Summary of the Report

A Prevalence Study on Rickets in Children of Chakaria

Institute of Child and Mother Health, Dhaka, 1998

Dr. ARM Luthful Kabir, Principal Investigator

Abstract

An epidemiological survey was conducted on 900 children between 1-15 years chosen randomly out of 30 villages sampled randomly from 340 villages of Chakaria thana of Bangladesh to determine the prevalence of rickets . After the recruitment of necessary staff a training of 6 days was conducted in the local SARPV office at Chakaria about the purpose and procedure of the study. Geographical reconnaissance sheets were used by the Health Assistants of selected 30 villages to identify and collect the children with the help of an identification slip to a particular place. Interview of the parents was taken and the children were examined for evidences of rickets and necessary radiological and blood examination (serum calcium and phosphorus and ALP) were done in all clinically suspected cases and in a control of every eighth child. Out of 900 children, there were 498 (55.3%) male and 402 (44.7%) female. The commonest food intake, other than rice, in last 24 hours was dry fish (49.6%) followed by fresh fish (46.6%). Only 11.9% children took milk or milk products and 16% had taken meat on the previous day. Seventy eight (8.6%) children had at least one feature suggestive of >clinical rickets=. Pectus carinatum was the most common clinical feature in 26 (33.3%) followed by genu valgum in 23 (29.4%) cases. Of them 20 (2.2%) children had raised Alkaline phosphatase (ALP) level (>biochemical rickets=) including all 8 (0.9%) having radiological features of rickets (confirmed rickets). Of 111 control children 22 (19.8%) had raised level of ALP. Further study is needed to find out the exact aetiology of >only biochemical= (1.3%) (children having clinical and biochemical features but negative radiology) and >only clinical rickets= (6.4%) (children having clinical features but negative biochemistry and radiology) and immediate intervention is to be started to treat the already affected children.

Introduction

Background

Social Assistance and Rehabilitation for the Physically Vulnerable (SARPV) has been working with the disabled people since 1991 in Chakaria. According to them they first reported large number of rickets cases in children in that area during a cyclone relief program in 1991. So far several other surveys were undertaken by different groups of people and organisations.

Memorial Christian Hospital (MCH) of Chakaria identified 93 cases of rickets. Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka reported 64 patients of rickets. DG Health conducted one survey by Dr Badrul Alam, Associate Professor of Chittagong Medical college and Dr Nazma Kabir of UNICEF and reported 28 cases of rickets out of 23 families on the basis of clinical assessment in June 1994. AEM, an organisation working for children in France, became interested as they happen to meet Mr Shahidul Haq, Executive Director of SARRPV. They investigated eight affected children out of forty referred to them by the local people. AEM also studied the nutritional and agronomic aspects to look into the causes of rickets. Biological, hormonal, radiological and chemical analysis results were suggestive of calcium deficiency rickets to be the cause in Chakaria.

Three paediatricians from ICMH visited five villages of Chakaria during 27-28th September 1996 and observed 15 cases of rickets including 8 out of 19 as registered to be cases of >rickets= by SARPV people. The other 11 cases were CP, , telepes, post-polio paresis, severe kyphosis, hydrocephalus, Down=s syndrome, short leg and probable Blount=s disease. ICMH recommended a rapid epidemiological survey in Chakaria and in its vicinity to see the prevalence of rickets over there.

In October 1997 an International group of 9 organisations (Utah University and Cornell University of USA, SARPV, ICMH, INFS , UNICEF and CYMMYT of Dhaka, AEM of France, CHM of Chakaria visited Chakaria. A case-control study of 27 children (14 rachitic cases and 13 control) was done. The conclusion were that : (1) active rickets in children in Chakaria is not usually associated with vitamin D deficiency (2) clinical presentation of rickets in Chakaria is similar to that of African children with calcium deficiency rickets and (3) subclinical calcium deficiency might be more prevalent as suggested by rachitic deformities and elevated serum 1,25(OH)2 vitamin D levels among unaffected children. ICMH submitted a project proposal to UNICEF for the epidemiological study and today=s achievement is the result of that proposal which UNICEF agreed to sponsor.

