NUTRITIONAL RICKETS IN ARAR CITY, NORTHERN SAUDI ARABIA; PREVALENCE, - - PDF document

European Journal of Research in Medical Sciences

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NUTRITIONAL RICKETS IN ARAR CITY, NORTHERN SAUDI ARABIA; PREVALENCE, PRESENTATION AND ASSOCIATED FACTORS: A CROSS SECTIONAL STUDY

Mahmoud Mohammed Alsharif2 , Nagah Mohammed Abo El-fetoh1 , Shahad Ahmed Alsharif2 , Nour Homoud Alanazi2, Naif Gharbi Alenazi2 , Abdulmajeed Ahmed Alenazi 2 , Nasser Ghadeer Alshamari2 , Omar Ayed Alanazi2, Yasser Hamoud Alanazi2 , Zainab Muhammed Ibrahim Ory3

1Family and Community Medicine Department faculty of Medicine NBU, Arar, KSA 2Faculty of Medicine, Northern Border University 3Pediatric Department, College Of Medicine, Khartoum University

ABSTRACT Nutritional Rickets is a common disease among our children and numbers of individuals suffering from it arising every year. Up to our knowledge no previous community based studies have been conducted in northern border of Kingdom of Saudi Arabia (KSA) addressing this issue could be traced. This study was carried out to estimate the prevalence, risk factors, presenting features and the previous treatment trials of nutritional rickets in northern Saudi Arabia, KSA. Methods: A cross-sectional study carried out on all children aged 6 months – 3 years attending the pediatrics outpatient clinic or the inpatient pediatrics department of the intended hospitals. Data were collected by means of personal interview with the children's mothers using pre designed questionnaire which include questions designed to fulfill the study objectives. Results: The overall prevalence of rickets among the studied children was 9%. There is no significant effect of child sex, age, arrangement between siblings, mother's age, mother's educational level, mother's work, father's age, father's educational level, father's work, parents consanguinity, skin color, exposure to sunlight, child feeding, Vitamin D supplementation, egg eating or diary milk consumption in the occurrence of rickets (P>0.05) but there is significant effect to presence of chronic diseases and family history of rickets (P<0.05). Conclusion: This study revealed that nutritional rickets is highly prevalent among children in Saudi Arabia. However, several factors seem to make important contributions. Appropriate preventive measures should include strategies such as health education, stressing the importance of exposure to sunlight, good quality weaning food and the right starting age for weaning. Mothers should be supplemented during pregnancy through food containing with vitamin D and infants may be supplemented after birth. Keywords: Nutritional rickets; Children; Vitamin D deficiency; Arar; Kingdom of Saudi Arabia. INTRODUCTION Rickets is emerging as a major public health problem worldwide. ] 1,9 [ It has been estimated that more than one billion people suffer from vitamin D deficiency. Nutritional rickets (NR) is a disease that affect children during times of rapid growth. It's characterized by defective mineralization and disorganization of the epiphyseal growth plates [2]. Vitamin D deficiency and/or nutritional rickets remain prevalent in developing regions of the world and rank among the 5 most common diseases in children [3,4]. Vitamin D deficiency causes rickets in children and will precipitate and exacerbate osteopenia,

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• steoporosis, and fractures in adults [1]. Prevalence of nutritional rickets in developed

countries appears to be rising [3,4,5,6,7,8]. There are also concerns for vitamin D deficiency in older children and adolescents. Because there are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual [4]. Suggested reasons in the literature for its reemergence include complacency in fortifying food, changing lifestyles where children spend most of their time indoors on various forms of technology and globalization which has resulted in immigration of different peoples to different geographic locations [4,10,11]. NR is distinct from other types of rickets in that it is merely caused by a simple deficiency in vitamins and nutrition and thus can be easily corrected if detected early [10]. Those particularly affected live in certain latitudes as is evident from numerous studies about immigrants to other nations [11,12,13]; winter season, atmospheric pollution and geographical latitude are also known to impair vitamin D absorption [14] and finally children spending prolonged hours inside on TV/computers rather than in the sun [15]. The second category of at risk individuals are those with an insufficient dietary intake of vitamin D: infants whose mothers are vitamin D deficient, as an infant's vitamin D concentration corresponds to that of its mother and especially breastfed infants (without vitamin D supplementation) as breast milk is very low in vitamin D [16]. In Almadinah Almunawwarah, Saudi Arabia, a study was conducted to show the presenting features of rachitic children, it is reported that The presenting features of the 136 cases of rickets seen were diarrhea and vomiting or cough and fever in 48, convulsions in 11 infants (8.1% of the total and 33.3% of those aged less than 1 year), bow legs in 78, delayed dentition in 33, delayed standing in 38, hypotonia in 25, abnormal gait in 54 and sweating in

• 33. ]17[

Despite its high prevalence, no previous studies that have been conducted in northern area of Kingdom of Saudi Arabia (KSA), addressing this issue could be traced. This study will describe magnitude and characteristics of vitamin D deficiency rickets, its presenting features and associated risk factors among children in northern Saudi Arabia, a very sun rich area. A study was conducted in Canada showed that The mean age at diagnosis was 1.4 years (standard deviation [SD] 0.9, min–max 2 weeks–6.3 years). Sixty-eight children (65%) had lived in urban areas most of their lives, and 57 (55%) of the cases were identified in Ontario. Ninety-two (89%) of the children had intermediate or darker skin. Ninety-eight (94%) had been breast-fed, and 3 children (2.9%) had been fed standard infant formula [11]. Aims & Objective To estimate the prevalence, risk factors, presenting features and the previous treatment trials

• f nutritional rickets in northern Saudi Arabia.

