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Interventions for the prevention of nutritional rickets in term born children

  1. Christian Lerch1,*,
  2. Thomas Meissner2

Editorial Group: Cochrane Metabolic and Endocrine Disorders Group

Published Online: 17 OCT 2007

Assessed as up-to-date: 21 AUG 2007

DOI: 10.1002/14651858.CD006164.pub2

How to Cite

Lerch C, Meissner T. Interventions for the prevention of nutritional rickets in term born children. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006164. DOI: 10.1002/14651858.CD006164.pub2.

Author Information

  1. 1

    Universitaetsklinikum Duesseldorf, Heinrich-Heine University, Department of General Practice, Duesseldorf, Germany

  2. 2

    University Children's Hospital, Department of General Pediatrics, Düsseldorf, Germany

*Christian Lerch, Department of General Practice, Universitaetsklinikum Duesseldorf, Heinrich-Heine University, PO Box 101007, Duesseldorf, 40001, Germany. t.c.l@gmx.net. Christian.Lerch@med.uni-duesseldorf.de.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 17 OCT 2007

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Nutritional rickets is a disease of growing children leading to bone deformities, bone pain, convulsions or delayed motor development. Today, high-incidence of nutritional rickets is mainly found in low-income countries.

Objectives

To assess the effects of various interventions on the prevention of nutritional rickets in term born children.

Search methods

Studies were obtained from computerised searches of The Cochrane Library, MEDLINE, EMBASE, LILACS and reference lists of relevant articles. We contacted authors of studies or reviews to obtain further studies.

Selection criteria

Studies were included if they were randomised controlled clinical trials, controlled clinical trials or prospective cohort studies comparing any intervention for the prevention of nutritional rickets in term born children with placebo or no intervention. Minimum duration of the intervention was three months for children under 12 months or six months for children over 12 months.

Data collection and analysis

Two authors independently extracted data and assessed study quality. Authors of studies were contacted to obtain missing information.

Main results

Four studies enrolled approximately 1700 participants. Trials lasted between nine months to two years. Three studies were randomised controlled trials, two of which showed a cluster randomised design; one trial probably was a controlled trial with researcher controlled group assignment. In children up to three years of age in Turkey, Vitamin D compared to no intervention showed a relative risk of 0.04 (95% confidence interval (CI) 0 to 0.71). Despite a marked non-compliance, a Chinese trial in children up to three years of age comparing a combined intervention of supplementation of vitamin D, calcium and nutritional counselling showed a relative risk of 0.76 (95% CI 0.61 to 0.95) compared to no intervention. In two studies conducted in older children in China and in France no rickets occurred in both the intervention and control group.

Authors' conclusions

There a only few studies on the prevention of nutritional rickets in term born children. Until new data become available, it appears sound to offer preventive measures (vitamin D or calcium) to groups of high risk, like infants and toddlers; children living in Africa, Asia or the Middle East or migrated children from these regions into areas where rickets is not frequent. Due to a marked clinical heterogeneity and the scarcity of data, the main and adverse effects of preventive measures against nutritional rickets should be investigated in different countries, different age groups and in children of different ethnic origin.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Interventions for the prevention of nutritional rickets in term born children

Although only a few studies with different results exist, preventive measures against nutritional rickets appear reasonable in high risk groups until new data become available.

Rickets is a disease which affects the bone of growing children. Calcium and phosphate are important elements which form the bone. In nutritional rickets, initially the availability of calcium is diminished, later disturbances in phosphate occur. The shortage of calcium may be caused by limited intake or limited resorption in the gut. The latter is highly regulated by vitamin D, which can be synthesised from the skin after sun exposure or can be acquired from dietary sources, for example cod liver. Therefore, shortage of calcium, vitamin D or both may lead to nutritional rickets, which is mainly characterized by deformed bones, bone pain, convulsions or delayed development. Since the 1930s supplementation of vitamin D is used for the prevention of rickets in children, mainly in high-income countries; several other measures like supplementation of calcium or longer exposure of the skin to sunlight are also used. Over the time many factors have changed, for example nutrition, which provides calcium, air pollution, through which sun light is absorbed leading to a diminished synthesis of vitamin D in the skin, or social issues, for example child labour, again leading to limited sun exposure. Because of these changes we looked for studies conducted in the last 50 years which investigated patient-relevant outcomes. As patient-relevant outcomes we defined the occurrence of rickets, adverse effects of the intervention, mortality, health-related quality of life and costs.
Four trials enrolled approximately 1700 participants and lasted between nine months and two years. Study participants were aged from one month to 15 years. There were different results on the occurrence of nutritional rickets in different settings. Adverse effects were investigated in one study only.
Considering the partial high frequency of nutritional rickets, the obvious way of action of supplementation of vitamin D or calcium and the favourable risk-benefit ratio, preventive measures are reasonable in high risk groups like infants and toddlers. New studies investigating main and side effects of preventive measures against nutritional rickets in different age groups and in different countries are indicated.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