Rickets

Rickets is a skeletal disorder of growing infants and children due to inadequate or delayed mineralization of bone. For normal bone formation the cartilage must first undergo provisional mineralisation before being resorbed and replaced by osteoid, which then undergoes mineralisation to create bone. Failure of mineralisation of the of cartilaginous spicules at the metaphyseal interface is the fundamental defect 6 cartilage cells do not mature and disintegrate not invaded by capillary fibroblasts 6 resultant overgrowth of cartilage with widened epiphysis 6 osteoid matrix is produced by normally functioning osteoblasts and is unmineralised 6 this zone of disorderly osteoid matrix and cartilage is soft and become distorted under the stress of weight bearing 6 bending, compression and microfracture of soft, weakly supported osteoid and cartilaginous tissue with resultant skeletal deformities.

The implications of rickets include: short stature, swelling of metaphysis of the wrists and ankles, deformity of limbs (genu valgum, genu vara, sabre tibiae), chest deformities (rickety rosary, Harrison=s sulcus, kyphoscoliosis, pectus carinatum), head deformities (delayed closure of fontanel, frontal bossing, box headedness, craniotabes), delayed development (sitting, standing, walking), delayed dentition (hypoplastic teeth).

Rickets can be caused by several factors: vitamin D deficiency due to inadequate vitamin D intake and/or lack of sun exposure leading to inadequate biosynthesis of the vitamin; dietary deficiencies of calcium and/or phosphorus deficiency; renal disease; abnormalities in the vitamin D receptors. Rickets due to calcium deficiency has been reported in South Africa and Nigeria.

It has been recently reported that there have been clustering of rickets in a coastal area, Chakaria, of Bangladesh. In few of the studied cases, calcium deficiency has been thought to be the cause responsible for causing rickets there. The salient features of the calcium deficiency rickets are (1) clinical, radiological and biochemical evidence of rickets with normal serum concentration of 25-hydroxyvitamin D (2) the patients are resident of a particular area (3) secondary hyperparathyroidism as manifested by high urinary cyclic adenosine monophosphate excretion and generalised aminoaciduria and (4) the rickets heals with a normal hospital ward diet without supplementary vitamin D therapy. Biochemically, it is characterised by increased parathyroid hormone, increased 1,25 (OH)2 D in the face of normal levels of 25 (OH) D, an increased 1,25 (OH)2 D to 25-hydroxyvitamin D ratio, increased osteocalcin, increased alkaline phosphatase and slightly decreased serum calcium. Calcium deficiency rickets may be differentiated biochemically from vitamin D dependent rickets by the elevated level of 1,25(OH)2D and normal 25(OH)D.

Methods

The study site

The study took place in Chakaria thana of Cox=s Bazar district, which is situated in the south-eastern part of Bangladesh. Chakaria is the biggest thana of Cox=s Bazar district in respect to both area and population. Chakaria thana occupies an area of 643.46 sq. km. including 38.95 sq. km. river area and 17.77 sq. km. forest area. The thana is bounded on the east by Lama and Nakhyongchhari thana of Bandarban district, on the west by Moheshkhali and Kutubdia district, on the north by Bashkhali and Lohagara thana of Chittagong district and on the south by Cox=s Bazar Sadar and Ramu thana. The thana consists of 17 unions, 66 Mauza and 340 villages. The total population of the thana is 468,000 as estimated in 1995 and about 50% of the population are under fifteen years of age. The socio-economic condition of the people are poor. In 1991 the literacy rate is 23.4% and occupation of the majority (about 54%) of the population are cultivation. However, about 62% of the population do not have agricultural land. There are 340 villages in Chakaria. For the purpose of study we needed 30 villages which had been selected randomly using a random number table. This selection of villages was due to avoid biases and giving the opportunity of equal chance to every village considered for the study, which was conducted during the period of April to June 1998.

Study population

Children between the ages of 1 year and 15 years were studied. In survey reports it was reported that majority of the rickets cases occurred in this age group. The estimated population of under 15s in Chakaria thana were 251,1392 (assuming annual growth rate of 1.89%). A sample of children was drawn from this population.

