Rickets in the midst of plenty of sunshine

It’s hard to imagine that any of the one billion people worldwide who suffer the effects of inadequate vitamin D from sunshine would be found in Africa, where warm sunshine is in plenty; but that is not the case.

Samira Nassir, a nutritionist in Mathare Valley, an informal settlement in Nairobi, sees the effects of vitamin D deficiency regularly, from the referrals she gets from Baraka Health Centre, which is run by German Doctors, a non-governmental organisation.

Between July 2013 and April 20114, a team of researchers from the Kenya Medical Research Institute (KEMRI), studying malnutrition in children under five, worked with Mrs Nassir and her colleagues at the nutrition centre that also has an outpatient therapeutic feeding programme.

Dr Kelsey Jones, the lead researcher, and his colleagues, wanted to find out whether rickets in this area was a result of lack of vitamin D or a result of insufficient consumption of calcium. It turned out to be the former – rickets was associated with lack of vitamin D, and many of the children with rickets were also suffering from malnutrition.

During the study, Mrs Nassir encountered Amani*, all covered up in a monkey hat or balaclava (commonly known as boshori) and heavily shawled when his mother brought him to the clinic. The way the child was covered set alarm bells ringing in Mrs Nassir’s head.

‘There is a lot of stigma attached to having a malnourished child in this area. Mothers are ashamed of the state of their children and afraid to bring them for treatment. But even I was surprised by Amani. I expected a much younger child, not a 13-month-old boy. He was so severely ill, he couldn’t even crawl,’ said Mrs Nassir.

Under the heavy covers was a boy with a gaunt face and copper-coloured hair. Amani’s facial skin was thin, like nylon, his neck too. His cheeks and wrists were swollen. His chest was just bones and skin. The ribs, which were sticking out, had little swellings, like those of a rosary chain.

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Children under the age of two are diagnosed with rickets if they present with one or more of the following signs: wrist widening, ribs with the appearance of a chain of rosary beads running down the chest, swollen knees, bow legs and bone pain on walking. Amani ticked each box but he was also suffering from marasmus and kwashiorkor. He was in a vulnerable position and had his mother left him home longer, Amani would have died.

Both kwashiorkor and marasmus are outcomes of severe malnutrition. To cure both conditions, Amani was put on nutritional supplementation with Plumpy’nut, a peanut-based paste used to treat severe malnutrition. Once he recovered, his mother was offered hands-on advice on preparation of nutritious food on a small budget.

Amani was also offered Vitamin D and calcium supplemens to cure the rickets. Within five weeks, Amani had improved significantly and was no longer suffering from marasmus or kwashiorkor. He had to continue with Vitamin D and calcium supplementation for another six weeks and during that period, Amani started walking for the first time. During treatment, children with deformities are also monitored for calcium levels.

It is only when the calcium levels are back to normal that physiotherapy and equipment to straighten legs is applied. Weak bones would be unable to take on the strain of these therapies.

It may be strange to hear that children in Nairobi, would be suffering from an illness which is a result of lack of exposure to sunlight, which is free and plentiful. However, Amani’s family is among many in the slums of Nairobi, living well below the poverty line.

Amani is the last of four siblings. His mother walks to the Eastleigh neighbourhood every day and waits for anyone to call on her to wash clothes or clean a house. Work is not guaranteed; she may wait all day and make no money. When she gets work, she earns between Sh100 and Sh150. While at work, she leaves Amani at a day care centre.

Her priorities are paying rent and day care so that her children are safe. Food comes a distant third and  her children often sleep hungry. When food is available, it will be cheap starchy foods.

It may be tempting to ask why Amani’s mother did not take her child to hospital earlier and why the little boy had to deteriorate so much.

“The boy’s mother is just trying to make ends meet. Time to bring the child to hospital is time away from making money. Time that would mean there is no rent, no food, no money for day care,” Mrs Nassir explained.

The day care centres in Mathare Valley are usually in someone’s house. Often it is one woman with about 10 to 15 children trying to provide care in a situation with inadequate sanitation and no access to clean water. The children not only get no sunshine, but also have poor diet. They are exposed to infectious diseases and get no stimulation or attention. But women like Amani’s mother have little option but to leave their children there, otherwise they would have to lock their babies in their shanty homes and leave them alone all day as they look for money for food.

Lack of sunshine in day care centres has also been observed in the flower farms of Naivasha, an area known to have high fluoride levels in water. The focus on fluoride detracts from the already important association found between the lack of vitamin D, as a result of poor sunlight exposure and poor bone development.

DEVELOPMENTAL MILESTONES

The investigators suggest that research is urgently needed to systematically access the general health of children that are in day care facilities in the slums of Nairobi. However, day care centres are implicated in a small fraction of the cases of rickets. The study in Mathare found that out of every 10 children diagnosed with rickets, only one was frequently left at a day care centre.

However, children left at day care centres are often not brought for treatment until they are very ill, like Amani, so this may be an underestimation. However, it still points to the fact that most children with rickets are not left at day care centres.

This lack of exposure to the sun is not unique to the Mathare Valley. Between September 2012 and October 2013, Jeffrey Edwards and his colleagues from Médecins Sans Frontières carried out a study investigating rickets among children in Kibera, another informal settlement in Nairobi. During that one year, 82 children were found to have rickets.

One thing that is clear is the underlying burden of extreme poverty that these children live under evidenced by the fact that the mothers are unable to provide a balanced diet.

In Mathare, about 70 per cent of the children with rickets were malnourished, while in Kibera, it was 40 per cent. These levels of malnutrition do not only affect the children but the mothers as well and it is likely that the problems start there. Children that are breastfeed by mothers deficient in vitamin D and calcium have a poor start.

The founder of the Rickets Foundation of Kenya, John Olunga, believes that the problem starts at pregnancy and is not limited to slums.

‘Vitamin D and calcium levels are not checked during pregnancy and the child’s  stores of Vitamin D run out quickly after birth. Many children are growing up in multi-storey buildings that have little natural sunlight getting in.

They have no outdoor play areas, so many of these young children do not get exposed to the sun,’ said Mr Olunga. He hopes that creating awareness of developmental milestones at antenatal and mother-and-child clinics will enable mothers to know when to seek help and encourage mothers to breastfeed their babies for six months and expose them to sunshine regularly.

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WITHOUT SUNSHINE, LEGS BOW

Although humans make vitamin D from freely available sunshine, about one billion people worldwide suffer the effects of inadequate levels of the sunshine vitamin.

In children, a lack of the sunshine vitamin D, leads to a condition known as rickets. Humans make vitamin D through exposure to sunlight. If a person fails to get enough vitamin D, the body is unable to absorb calcium into the bones. This means the bones do not harden as they should. They are brittle and break easily.

If they are forced to bear weight, the large bones curve under that pressure. Hence, the most commonly known sign associated with vitamin D deficiency is bowed legs. Rickets can also occur when vitamin D levels are enough but the child does not have enough calcium in their diet.

After all, vitamin D can only help in the absorption of calcium in the intestine, if it is there.

Children under the age of two tend to get most of their calcium in milk, in Africa, mainly through breastfeeding.