ABSTRACT
A 4-year-old girl of African origin presented to an emergency department with a convulsion and was found to be hypocalcaemic (Ca 1.2 mmol/L; normal range: 2.1–2.65 mmol/L) with a serum 25-hydroxyvitamin D of 6 nmol/L (normal range: 50–125 nmol/L). She was admitted, received intravenous calcium and was discharged home after 3 days when the blood calcium had risen to 2.1 mmol/L, on oral calcium supplements and vitamin D 3000 units (75 mcg) daily. The parents were asked to return for further blood tests to assess the adequacy of supplementation, but failed to attend and could not be contacted at the given address or by telephone. Six weeks later the girl was seen again in the same emergency department. She was not moving her leg and an x-ray showed several findings (Images 114a and 114b). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig114a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig114b.jpg"/>
Is this a non-accidental injury?
260The x-ray shows abnormal bones with frayed metaphyses and osteopenia. These are signs of rickets. These findings are not from abuse, however, they may result from medical neglect if the parents have not been providing recommended vitamin D and mineral supplementation. Rickets result in weakening of bone tissue; bone demineralization results in a loss of bone stiffness, which in turn means that the bone cannot resist deformation due to mechanical loading. It is difficult to know how much bone demineralization needs to occur to make a functional difference in the growing skeleton; however, when there are radiologically clear signs of rickets, it is likely that bone strength has been lost. 1 , 2 The bone changes on x-ray would therefore suggest that the child is at risk of easy fractures. However, bone disease and non-accidental trauma can co-exist and this child may be found to be abused in the future. Preliminary checks should therefore be undertaken to make sure there are no concerns about the parenting before the child is discharged from hospital. Failure to attend health appointments or to give medications can be a sign of poor parenting.
