Still, many modern clinicians in developed countries have little experience or training in the management of this condition. The study published in this issue [3] is helpful in highlighting the efficacy of a simple single dose regimen, and shows that the lower dose of 300,000 units is not inferior to double this dose. It is also important to stress that the dose is effective orally. Many children are treated with the same dose by intra-muscular injection which is painful and unnecessary. This study shows good clinical outcomes, and is in line with other clinical and pharmacokinetic studies showing effectiveness of oral Vitamin D therapy [4,5]. The practice of injecting children should stop, except for rare instances – such as rickets associated with severe malabsorption – where even high oral doses are ineffective.

The authors comment on the risk of hypercalcaemia, but this study was not designed or powered to assess this potential side-effect of vitamin D therapy. Hypercalcemia may be due to other causes and should not prevent clinicians treating rickets with adequate doses of vitamin D and/or calcium. Also it is important to remember that after effective treatments, such as those used in this study, a satisfactory blood level of vitamin D at follow-up should not encourage clinicians or families to stop the regular low-dose prevention of doses of vitamin D which are required long-term to prevent relapse of rickets. It is my practice to recommend children diagnosed with rickets to take 1000 units of vitamin D daily to until they have finished growing, which would be more than 10 years for most of the children in this study. Appropriate vitamin D and calcium intake should be also encouraged for their siblings. That way many cases of rickets can be prevented. The financial savings in terms of blood tests, X-rays and clinical follow-up should more than balance the cost of the vitamin D.

Funding: None; Competing interests: None stated.

1. Lowdon J. Rickets: concerns over the worldwide increase. J Fam Health Care. 2011;21:25-9.

2. Goldacre M, Hall N, Yeates DG. Hospitalisation for children with rickets in England: a historical perspective. Lancet. 2014;383:597-8.

3. Mittal H, Rai S, Shah D, Madhu SV, Mehrotra G, Malhotra RK, et al. 300,000 IU or 600,000 IU of oral vitamin D3 for treatment of nutritional rickets: A randomized controlled trial. Indian Pediatr. 2014; 51:265-72.

4. Balasubramanian S, Dhanalakshmi K, Amperayani S. Vitamin D deficiency in childhood – a review of current guidelines on diagnosis and management. Indian Pediatr. 2013;50:669-75.