Rickets and Exposure to Sunshine

UENCiT 1IOJER A M ) MEIIARI GEHRE-MEUHIN

Rickets and Exposure to Sunshine * (Presentation of Two Cases) by BENGT HOJER, M.D. AND MEHARI GEBRE-MEDIN, M.D. From the Department of Paediatrics, Faculty of Medicine, Haile Selassie I University and the Ethiopian Nutrition Institute, Addis Ababa

Material and Methods Clinical Material Seven months old female twins, 4th and 5th in birth order were admitted to the Metabolic Ward of the Ethiopian Nutrition Institute in connection with a larger study of rickets in Addis Ababa children. Since the infants were born in their home no information is available on their birth weights. Gestational age at birth was not known. Their diet prior to admission consisted of breast milk and barley gruel. They had never been taken out in the sun or received any medical treatment. Physical examination revealed clinical signs of advanced marasmus (body weights of 3-70 kg. and 3-80 kg. respectively) and rickets (craniotabes, rachitic rosary and enlarged epiphyses). Radiography of the right wrist and chest showed active rickets. Serum albumin was slightly reduced in one of the infants (3-62 g./IOO ml.). Initial alkaline phosphatase, calcium and phosphorus values are indicated in Fig. 1. Alkaline phosphatase values were only slightly elevated—a usual finding in rickets associated with protein-energy-malnutrition. Acknowledgements We thank Dr. Kessete Daniel for laboratory assistance. The collaboration of the Metabolic Ward staff and the Department of Paediatrics is gratefully acknowledged.

The colour of the skin of both infants could be described as light brown which is somewhat typical of most highland Ethiopians. On admission both infants were very pale and had haemoglobin levels of 11-7 and 10-7 g./IOO ml. respectively. Examination Methods and Procedures Routine procedures were used to determine serum alkaline phosphatase'6', calcium'7', and phosphorus'8'. The children stayed in the Ward for six weeks. They were given only breast milk and cow's milk during the first three weeks' of the trial. No drugs containing vitamin D were administered. They were exposed to sunshine with minimal mg/iooml 10

CALCIUM

0 mg/lOOml ' 4,o

5

12

19

26

33

days

33

days

PHOSPHORUS

3,0

~ti 5

int.units \ 200

i^

19"

215

ALC. PHOSPHATASE

150

100 50

ft

2^6

33

days

FIGURE 1. Serum calcium, phosphorus and alkaline phosphatase levels at admission and during daily sunshine exposure* April 1975, Environmental Child Health

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Vitamin D deficiency rickets, often in association with an increased morbidity and mortality is known to be highly prevalent in many parts of Ethiopia'1- 2'. This is remarkable since most of the country enjoys abundant sunshine, high altitude and clean air which should more than ensure the small amounts of ultraviolet radiation sufficient to protect against rickets*3'. However, fear of dark complexion, the "evil eye" and "bad air" are believed to cause mothers to protect their children from the rays of the sun. Rickets has been reported among infants who appear to have been exposed to adequate amounts of sunshine. In cases such as these dietary deficiencies together with genetically determined abnormalities in vitamin D metabolism may predispose towards the development of the disease'1). The present report describes the treatment of rickets in a set of Ethiopian twins solely by daily exposure to sunshine under controlledconditions.

BENGT HOJER AND MKHARI GhHRE-MKDHtN

clothing for approximately 30 minutes every morning. Improvement was gauged weekly by clinical, radiological and biochemical examinations. Results Normalisation of alkaline phosphatase, calcium, and phosphorus (Fig. 1) and appearance of radiological signs of healing (Fig. 2) were evident within three weeks of admission and after daily exposure to sunsLh-e of aroat 12 hours.

Summary

A pair of Ethiopian twins with advanced vitamin D deficiency rickets were treated solely by brief daily exposure to sunshine under controlled conditions. Clinical improvement, normalisation of serum biochemical values and radiological signs of healing were registered after a total exposure to sunshine of 12 hours during a period of three weeks. The importance of intensified health education and in areas with a high prevalence of the disease, prophylactic administration of a single massive oral dose of vitamin D during the first few months of life are suggested.

At the end of the three weeks of exposure to sunshine the mother seemed convinced of its value and safety. Subsequently stie learned to supplement her breast- milk with a locally produced high protein, low-cost additional food, FAFFA before the children were discharged to their home in good condition.

Reprint address: (M.G.-M.) Ethiopian Nutrition Institute, P.O. Box 5654, Addis Ababa, Ethiopia.

Discussion if abundance of sunshine alone could prevent rickets, virtually all subtropical countries would be free of this disease. That it is highly prevalent in countries like Ethiopia where sunshine is hardly avoidable is suggestive of the strong Influence of tradition and beliefs as well as socio-economic conditions. Ordinary foods are generally very poor in their vitamin D content and should neither be regarded as adequate substitutes to sunshine nor be relied upon to supplement satisfactorily the amount derived from sporadic exposure to the sun. This is particularly true of twins and low birth weight infants who are especially susceptible to rickets due to increased demands for rapid growth. These facts as well as the importance and complete safety of sunshine to infants and children is not fully appreciated by most health workers in Ethiopia. The present brief report gives support to the op'nion that rickets in Ethiopia responds readily -no effectively to ultraviolet irradiation. As milk provides only 4 IU or 0-1 ug. of vitamin D per 0C em. it is evident that the children in this trial

References (1) Anst-Kettis, A., Bjornesjo, K. 8., Mannheimer, E., ' Cvibah, T., Clark, P., and Debelle, M. (1965). Rickets in Ethiopia, Ethiopian Med. J., 3, 109. (2) Woidemariam, T., and Sterky, G. (1973). Severe rickets in infancy and childhood in Ethiopia, J. Paediatr., 82, 876. (3) Loomis, W. F. (1967). Skin-pigment regulation of vitamin D biosynthesis in man, Science, 157, 501. (4) Stamp, T. C. B. (1973). Vitamin D metabolism, Arch. Dis. Child, 48, 2. ' (5) Gebre-Medhin, M., and Vahiquist, B. (1972). Effect of single massive dose vitamin D therapy (oral or intramuscular) on rickets in Addis Ababa children, Courrier, 22, 12. (6) Bessey, O. A., Lowry, O. H., and Brock, H. J. (1946). Method for the rapid determination of alkaline phosphatase with five cubic tnillilitres of serum, J.Biol. Client., 164, 321. (7) Kingsley, G. R., and Schaffert, R. R. (1953). Direct microdetermination of sodium, potassium and caiciuin in a single biological specimen, Anal. Chem., 12, 1738. (8) Annino, J. S. (1964). Clinical Chemistry. Boston, Little Brown, p." 201. (9) Loomis, W. F. (1970). "Rickets, Scientific American, 223 77 (10) Gupta, M. M., Round, J. M., and Stamp, T. C. B. (1974). Spontaneous cure of vitamin D deficiency in Asians during summer in Britain'*Lancet, i, 586.

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have obtained this vitamin almost entirely through exposure to sunshine. This report also conforms well with earlier studies in other countries where it has been found that sunshine effectively heals rickets^9| and with recent findings of spontaneous increase in the level of hydroxylated cholecalciferol during summer months in healthy Asians living in BritainC0', Until the standard of living of the average citizen has been raised and health education has effectively eliminated bad child rearing practices prophylactic administration of vitamin D remains advisable. The administration of a single massive oral dose of vitamin D to rachitic infants has been found to be safe and effective in large scale trials in Ethiopia^'5.'. "Under the prevailing conditions this method should in our opinion be recommended for prophylactic use as welt.