Although there are no national statistics on the prevalence of rickets in the country, UNICEF estimates that the proportion of rickets cases among under 15 children at Chakaria could be as high as 12-14%15. However, other casual observations have indicated a much lower prevalence. For the calculation of sample size for this survey a prevalence of 1% was assumed.

Sampling : Chakaria thana

30 villages

1-15 year old children

30 X 30 = 900 children

A data sheet was completed during screening of the children who will be positive for evidence of rickets and those children will be transported on the same day for blood biochemistry (serum calcium, phosphate and ALP) and x-ray of wrists and knees in a local private health centre.

The following signs were used as clinical evidence of rickets: widening of wrists, ankle and knees; macrocephaly; frontal bossing; rachitic rosary; Harrison=s sulcus; pigeon breast deformity; genu valgum; genu vara; delayed dentition and caries tooth. If a child was found to have any one of these signs he/she was subjected to radiological examination of the wrist and knee.

Radiographs were examined for the following signs of rickets: splaying, fraying or cupping of metaphyses; increased distance between metaphysis and diaphysis; osteopenia; fracture. The radiological investigation was conducted at a private x-ray diagnostic facility in Chakaria.

Blood was collected on all positives for clinical features and every eighth child by the physician/ lab technician for serum alkaline phosphatase, calcium and inorganic phosphorus.

Ten staff were recruited including 3 physicians, 1 field co-ordinator, 4 field workers, 1 lab technician and 1 data enterer.

Before starting, parents and children were briefed about the purpose of our visit as to finding out of rickets cases among 30 children chosen by lottery and the necessary interview of the parents particularly the mothers and required physical examination and subsequent radiological and blood examination at a central location. Immediately after the briefing, a 5-7 minute session was used for feedback to ensure participant understanding of the purpose of the study and to obtain informed consent for interview, physical examination and necessary radiology and blood drawing.

Results

Nine hundred children were interviewed and examined for clinical evidences of rickets. There were 498 (55.3%) male and 402 (44.7%) female. A total of 78 (8.7%) children had at least one feature for clinical suspicion of rickets. Seventy three children could be examined radiologically and 71 biochemically. Of which 20 (2.2% of 900) had raised ALP( >300 u/L) including all of 8 (0.9% of 900) radiologically confirmed rickets cases (Table-I). Among 111 normal randomly selected children who were subjected to blood biochemistry, 22 (20% of 111) showed raised ALP. There were more or less equal distribution of children in all age groups (Table-II). The mean age of children was 77.6 mo(45.3). Most of the fathers were illiterate or minimally educated considering year of schooling (81%). They were mostly day labourers and their economic status was very poor as reflected by deficit budget in 62% families (Table-III). The children were found to take, other than rice, mostly dry fish (50%) and fresh fish (47%) but little meat and milk or milk products (Table -IV). Consanguinity between the parents were 14% and there was history of developmental delay in children in 8% cases (Table-V). Pectus carinatum (33%), genu valgum (29%), Harrison=s sulcus (27%) and wide wrist (18%) were the most common features suggestive of rickets (Table-VI). Fifty six percent children had at least one feature suggestive of clinical rickets (Table-VII) and more than 62% children had 2 or more clinical features in case of confirmed rickets (Table-VIII). The nutritional status were uniformly poor in all groups of children with more stunting in confirmed rickets cases when compared to controls (though not significant OR 4.04, CI 0.48-89.6) (Table-IX and X). The mean serum ALP level was very raised (787.87 U/L) in confirmed rickets and to some extent (375.83 U/L) in >only biochemical rickets= but the serum calcium (2.24 mmol/L) and phosphorus level (1.25 mmol/L) were lower normal in confirmed rickets but exactly normal in only biochemical and >only clinical rickets= (Table-XIV). On analysing the association of health factors between confirmed rickets and the controls, there was found strong association between developmental delay and the presence of >clinical rickets= (Table XVIII and XIX) . Similarly among the socio-economic factors, the intake of dry fish had negative association for the development of clinical rickets (Table- XIX).

