail. Have a look.



Dr. André Briend

Mon, 8 Sep 1997 18:45:42 +0100 (BST)

Subject: rickets

From: Michael H.N.Golden


The messages from George in Bangladesh, saying that there are cases being seen in that country is very interesting. As Andre' Briend points out rickets is widespread in the former soviet Union. I have now had a message from Carrie who works with the National Nutrition Institute in Mongolia to say that rickets is a very severe problem in that country as well.

Recently in South Africa, I was shown several cases of rickets by Professor John Pettifor (Baragwanath hospital), which came from an area near the Mozambique boarder.

These he ascribed to dietary calcium deficiency. I am also reminded of several cases of advanced coeliac disease I saw in Belfast many years ago that did not respond at all to vitamin D until we gave them magnesium (in the first case we gave very large doses of vitamin D and calcium without response - later when we recognised and corrected the magnesium deficiency the vitamin D started to work and the patient achieved a level of serum calcium that is frequently fatal - although my case did not die thankfully).

It would seem that rickets is very much more geographgically widespread than most of us suppose. And that it is a much more complex illness nutritionally, metabolically and socially than the textbooks would lead us to believe.

Best wishes,


Prof. Michael H.N.Golden

Tue, 9 Sep 1997 10:17:25 +0100

From: "Ariane Curdy"<acurdyaticrc.org>

Subject: Rickets in Iraq


Hello Marion

I can confirm that, at least back in 1991 / 92, rickets was common in Iraq. Personally, I have rarely seen that many rickets cases in pediatrics wards in my life.

Main reasons appeared to be poor Vitamin D intake associated to the tradition of wrapping up / swaddling the babies and toddlers. Aware of the potential harmful impact this tradition may have on the children's health, vitamin D had been distributed quite routinely via MCH-programs before the war, but had then to be interrupted because of lack of medicines, Usually, the medical staff was well trained in diagnosing rickets, whereas it had many more problems in identifying the different forms of PEM properly.


Best regards.


Date: Tue, 9 Sep 1997 08:28:49 -0400

From: dalnwickathqfaus01.unicef.org (David Alnwick)

Subject: Re: Rickets in Iraq


To all on NGONUT interested and concerned about rickets.

I thought I would comment from UNICEF that we have been concerned for some time about the growing evidence that rickets is an important nutrition problem in children in many parts of the world. Consequences of rickets may go beyond the classical picture - eg note article in recent Lancet on association between acute lower resp. infection and rickets in Ethiopia.

UNICEF participated in the recent International Vitamin D Workshop in Strasbourg, France. At that workshop and 'informal and ad-hoc' working group of vitamin D/calcium experts was established (about 10 people from around the world) who agreed to help draft up to date guidelines on rickets, its prevention and treatment - for use by UNICEF field offices and any others interested and concerned. Dr Barbara Mawer of the University of Manchester, UK, offered to coordinate this effort and I anticipate that UNICEF will hear from her within next month or so with a first draft of these guidelines.

It also seems perfectly feasible to provide a combined vitamin A/vitamin D supplement wherever their is a risk of deficiency of both of these important fat soluble vitamins. At a consultation last year, it was recommended that UNICEF provide a combined weekly supplement. UNICEF has provided daily vitamin D/vitamin A supplements to children in DPR Korea.

Date: Tue, 09 Sep 1997 14:36:00 +0002

From: ", Florence (ESNP)" <Florence.Egalatfao.org>

Subject: FW: Rickets in Iraq


Further anecdotal evidence (dates back a couple of months)... Confirms the information which was recently exchanged. Specific attention should probably be paid to rickets in future.


To: Brian Thompson, FAO Rome.

From: Peter L. Pellett <pellettatnutrition.umass.edu>

Subject: Rickets in Iraq

Date: Friday September 05 09:15 EDT

Dear Brian,

I am not a clinician but I saw a couple of cases that I took to be rickets and I do have a photograph of one child with knock-knees. I did not note craniotabes in the wards that I visited. Physicians in the hospitals and PHC's mentioned, however, that rickets was an increasing problem along with many other conditions but did not present specific evidence.

Rickets was not tabulated as one of the conditions in either the Unicef PHC Centre survey of April 1997 nor in the Unicef Multiple Indicator Cluster Survey (published May 1997) so seems it either was not perceived by them as of major importance or else they had other priorities. Best wishes, Peter.