On 2014 Oct 30, David Ayoub commented:

Elder and Bishop [1] express uncertainty in the role of vitamin D and rickets in unexplained fractures during infancy that can potentially mimic abuse but misquote a key finding of Chapman et al. [2]. Contrary to their claim that multiple fractures were unreported in rickets, the Chapman study actually reported more multiple fractures (n=5) than solitary injuries (n=2). Since skeletal surveys were only done in 25% of patients, additional subclinical insufficiency fractures could have been missed in that series. Even though multiple fractures in rickets are historically established, particularly in preterm infants, a recent family court decision reminds us that a comprehensive evaluation is still sometimes not performed and evidence ignored [3].

Cohen et al. [4] demonstrated histological rickets in 87% of infants dying <1 year of age yet rarely detected clinically or radiologically prior to death, a finding reaffirmed in several historical autopsy studies. Therefore, Elder and Bishop’s claim of no association between vitamin D deficiency and fractures in the “absence of rickets” is meaningless without histological confirmation.

Therefore, we do not believe there is a basis to dismiss rickets in infants based upon biochemical testing or radiography alone. Histological healing may lag biochemical and radiological recovery. Additionally, Wharton and Bishop have previously stated that early infantile rickets is difficult to detect radiographically [5]. Comparing radiology with histology when possible will help to understand the accuracy and limitations of imaging and allow for recognition of subclinical and lesser known forms of this disease.

1) Elder CJ, Bishop NJ. Rickets. Lancet. 2014 Jan 9. pii: S0140-6736(13)61650-5. doi: 10.1016/S0140-6736(13)61650-5. 2) Chapman T, Sugar N, Done S, et al. Fractures in infants and toddlers with rickets. Pediatr Radiol 2010;40:1184-1189. 3) London Borough of Islington v. Chana Al-Alas, Rohan Wray, Jayda Faith Al-Alas Wray. Neutral Citation Number: [2012] EWHC 865 (Fam)http://www.judiciary.gov.uk/media/judgments/2012/lb-islington-al-alas-wray-judgment-19042012 4) Cohen MC, Offiah A, Sprigg A, Al-Adnani M. Vitamin D deficiency and sudden unexpected death in infancy and childhood: a cohort study. Pediatr Dev Pathol 2013;16:292-300. 5) Wharton B, Bishop N. Rickets. Lancet 2003;362:1389-400.

On 2014 Oct 30, David Ayoub commented:

Elder and Bishop [1] express uncertainty in the role of vitamin D and rickets in unexplained fractures during infancy that can potentially mimic abuse but misquote a key finding of Chapman et al. [2]. Contrary to their claim that multiple fractures were unreported in rickets, the Chapman study actually reported more multiple fractures (n=5) than solitary injuries (n=2). Since skeletal surveys were only done in 25% of patients, additional subclinical insufficiency fractures could have been missed in that series. Even though multiple fractures in rickets are historically established, particularly in preterm infants, a recent family court decision reminds us that a comprehensive evaluation is still sometimes not performed and evidence ignored [3].

Cohen et al. [4] demonstrated histological rickets in 87% of infants dying <1 year of age yet rarely detected clinically or radiologically prior to death, a finding reaffirmed in several historical autopsy studies. Therefore, Elder and Bishop’s claim of no association between vitamin D deficiency and fractures in the “absence of rickets” is meaningless without histological confirmation.

Therefore, we do not believe there is a basis to dismiss rickets in infants based upon biochemical testing or radiography alone. Histological healing may lag biochemical and radiological recovery. Additionally, Wharton and Bishop have previously stated that early infantile rickets is difficult to detect radiographically [5]. Comparing radiology with histology when possible will help to understand the accuracy and limitations of imaging and allow for recognition of subclinical and lesser known forms of this disease.

1) Elder CJ, Bishop NJ. Rickets. Lancet. 2014 Jan 9. pii: S0140-6736(13)61650-5. doi: 10.1016/S0140-6736(13)61650-5. 2) Chapman T, Sugar N, Done S, et al. Fractures in infants and toddlers with rickets. Pediatr Radiol 2010;40:1184-1189. 3) London Borough of Islington v. Chana Al-Alas, Rohan Wray, Jayda Faith Al-Alas Wray. Neutral Citation Number: [2012] EWHC 865 (Fam)http://www.judiciary.gov.uk/media/judgments/2012/lb-islington-al-alas-wray-judgment-19042012 4) Cohen MC, Offiah A, Sprigg A, Al-Adnani M. Vitamin D deficiency and sudden unexpected death in infancy and childhood: a cohort study. Pediatr Dev Pathol 2013;16:292-300. 5) Wharton B, Bishop N. Rickets. Lancet 2003;362:1389-400.