Distribution of Subjects by Findings:

*Confirmed rickets 8 0.9

**Only Biochemical rickets 12 1.3

***Only clinical rickets 58 6.4

_____________________________________________________________

*Confirmed rickets : clinical + raised ALP + radiological

**Biochemical rickets : clinical + raised ALP

***Clinical rickets : having at least one feature suggestive of rickets with normal ALP

Table II : Age structure of children (n=898)

Age group, months	children	%
12 - 35	193	21.5
36 - 59	163	18.2
60 -119	335	37.3
120 - 180	207	23.1

Total: 898 100

Distribution of age showed more or less equal distribution of children in different age groups excepting more children in the age group of 60-119 months (37.3%).

Table III : Socio-economic characteristics of the families (n=900)

Characteristics	Number	Percentage
Father=s education
No schooling	539	59.9
Primary	189	21.0
Secondary	121	13.4
Above secondary	51	5.7
Father=s main occupation
Day labour	348	38.7
Business	181	20.1
Agriculture work	167	18.6
Service	88	9.8
Others	116	12.8
Economic status
*Deficit	555	61.7
**Balance	307	34.1
***Surplus	37	4.1
Family members
1-3	53	5.9
4-6	399	44.3
7-10	383	42.6
11+	65	7.2

*Deficit : when one has to lend to run family

**Balance : When one manages family expenditure without landing

***Surplus : When one can save after family expenditure

Most of the fathers were either illiterate (never gone to school) or having minimum education (primary education) (80%). A large number of fathers= occupation (38.7%) were day labour. The economic status was poor as reflected by the deficit budget in 61.7% families. The size of the family were 4-10 members in 86.9% cases.

Table IV : Selected food habits as reported by the parents (n=900)

Food	No. children taking food in last 24 hrs.	%
Dry fish	44	49.6
Fresh fish	419	46.6
Fruits	260	28.9
Meat	144	16.0
Milk	107	11.9

The children took mostly dry fish (49.6%) and fresh fish (46.6%) but little meat (16.0%) and milk or milk products (11.9%) in last 24 hours.

Table V: Selected health factors as reported by the parents (n=900)

Health characteristics	Number	Percentage
Consanguineous parents	130	14.4
Family history of rickets	40	4.4
History of chronic diarrhoea	31	3.5
History of malaria	129	14.4
History of other illness (Wheeze)	234	26.0
Developmental delay	70	7.8

Consanguineous parents were in 14.4% families and there was history of ever wheeze in 26% children and developmental delay in 7.8% cases.

Table VI: Evidences of rickets among clinically suspected cases (n=78)

Features	cases	%
Pectus carinatum	26	33.3
Genu vulgum	23	29.4
Harrison sulcus	21	26.9
Wide wrist	14	17.9
Frontal bossing	12	15.3
Genu vara	10	12.8
Wide ankle	06	07.6
Chest beads	06	07.6
Delayed dentition	06	07.6
Wide knee	05	06.4
Sabre tibiae	04	05.1
Others	06	07.6

Multiple features were present in some cases. Pectus carinatum (33.3%), genu valgum (29.4%) and Harrison=s sulcus (26.9%) were the commonest clinical features suggestive of rickets.

Table VII : Distribution of rickets signs in children of Chakaria (n=900)

No. of signs	children	%
No sign	822	91.3
signs found	78	08.7

Distribution of rickets signs in clinically positive cases (n=78)

1 sign	44	56.4
2 signs	22	28.2
3 or more signs	12	15.3
Total		100

Eighty five percent of clinically suspected children presented with 1 or 2 clinical signs suggestive of rickets.

Table VIII : Distribution of rickets signs in confirmed rickets cases (n=8)

No. of signs	cases	%
1 sign	03	37.5
2 signs	02	25
3 or more signs	03	37.5
Total	08	100

C Two patients had 8 features of rickets

More than 62% children having confirmed rickets presented with 2 or more signs of rickets

Table IX: Nutritional status of the studied children < 10 years (n= 690)

Nutritional status	Confirmed rickets (7)	Only biochemical rickets (8)	Clinical rickets (67)	Other children (608)
Stunted	06 (86%)	05 (62.5%)	47 (70%)	367 (60.3%)
Wasted	01 (14.2%)	00	07 (10.4%)	128 (21.05%)

Table X: Nutritional status of children of 10 years or more (n= 169)

BMI	children	%
<16 16-18.5 > 18.5	116 39 14	68.6 23.1 08.3

About 92% children over 10 years were found thin and only 8% children found having normal state of nutrition considering BMI.

