Management of nutritional rickets in Indian children: A randomized controlled trial

Introduction: Rickets is usually attributed to vitamin D deficiency. However, recent studies have implicated dietary calcium deficiency in its etiology. Information on relative efficacy of calcium, vitamin D or both together in healing of rickets is limited. Objective: To study effect of treatment with calcium, vitamin D or a combination of these two on healing of nutritional rickets in young children. Design: Randomized controlled trial. Methods: Sixty-seven cases of nutritional rickets in the age group of 6 months to 5 years were randomly allocated to receive vitamin D (600 000 IU single intramuscular dose), calcium (75 mg/kg/day elemental calcium orally) or a combination of the above two for a period of 12 weeks. The demographic parameters, nutritional status, dietary calcium and phytate intake were assessed for all. Radiographs (wrist and knee) and biochemical parameters (serum calcium, inorganic phosphate, alkaline phosphatase, 25-hydroxycholecalciferol and parathyroid hormone) were evaluated at baseline, 6 and 12 weeks for evidence of healing. Results: Mean dietary intake of calcium in all cases was low (204±129 mg/day). Mean serum 25-hydroxycholecalciferol D level was 15.9±12.4 ng/ml, and 82.1% of patients had serum vitamin D levels <20 ng/ml, indicative of vitamin D deficiency. After 6 and 12 weeks of treatment, radiological and biochemical evidence of healing rickets was observed in all treatment groups, albeit to a variable extent. The combined end point of normal serum alkaline phosphatase and complete radiological healing at 12 weeks was observed in 50% subjects on combination therapy as compared with 15.7% subjects on vitamin D alone and 11.7% on calcium alone. Conclusions: Children with rickets had a low serum vitaminDlevel and a low dietary calcium intake. The best therapeutic response was seen with a combination of vitamin D and calcium than either of them given alone.