Bulging anterior fontanelle: an unusual presenting sign of nutritional rickets
Abstract
Aim: To report the first case series of infants with nutritional rickets who presented with bulging
anterior fontanelle
Methods: infants who were admitted to Alrass General Hospital, Qassim, Saudi Arabia, between
October 2004 and October 2007, with bulging anterior fontanelle and later found to have nutritional
rickets were reviewed. Diagnosis of rickets was based on typical biochemical and radiological
findings with or without clinical signs of rickets and with a good response to treatment with vitamin
D with or without calcium.
Results: Nine cases of nutritional rickets who presented with bulging anterior fontanelle are
reported. All were below 12 months of age and the majorities are boys. All patients are exclusively
breast-fed. Five cases had hypocalcaemia and three of them presented with hypocalcaemic seizures.
Five cases showed no clinical signs of rickets. Clinical, biochemical and radiological signs of
rickets as well as the status of the anterior fontanelle reverted to normal within six weeks after
treatment with vitamin D in all except one patient who took four months to respond.
Conclusion: Nutritional rickets remains a problem in Saudi Arabia. A bulging anterior fontanelle is
an important, but under- recognized presenting feature of nutritional rickets. Recognition of this
association will alley anxiety when confronted with a case of rickets with a bulging anterior
fontanelle.
References
Jacobsen ST, Hull CK, Crawford AH. Nutritional rickets. J Pediatr Orthop 1986; 6: 713–6
Thomas MK, Demay MB. Vitamin D deficiency and disorders of vitamin D metabolism. Endocrinol Metab Clin N Am 2000; 29: 611 – 27
Ladhani S, Srinivasan L, Buchanan C, et al. Presentation of vitamin D deficiency. Arch Dis Child 2004;89: 781 – 4
Biswas AC, Molla MAM, Ijemba JC. Febrile convulsions in infancy: beware of nutritional rickets. Middle East Paediatrics 2004; 9: 12 – 14
Biswas AC, Al Khalaif RA, Molla MAM. Infantile hypophosphatasia. Annal Saudi Med 1999; 19: 345 – 6
Biswas AC, Molla MAM; Al – Moslem K. A baby with bulging anterior fontanelle. Lancet 2000; 356: 132
Al- Najjar FY. Bulging anterior fontanelle and transient intracranial hypertension. Middle East Paediatrics 2005; 10: 88 - 9
El – Kholy MS, Abdel Maged FY, Farid FA. A genetic study of vitamin D deficiency rickets. 2 – sex differences and ABO typing. J Egypt Public Health Association 1992; 62: 213 – 22
Adekunle D, Mukesh A, Kochiyel HM et al. Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer: A justification for vitamin D supplementation of breast-feedinf infants. J Pediatr 2003:142:16 -173
Hag A, Rajah J, Abdel-Wareth LO. Vitamin D: measurement, deficiency, and health consequences. Middle East Laboratory. 2009;12:6-10
Zipitis CS, Markider GA, Swann IL. Vitamin D deficiency: prevention or treatment?. Arch Dis Child 2006;91: 1011-14.
Clemens JL, Adams JL, Henderson SL, et al. Increased skin pigmentation reduces the capacity of the skin to synthesizes vitamin D3. Lancet 1982;i: 74 -6
Sedrani S Elidrissy ATH, El Arabi KM. Sunlight and vitamin D status in normal Saudi subjects. Am J Clin Nutr 1983; 36: 129 – 32
Holick MF. Photosynthesis, metabolism and biologic action of vitamin D. In Nestle Nutrition Workshop Series Vol 21, Nestic Ltd, Vevey/ raven press, ltd. New York 1991; 1 – 22.
Ahmed I, Atiq M, Igbal M, et al. Vitamin D deficiency rickets in breast – fed infants presenting with hypocalcaemic seizure. Acta Paeditr 1995; 84: 941 – 2
Kesler A, Fattal-Valevski A. Idiopathic intracranial hypertension in the pediatric population. J Child Neurol.2002;17 : 745-748
Lim M, Kurian M, Penn A, et al. Visual failure without headache in idiopathic intracranial hypertension. Ach Dis Child 2005; 90: 206 – 10
Digre KB, Cabett JJ. Idiopathic intracranialhypertension ( pseudotumor cerebri ) : a reappraisal. Neurologist 2001; 7: 2 – 67
Haslam RHA. Pseudotumor cerebri. In; Behrman RE, Nelson Textbook of Pediatrics, 18th ed 2007, Sauners, Elsevier Sciences; 2525 – 26
Cross TP, Milstien JB, Kuritskey TN. Bulging fontanelle after immunization with diphtheria – tetanus – pertussis and diphtheria – tetanus vaccine. J Pediatr 1989; 114: 423 – 425.
Brunvond L, Quigsted E, Urdal P et al. vitamin D deficiency and fetal growth. Early Hum Dev 1996; 45: 27 – 33
Sandgreen ME, Bronnegard M, Deluca HF. Tissue distribution of the 1,25 dihydroxyvitamin D3 receptor in the male rat. Biochem Biophys Res Commun 1999; 81: 611 – 16
Zehnder D, Bland R, Williams MC, et al. Extrarenal expression of 25 – hydroxyvitamind (3) – 1 – alpha – hydroxylase. J Clin Endocrin Metab 2001; 86: 888 – 94
Zafer B. The relationship of hypocalcemic convulsions related to nutritional rickets with age, gender, season and serum phosphorus levels. Neurosciences 2007. 12: 302-305
Yager TY, Hartfield DS. Neurologic manifestations of iron deficiency in childhood. Pediatr Neurol 2002;27:85-92
Henry M, Driscoll MC, Miller M et al. Pseudotumor cerebri in children with sickle cell disease: A case report series. Pediatrics 2004;113: e265-e269
Jeng MR, Rieman M, Bhakta M et al Psudotumor cerebri in two adolescents with acquired aplastic anemia. J Pediatr Hematol Oncol 2002; 24: 765-768
Tugal O, Jacobson R, Berezin S et al. Recurrent benign intracranial hypertension due to iron deficiency anemia. Case report and review of the literature. Am J Pediatr Hematol Oncol 1994;16:266-270.