Table XI: Unadjusted Odds Ratio (OR) and its 95% confidence interval for the association of Nutritional status (stunting) of children having clinical rickets (67) vs. other children (623) under 10 years

Total children below 10 years (690)

Cases (n=67)

Controls (n=623)

Odds Ratio

95% CI

p-value

	No.	%	No.	%
Stunting	47	70	367	59	1.64	0.92-2.94	NS
Not stunting	20	30	256	41

Table XII :Unadjusted Odds Ratio (OR) and its 95% confidence interval for the association of Nutritional status (wasting) of children having clinical rickets (67) Vs other children (623) under 10 years

Total children below 10 years (690)

Cases (n=67)

Controls (n=623)

Odds Ratio

95% CI

p-value

	No.	%	No.	%
Wasted	7	10.4	128	20.5	0.45	0.18-1.05	NS
Not wasted	60	89.5	495	79.5

Table XIII: Radiological evidence in clinically suspected cases (n=73)

Findings	cases	%
Positive	08	10.9
Negative	65	89.0

Total 73 100

Clinically suspected cases were 78, and 5 children did not turn up for x-ray examination.

Table XIV: Mean levels of serum calcium, phosphorus and alkaline phosphatase in different groups of children

Groups of children	Calcium	Phosphorus	ALP
Confirmed rickets (8)	2.24 (0.15 )	1.25 (0.28 )	786.87 ( 334.69)
Biochemical rickets (12)	2.45 (0.12)	1.61 (0.15)	375.83 (88.41)
Clinically suspected (51)	2.45 (0.15)	1.66 (0.27)	216.98 (46.98)
Controls (111)	2.45 (0.12)	1.66 (0.21)	252.68 (88.78)

(Normal values : serum calcium = 2.02-2.60 mmol/L,,phosphorus = 1.30-2.26 mmol/L, ALP = upto 300 U/L)

The serum ALP level were very raised (787.87 U/L) in confirmed rickets and to some extent raised (375.83 U/L) in biochemical rickets but the serum calcium and phosphorus level were lower normal (2.24 mmol/L) and (1.25 mmol/L) respectively in confirmed rickets but almost normal only biochemical and clinical rickets.

Table XV : Comparison of blood biochemistry between controls and confirmed rickets

Parameters	Controls (111)	Confirmed rickets (8)	t-value	p-value
Calcium (mmol/L)	2.45 (0.12)	2.24 (0.15 )	4.63	<0.0001
Phosphate (mmol/L)	1.66 (0.21)	1.25 (0.28)	5.26	<0.0001
ALP (U/L)	252.68 (88.78)	786.87 (334.69 )	12.28	<0.0001

Though the serum calcium and phosphorus levels of confirmed rickets are within normal range but there are significantly different from those of the controls.

Table XVI : Comparison of blood biochemistry between controls and biochemical rickets

Parameters	Controls (111)	Only biochemical rickets (12)	t-value	p- value
Calcium (mmol/L)	2.45 (0.12)	2.45 (0.12)	0.10	0.91ns
Phosphate (mmol/L)	1.66 (0.21)	1.61 (0.15)	0.79	0.56 Ns
ALP (U/L)	252.68 (88.78)	375.83 (88.41)	4.57	<0.001

The serum ALP of the >only biochemical rickets= are significantly raised than that of the controls.

Table XVII: Comparison of blood biochemistry between biochemical rickets and confirmed rickets

Parameters	Biochemical rickets (12)	Confirmed rickets (8)	t-value	p- value
Calcium (mmol/L)	2.45 (0.12)	2.24 (0.15)	3.28	0.004
Phosphate (mmol/L)	1.61 (0.15)	1.25 (0.28)	3.69	0.002
ALP (U/L)	375.83 (88.41)	786.87(334.69 )	4.09	<0.001

All the biochemical values (serum calcium, phosphorus and ALP) of confirmed rickets are significantly different from those of the confirmed rickets.

