As a couple call for an inquiry into the failure to diagnose their son's rickets, which they say led to his death, Channel 4 News examines whether there is enough awareness of its symptoms.
Once a disease confined to working-class children in the Victorian era, rickets is returning to the UK. Cases of vitamin D deficiency, which can lead to the disease, have been on the increase in areas of northern England and Scotland, and a young couple on Friday called for an investigation into the death of their son, who was suffering from rickets.
Rohan Wray, 22, and his partner Chana al-Alaswere, 19, were originally accused of abusing their four-month-old son Jayden, who suffered a fractured skull and died of brain damage in 2009.
They were cleared of murder last December, and it later emerged that Jayden was suffering from rickets, which weakens bones and could have led to the fracturing that caused his death. The couple from north London said on Friday that the Great Ormond Street and University College hospitals should have diagnosed the problem earlier and blame them for their son's death.
There have been a number of child deaths linked to vitamin D deficiency, and subsequently rickets, according to senior paediatric pathologists Dr Irene Scheimberg and Dr Marta Cohen, who are both calling for further investigations and awareness into the impact of vitamin D deficiency.
But what causes rickets in the first place, and is there enough awareness of its symptoms among health professionals? Channel 4 News has the answers.
What causes rickets?
In most cases, a lack of vitamin D and calcium causes rickets. In the past, a poor diet was thought to be responsible for a lack of vitamin D, which can be absorbed from oily fish, eggs and some fortified breakfast cereals. In the 1940s, vitamin D was added to some foods, such as margarine and cereals, which helped to boost children's immunity to the disease.
However only 10 per cent of our vitamin D comes from diet: exposure to sunlight is the body's most effective way of absorbing the vitamin, and a lack of sunshine is thought to be behind the modern incarnation of rickets.
What are the symptoms?
Rickets causes the bones to become painful, soft and weak, which can lead to deformities of the skeleton, such as bowed legs, spine curvature and thickening of the ankles, wrists and knees. Children with rickets may be reluctant to walk or get tired more easily, and can develop bowed legs. Dental problems can also be a sign of rickets.
What is the government advice?
In January, the government recommended that vitamin D supplements be taken by all pregnant and breastfeeding women, children aged six months to five years, people aged 65 and over, people with darker skin, as well as those who cover up for cultural reasons.
Dr James Greening, consultant paediatrician and endocrinologist, told Channel 4 News that most paediatricians have been made aware in recent years of the signs of vitamin D deficiency and rickets, to inform their practice.
Does current advice go far enough?
Following recent reports that vitamin D deficiency is on the increase, the Royal College of Paediatrics and Child Health is leading an investigation into the effects of the problem. But it is also looking at what it calls "inconsistent" guidance. The study will be complete in September, and hopes to help "evaluate the effectiveness of current public health measures".
Who is most vulnerable to rickets?
In recent years, there has been an increase in cases of rickets in the UK, mainly among children of Asian, African-Caribbean and Middle Eastern origin. They are at a higher risk because their skin is darker and they need more sunlight to get enough vitamin D.
"Some ethnic minorities may have a poor intake of vitamin D on top of that. For example vegetarians are at higher risk, as well as those who cover their skin, and a lot of Muslims fit into both those categories," Dr Greening told Channel 4 News. "Babies who are born to mothers with a vitamin D deficiency are also more at risk. And additionally, the milk they get from the mother will be lacking."
Other at risk groups include children born prematurely and children taking medication that interferes with vitamin D.
Where are the UK hotspots?
Rickets is more prevalent in areas with a high ethnic-minority population. But some parts of northern England and Scotland also have higher instances because of a lack of exposure to sunlight.
How is it treated?
Taking vitamin and mineral supplements, and eating vitamin-rich foods is usually a successful way of treating rickets. In some cases a higher dose or yearly vitamin D injection will be necessary. In winter months, the government recommends ensuring our diet is rich in calcium and vitamin D as there is not enough sunlight in the UK.