預防足月孩童之營養性佝僂病之介入

營養性佝僂病是生長中孩童的疾病,會造成骨骼畸形、骨疼痛、抽搐或運動發展延遲。今日,高發生率之營養性佝僂病主要在低收入國家

目標

評估預防足月孩童之營養性佝僂病的各種介入措施的效益

搜尋策略

研究的獲取是由電腦搜尋Cochrane書庫、MEDLINE, EMBASE, LILACS與參考文獻表單之相關文章。聯絡研究或評論之作者以取得更深入的資料。

選擇標準

研究的收錄,包括隨機控制之臨床試驗、控制之臨床試驗或前瞻性的世代研究,預防足月孩童營養性佝僂病之任一種介入法與安慰組或無介入組比較,介入的期間在小於12個月大的幼童最少三個月、大於12月者至少六個月。

資料收集與分析

兩位作者分別獨立擷取數據和評估研究品質。聯絡研究的作者獲取缺漏的資料

主要結論

四個研究收錄將近1700個受試者。試驗期間從9個月到2年。三篇研究為隨機控制試驗,其中兩個為群集隨機設計,另一篇可能是控制試驗由研究者控制團體的分配。土耳其三歲以下孩童,維生素D與無介入組相比,顯示相對風險0.04 (95% 信心區間 (CI) 0 to 0.71)。一個中國三歲以下孩童的試驗,即使明顯的沒有遵囑性,使用維生素D、鈣補充與營養諮詢合併介入,與無介入組相比顯示其相對風險0.76 (95% CI 0.61 to 0.95)。兩個在中國與法國施行之年齡較大孩童的試驗,介入組與控制組均無佝僂症發生。

作者結論

預防足月兒童營養性佝僂病的研究不多。除非有可用之新資料,否則提供預防措施(維生素D或鈣)給高風險組群,如嬰兒與幼兒;生長在非洲、亞洲、中東的兒童或由這些地方移民到少有佝僂病地方的兒童,看來是合理的。由於臨床的異質性很高而且資料又很少,應該調查對抗營養佝僂病之預防措施在不同國家、不同年齡層與不同種族來源的主要效果與不良反應。

翻譯人

本摘要由慈濟醫院吳篤安翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

雖然只有少數研究且存在不同的結果,除非有新資料,對抗高風險族群營養性佝僂病之預防措施應為合理。佝僂病是影響兒童骨骼生長的疾病。鈣與磷是構成骨骼的重要成分。營養性佝僂病,在剛開始其可獲得的鈣減少,後來磷的障礙也會發生。鈣的缺乏可能因為攝取不足或腸道胃吸收不足所致。後者乃由維生素D高度調控,維生素D經陽光曝曬後由皮膚製造或由飲食獲取,如鱈魚肝。因此,缺乏鈣、維生素D或兩者都缺會造成營養性佝簍病,此病主要特徵是骨頭變形、骨頭疼痛、抽搐或發育遲緩。從1930年代,主要在高收入國家,採用補充維生素D預防兒童佝僂病;一些其他措施,如補充鈣或較長皮膚日曬也採用過。經過一段時間許多因素有了改變,例如提供鈣的營養,空氣污染會吸走陽光使得皮膚維生素D製造減少,或社會因素如童工也會造成陽光的曝曬不足。因為這些改變我們尋找過去五十年所做過的研究,調查病患相關的結果。依病患相關的結果,我們界定佝僂病的發生率、介入治療的不良反應、死亡率、健康相關之生活品質以及花費。4個試驗納入1700個受試者,為期九個月到兩年。受試者年齡從1個月大到15歲。營養性佝僂病依不同背景有不一樣的結果;其中只有一個研究有調查不良反應。考慮到營養性佝僂病的部分高發生率,明顯實施補充維生素D或鈣的方式,其風險利益之比是有利的,預防性措施在高風險的嬰兒與幼兒是合理的。新的試驗調查預防措施對抗營養性佝僂病之主要效果與副作用在不同的年齡層與不同國家是必要的。