Presentation on theme: "Vitamin D Deficiency and Fractures Bone Study Day, 28th September 2012"— Presentation transcript:
1Vitamin D Deficiency and Fractures Bone Study Day, 28th September 2012 Dr. Zulf MughalConsultant in Paediatric Bone DisordersDepartment of Paediatric EndocrinologyRoyal Manchester Childrens HospitalM13 9WLBone Study Day, 28th September 2012
2Sue Reid 18th December 2011Four-month-old baby with rickets 'was shaken to death‘Brain damage so severe he was 'incompatible with life'Staff at Great Ormond Street Hospital found multiple fracturesincluding to Jayden's arms, leg and skull. (He also hasRetinal Haemorrhages.)Jayden had been born a normal baby when his mother was 16 and his father 19. On July 22, 2009, he was admitted as an emergency to University College Hospital and placed on life support. Within hours, Jayden's condition deteriorated and he was transferred to Great Ormond Street Hospital for Children. He did not survive. Jayden was found multiple fractures including to his arms, leg and skull. He has haemorrhaging in his retinas.Professor Archibald Malcolm found that he had been suffering from rickets, which explained some of his fractures. However, fractures of Jayden's skull, humeri and femora had been caused by non-accidental injury.“This horrific story unfolded over six weeks in a panelled courtroom of London’s Old Bailey. Yet today, Jayden’s father and mother — Rohan, 22, and 19-year-old Chana — are free. The case against them was thrown out ten days ago after 60 medical and forensic experts at their murder trial disagreed over what really killed their son.Finally, the judge told the jury to find the couple not guilty because Jayden’s post-mortem revealed he had rickets, a serious childhood bone disease which had once been eradicated in this country nearly a century ago.”
3LB of Islington v Al Alas and Wray  EWHC 865 (Fam) Jayden was an infant born to young parents of Afro-Caribbean originMother not advised to take vitamin D supplements during pregnancyHe was breast fed from birth (no vitamin D supplement)At age of 4½ months, referred to the University Collage Hospital,London, with a history of:Not crying or making any noise.Not opening his mouth (tongue was stuck to the roof of the mouth).Possibly having fits.After admission he started to fit & his condition rapidly deteriorated.
4LB of Islington v Al Alas and Wray  EWHC 865 (Fam) The radiologist at UCH had queried the possibility of ametabolic bone disorder, such as rickets on CXRRadiological investigations : multiple fractures, includinga fracture of the skull & subdural brain haemorrhagesBilateral retinal haemorrhages.Jayden died three days later on the PICU at GOSH.Coroner's PM: Pathologist noted that Jayden had lowserum Ca & raised ALP. She also noted radiologicalfeatures of rickets. Histology showed florid rickets .
5LB of Islington v Al Alas and Wray  EWHC 865 (Fam) At the conclusion of the hearing held beforeMrs Justice Theis, all allegations against Jayden’sparents were found not proven.Mrs Justice Theis concluded that Jayden’s fracturescould have been caused by the day to day handling,due to fragility of Jayden's bones as a result of thehis severe vitamin D deficiency rickets.However, she concluded that the subduralhaemorrhages were more likely to be caused by trauma.
6LB of Islington v Al Alas and Wray  EWHC 865 (Fam) IMPLICATIONSJo Delahunty QC & Kate Purkiss
13Case of AR At the age of 9 weeks AR sustained a head injury HISTORY: Mum giving a massage with Johnson’s baby oil.AR slipped out of her hands and fell head first onto the living room floor.Height of fall ~ 45 inches.Communication problems – inconsistent history.SKELETAL SURVEY:A parietal fracture extending from ‘ear to ear’Compression fractures of T2, T3, T4 & T5
17Case of AR FINDING OF FACT HEARING: pregnancy. Mum of Pakistani origin. Not prescribed vitamin D duringpregnancy.AR born at term & exclusively breast-fed after birth.He was not receiving vitamin D supplements.November GP tested mum’s vitamin D status because ofH/O ‘aches & pains’. Her serum 25OHD 6 ng/ml. (AR’s serum25OHD at presentation 13 ng/ml.)FINDING OF FACT HEARING:Was AR’s low serum 25OHD (& possibly maternal vitamin Ddeficiency during pregnancy ) responsible/contributory factorin causation of fractures?
18118 < 2 year old with fractures - 60% accidental, 31% non-accidental & 9% indeterminate cause39% were vitamin D deficient or insufficientVitamin D levels in those with accidental & non-accidental fractures not different.
19Summary Subclinical vitamin D deficiency is very common. Severe vitamin D deficiency is usually associated with elevated serum PTH concentrations.Pathological fractures do occur in infants who suffer from severe vitamin D deficiency rickets.There is no evidence that subclinical vitamin D deficiency causes fractures.
20Vitamin D deficiency and Fractures Position statement of the British Paediatric & Adolescent Bone GroupIn the context of unexplained fractures in infancyit is our opinion that unless there is radiologicalevidence of rickets using conventional X-raytechniques and biochemical evidence of rickets(i.e. abnormal blood levels of calcium, phosphate,alkaline phosphatase or parathyroid hormone)that the level of 25 hydroxyvitamin D is not relevantto the causation of the fractures.