Table XVIII: Unadjusted Odds Ratio (OR) and its 95% confidence interval for the association between confirmed rickets cases and some selected risk factors

Factors

Cases (n=8)

Controls (n=892)

Odds Ratio

95% CI

	No.	%	No.	%
Consanguineous parents	3	37.5	127	14.2	3.60	0.85-15.27
Developmental delay	4	50	66	7.4	12.48	2.56-60.97
Family history of rickets	0	0	40	--	--	--
History of major illness	3	37.5	137	15.3	3.29	0.77-13.95
History of malaria	1	12.5	128	14.3	0.850	0.10-6.97
Low economic condition	6	75	549	61.5	.99	0.98-.99
Illiterate father	7	87.5	532	59.4	4.73	0.58-38.66
Intake of dry fish	4	50	442	49.5	1.01	0.25-4.08
Intake of fresh fish	3	37.5	416	46.6	0.68	0.16-2.88
Intake of fruits	3	37.5	257	28.8	1.48	0.35-6.23
Intake of milk	0	0	107	20	--	--
Intake of meat	1	12.5	143	16	0.74	0.09-6.12
Sex (male)	4	50	494	53.4	0.80	0.20-3.24

There is a strong association between developmental delay and confirmed rickets.

Table XIX : Unadjusted Odds Ratio (OR) and its 95% confidence interval for the association of different factors (age, socio-economic, food, health and clinical) between clinically suspected (78) and the controls(820)

Factors	Case	Controls	OR	95% CI
Age < 5 years > 5 years	48 (61.5%) 30 (38.4%)	344 (41.9%) 476 ((58.0%)	2.21	1.37-3.56
Father=s education No schooling Literate	46 (58.9%) 32 (41.0%)	393 (47.9%) 329 (40.1%)	0.959	0.598-1.53
Family size <5 >5	27 (34.6%) 51 (65.3%)	252 (30.7%) 570 (69.5%)	1.19	0.734-1.954
Hist. chron. diarrhoea yes no	3 (3.8%) 75 (96.0%)	28 (3.4%) 792 (96.5%)	1.13	0.336-3.809
Consang. parents yes no	16 (20.0%) 62 (79.4%)	114 (13.9%) 706 (86.0%)	1.59	0.891-2.866
Delayed developmnt. Yes no	54 (69.2%) 24 (30.7%)	46 (5.6%) 774 (94.3%)	7.48	4.09-13.65
Exposure to sun : yes no	77 (98.7) 01 (1.2%)	809 (98.6%) 11 (1.3%)	1.04	0.133-8.218
Intake of fresh fish yes no	38 (48.7%) 40 (51.2%)	381 (46.4%) 440 (53.6%)	1.09	0.689-1.746
Fruits in last 24 hours yes no	27 (34.6%) 51 (65.3%)	233 (28.4%) 588 (71.7%)	1.336	0.818-2.182
Hist. major illness yes no	17 (21.7%) 61 (78.2%)	123 (15.0%) 697 (85.0%)	1.59	0.892-2.794
Intake of meat yes no	12 (15.3%) 66 (84.6%)	132 (16.0%) 689 (84.0%)	0.949	0.499-1.805
Intake of milk : yes no	7 (8.9%) 71 (91.0%)	100 (12.1%) 721 (87.9%)	0.71	3.18-1.589
Sex : male female	49 (62.8%) 29 (37.1%)	449 (54.7%) 373 (45.4%)	1.40	0.869-2.262
Intake of dry fish yes no	29 (37.1%) 49 (62.8%)	417 (50.8%) 404 (49.2%)	0.573	0.355-0.926
Family hist.rickets yes no	8 (10.2%) 70 (89.7%)	32 (3.9%) 788 (96.0%)	2.81	1.249-6.341

It is interesting to note that intake of dry fish appears to be a protective factor for the development of rickets. All other factors do not show any positive association with the development of rickets.

