Rickets

This editorial was written by Dr. Romaina Iqbal during a Writers Without Borders workshop in Karachi, Pakistan, in January 2008.

Rickets in children in Pakistan – A call for reviewing building construction policies

“The doctor sahib said that Ahmed has rickets,” said Nafeesa, a young mother in her early 20’s, glancing lovingly at her 9-month-old son Ahmed. “He said that is why he has not been able to sit up properly as most kids do by this age.”

The electric light is on in the room, even in the morning, because the high rise apartment building across the street blocks the sun’s rays from entering.

Deficiency of vitamin D (which is also called the sunshine vitamin) can lead to the development of Rickets in children. A child with Rickets is restless and sleepless, the bones of the skull are soft, and sitting, crawling and walking are delayed. Often the legs and arms are bowed because the soft bones bend under the weight of the child’s body. This condition is reversible if it is identified at an early stage and treated adequately. Typically, in children, Rickets develops when there isn’t sufficient exposure to sunlight or/and in breastfed infants of mothers who do not have adequate vitamin D levels.

For many years Rickets was considered an “Englishman’s” disease only. South Asia, historically, was considered to be immune to the development of vitamin D deficiency related health issues as we have plenty of sunshine. However, lately, several reports of vitamin D deficiency – Rickets in children have been reported from South Asia in places such as Calcutta and Kashmir, despite ample sunshine. Reports suggest that crowded cities have a higher prevalence of Rickets where as children that were raised in less crowded rural settings did not have the condition.

In a study conducted in inner city area of Karachi to understand the risk factors that lead to Rickets in children, it was observed that healthy children (i.e. those who did not have Rickets) had more exposure to early morning and day time sunlight, with the child in minimal clothing at the time of exposure compared to children who had Rickets. However, there was no difference in the total time of exposure to sunlight in children who had Rickets compared to those who did not. In other words, the time of the day when a child is exposed to sunlight is very important for optimum bone health. Other studies confirm this finding that early morning sun rays and late afternoon sun rays are beneficial for the photolysis of pre-vitamin D3 in the skin. Twenty to thirty minutes of sun exposure in a week is considered adequate for photolysis of pre-vitamin D3 in the skin.

In addition to sunlight, the other (although small) source of vitamin D for young children is breast milk. It was observed that children who did not have Rickets were breastfed for longer duration of time compared to children who had Rickets (mean duration 16.2 months compared with 9.2 months), indicating that breast feeding for a longer duration of time can prevent the development of Rickets. Lactating mothers should be encouraged to have adequate sun exposure and sufficient amounts of vitamin D fortified products as breast milk vitamin D levels depend on current maternal diet and stores in the body.

“Give him some clear soup broth, it’s good for the bones,” suggests the guest.

“Actually, the doctor said that in addition to the vitamin D injections that Ahmed has had, he should be laid in the sun for a few minutes every morning,” says Nafeesa.

From this study, we learned that Rickets is an example of a nutrition deficiency which is more related to the kind of dwelling conditions (i.e. adequate sunlight exposure) than diet per se. It makes sense as the main source of vitamin D for breast fed children is production in the skin upon adequate sunlight exposure rather than dietary intake. Vitamin D deficiency has been reported in over crowded, polluted areas where two factors seem to interrupt the production of vitamin D in the skin. These factors are as follows: smog, related to pollution, decreases UV rays which consequently leads to less production of vitamin D in the skin. Secondly, often overcrowded areas have high rise buildings which can block the passage of sunrays into homes in the area.

Reviewing housing and construction policies of the country to ensure that the direction of rooms (bedrooms specifically) is such that morning sun rays are not blocked from entering the house is important. This would be particularly important for apartment buildings where the space between two opposite apartments is so little that an apartment may not be able to get adequate sunlight throughout the day.

The study’s findings suggest that the population living in large cities not only needs education regarding good diet and exposure to sunlight for self and the child, but also some consideration should be given to the direction of the rooms with respect to sunlight so that sufficient sun rays enter the house. The long term implication of this work is that the housing should be constructed in such a manner that sunlight penetration during morning hours and in the evenings is ensured.