Rickets Rising – A Preventable 19th Century Disease in a Nairobi Slum

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Rickets is a well known nutritional disease process related to the lack of vitamin D and primarily sunlight exposure that was frequently seen prior to the early 20th century. Rickets can cause devastating permanent health problems including: profound developmental delay, skeletal abnormalities, painful pathological fractures and if left unrecognized can progress to severe hypocalcemia with seizures and death. However, with the intervention of vitamin D, it has virtually disappeared from the developed world.

In most industrialized countries there are now standardized national guidelines for the supplementation with vitamin D of infants and children to prevent rickets. Despite progress in the knowledge in the development of rickets and prevention, it remains an endemic problem within certain populations of the developing world.

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These children usually present between the ages of 7 and 18 months with developmental delays such as being unable to sit, stand or walk independently. They are lethargic and have the typical findings of rickets which includes enlarged heads, swelling at the wrists and of the ribs. Frequently within three weeks of starting daily vitamin D and calcium replacement they return remarkably improved – bright, interactive, eating well and gaining on previously unachieved developmental milestones.

Risk factors identified include:

  • Lack of sunlight because of cultural beliefs and over dressing.
  • Lack of sunlight in slum homes.
  • Prolonged breast feeding.
  • Early supplemental feeding with vitamin D poor foods.
  • Maternal vitamin D deficiency.
  • Malnutrition secondary to the lack of adequate food security and recurring infections in a slum setting.

The WHO has yet to provide definitive international guidelines for the prevention and treatment of rickets. Likewise the Kenya Ministry of Health has no recommendations yet either…

Clearly there is a huge need for providing free prenatal vitamins with calcium and vitamin D to pregnant/lactating mothers. A simple vitamin D supplementation program at 6 month intervals for high risk infants/children would also virtually eliminate this problem.

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4 Responses to “Rickets Rising – A Preventable 19th Century Disease in a Nairobi Slum”

  1. ymc0214 Says:

    Thank you for sharing your discussion. It appears as though there is no set policy to improve the rate of vitamin D deficiency in Kenya. Who would be the key stakeholders if the policy to supplement vitamin D in foods and milk formula was to be implemented?
    The policy maker (most likely the Kenya Ministry of Health) is faced with two issues: prevention of vitamin D deficiency in child-bearing mothers and children, and treatment for those affected by rickets (such as braces). Did you have any ideas on specific interventions you would suggest?
    The Kenyan government may be able to sponsor milk formula-producing companies to supplement vitamin D and to sell it for cheaper price so that mothers reduce the period of breastfeeding.
    Another intervention may be to educate people so that they get plenty of sunlight during day time. However, this would cause cultural conflicts if people had been avoiding the sun due to religious/cultural reasons.

  2. dc777 Says:

    Thanks for sharing your thoughts.

    Are there particular slums in Nairobi where this is a more prevalent problem? And if so, is there a reason why?

    I’m wondering how the Kenyan Dept of Health is able to quantify that this is a significant problem in these sub-populations. Is there over/under estimation of the problem? How are the children in the slums screened/assessed? Do all of them present for medical care, or are there sub-clinical cases which are being missed.

    A population wide supplementation program will likely only be effective if there is good penetrance into the slums or areas where it is needed the most.

  3. afitzgallagher Says:

    Vitamin D deficiency has been a hot topic in healthcare recently.This case of risks to youths associated with a severe deficiency is a powerful example of an unmet need. Since no guidelines are currently available by the WHO, I wonder if they couldn’t piggyback off of already existing programs which has showed success in the past. One program that comes to mind is vitamin A distribution. It would be great to develop a distribution program where communities can receive vitamin A and D supplements concurrently (pending any adverse events from taking both at the same time). I found an organization, Micronutrient Initiative which runs distributions programs to populations most at need. Since they already have an establishment in Kenya (http://www.micronutrient.org/english/view.asp?x=595), adding vitamin D to their rolodex seems like a viable solution.

  4. jkedwards Says:

    Thanks for the comments! We are currently looking at the frequency of rickets within our primary care clinics which operate in Kibera. It is widely recognized that rickets is a problem throughout the other major slums in Nairobi. There is no set policy to prevent or treat vitamin D deficiency by the MOH. The key stake holders are the population of Kibera, MOH, Dept. of Nutrition, UNICEF who oversees much of the malnutrition within Kenya/Nairobi, MSF who provides primary care in Kibera, KEMRI who oversees much of the malnutrition research in Kenya and USAID who currently has the Kenya contract to provide supplements for the malnourished.

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