Table XX : Clinical features in number in different groups of rickets

Features	Confirmed rickets (8)	Biochemical rickets (12)	Clinical rickets where blood biochemistry not done (7)
Pcetus carinatum	2	6	3
Genu valgum	3	3	2
Harrison=s sulcus	2	1	3
Wide wrist	3	5	1
Frontal bossing	1	-	1
Genu vara	3	-	-
Wide ankle	2	1	-
Chest beads	2	1	-
Delayed dentition	1	1	-
Wide knee	3	1	-
Sabre tibiae	2	1	-
Delayed fontal closure	1	-	-
Box head	-	-	1
Mean age (mo)	63.8 (SD 45.1)	78.6 (SD 41.4)	-

Discussion

The study showed that the prevalence of confirmed rickets was 0.9%, >only biochemical rickets= 1.3% and that of >only clinical rickets= 6.4% (Table-1). Traditionally, the clinical impression of active rickets is confirmed by roengenographic evidences of changes at the epiphysis and metaphyseal plates combined with biochemical analysis revealing alterations in serum calcium, ALP, phosphorus and vitamin D concentrations. In some studies rickets have been diagnosed only clinically15 in a community study or clinically and biochemically16. Pectus carinatum (33%), genu valgum (29%), Harrison=s sulcus (27%) and wide wrist (18%) were the most common features suggestive of rickets (Table-VI). Fifty six percent children had at least one feature suggestive of clinical rickets (Table-VII) and more than 62% children had 2 or more clinical features in case of confirmed rickets (Table-VIII).

We have confirmed some cases radiologically and with limited biochemical analysis. The serum ALP level were very raised (mean 87.87 U/L) in confirmed rickets and to some extent raised (mean 375.83 U/L) in >only biochemical rickets= but the serum calcium and phosphorus level were lower normal (2.24 mmol/L) and (1.25 mmol/L) respectively in confirmed rickets but exactly normal in >only biochemical= and >only clinical rickets=. All the mean biochemical parameters of confirmed rickets were significantly different than those of controls (Table- XV) and biochemical rickets (Table-XVII). The mean serum ALP of >only biochemical rickets= is also significantly higher than that of controls. Sometimes it needs extensive laboratory approach to find out the exact aetiology of the conditions the children are suspected to have disorders of calcium and bone metabolism17. Bony deformity can also result from fluorosis which can make bones weaker resulting in deformities as reported in endemic form in parts of Andhra Pradesh and Panjab because of high fluoride content in water and soil18. It is interesting to note that the mean serum ALP level was raised (387.9 U/L) in 22 controls. Normal level of ALP varies considerably throughout life, and absolute upper and lower values are not clearly defined. Elevated values derived from osteoblasts occur in any condition with increased bone turn over, such as all forms of rickets, fractures, osteogenic sarcoma, osteomalignancies or Juvenile Paget=s disease and also whenever bile duct epithelium is damaged, as in obstructive jaundice19.

Clinically, all the control children appeared to be otherwise healthy.

We found mostly illiterate (60%) and poor socio-economic background (62%) of the families of the children of Chakaria. The significant number of children were used to taking dry fish and it is interesting to note that this dry fish intake has proved to be having a negative association for the development of rickets in children (OR 0.573, 95% CI 0.355-0.926, Table-XIX). History of developmental delay was strongly associated with the presence of rickets in children (OR 10.96 95% CI4.00-29.84,).

The nutritional status of children showed that the children have severe stunting (60%) like other rural area (61%) of Bangladesh20. The children who had rickets were less wasted than the controls (Table-IX) which is comparable to other study16.

Recommendations

The Chakaria rickets study has confirmed the existence of rickets in whole area of Chakaria. The study showed the prevalence of confirmed rickets to be 0.9%, >only biochemical rickets= 1.3% and >only clinical rickets= 6.4%. There is no doubt that 8.7% children are having some >bony disorders= mimicking rickets at least clinically. That means about 40,000 children up to 15 years of age are suffering from >rickets like conditions= only in Chakaria thana. Keeping in the backdrop of mind all the previous sporadic studies conducted so far at Chakaria the following recommendations are being put forward for future considerations :

References