PARTICIPANTS AND METHODS Study design and setting A cross-sectional study carried out in Children and Maternity Hospital in Arar city.

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Study period and target population This study was conducted during the period from 1 July to 30 December 2016, on all children aged 6 months – 3 years attending the pediatrics outpatient clinic and the inpatient pediatrics department of the intended hospitals. Sampling The sample size was calculated using the sample size equation: n=z2p(1-p)/e2. Systematic random sampling technique was followed. Data was collected from 400 children aged between 6 months to 3 years. Data collection Data were collected by means of personal interview with the children's mothers using pre designed questionnaire which include questions designed to fulfill the study objectives.

(1)

Socio-demographic characteristics including age, sex, nationality and arrangement between siblings

(2)

Factors associated with rickets as family history of rickets, skin color, exposure to sunlight, rickets related child feeding and supplementation …etc.

(3)

Certain manifestations that may be prevalent among those children suggested to effect nutritional rickets such as delayed teething and delayed walking, bowleg, delayed standing, abnormal gate, short stature, history of easy fracture and convulsions etc...

(4)

The questionnaire included also questions regarding the already previously diagnosed nutritional rickets, its causes and its determinants, after ensuring the diagnosis by reviewing the accompanied health records and prescriptions and asking the caregivers about the case. (4) Questions regarding the previous treatment trials of rickets and history of hospital admission due to rickets. Ethical considerations Permission to conduct the study was obtained from the Research and Ethics Committee at the College of Medicine, Northern Border University, Arar, Saudi Arabia. Data collector gave a brief introduction to the patients by explaining the aims and significance of the study to the

• mothers. Written consent was obtained from all children's mothers. Confidentiality of data

was maintained throughout the study. Statistical analysis Collected data were coded and analyzed using statistical package for the social sciences (SPSS, version 15). The X2-test was used as a test of significance, and differences were considered significant at P value 0.05 or less. RESULTS Table (1): illustrates the Socio-demographic characteristics of studied children, northern Saudi Arabia, 2016. The table showed that mean age (± SD) was 31.4 (±14.7) months, Male to female ratio was 57.8 to 42.2, Saudi to non Saudi ratio 96.8 to 3.2, the first child were 37.5%, the second child were 20.2%, the third child was 12.0% and 30.2% of the group studied children were more than the third child. The mean mother age (± SD) was 31.2 (±6.7) years, primary education constitutes 3%, 6.2% had Preparatory education, 21% had secondary education, 65% university education, 1.8% More than university and 3% were illiterate, working to non working mother ratio was 29.5 to 70.5. The mean father age (± SD) was 31.1 (±8.9) years, primary education constitutes 4%, 5.2% had Preparatory education, 32.8% had secondary education, 52% university education, 4% More than university and 2%

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were illiterate, as regard the father work 17% of them working in private sector, 39% in governmental sector, 31.8% in army forces, 4.5% they are businessman and 7.8% of them were retired. As regard consanguinity 33.2% were cousins, 22% Relatives of the same family, 16.8% Non relatives of the same family and 28% there was no relation. Table (2): illustrate the prevalence of rickets and of suspicious cases of rickets among studded children, northern Saudi Arabia, 2016. The overall prevalence of rickets among the studied children was 9%, delayed teething constitute 16%, bowleg 9%, delayed standing 13.8%, delayed walking 11%, abnormal gate 8.2%, short stature 13.8%, muscle flaccidity or weakness 11.5%, history of easy fracture 4.8%, fracture due to calcium deficiency or unknown cause 3% and convulsions in 4.5%. Table (3): illustrate the relationship between socio-demographic characteristics and rickets among studded children, northern Saudi Arabia, 2016. There is no significant effect of child sex, age, arrangement between siblings, nationality, mother's age group, mother's educational level, mother's work, father's age, father's educational level, father's work and consanguinity between parents in the occurrence of rickets (P>0.05). Table (4): illustrates the relationship between rickets and daily exposure to sunlight, rickets related child feeding and supplementations and other related characteristics among studied children, northern Saudi Arabia, 2016. There is no significant effect of skin color, exposure to sunlight, child feeding, Vitamin D supplementation, egg eating or diary milk consumption in the occurrence of rickets (P>0.05) but there is significant effect to presence of chronic diseases and family history of rickets (P<0.05). Table (5): illustrates the relationship between rickets and presence of rickets manifestations among all of the studied children, northern Saudi Arabia, 2016. There is significant relation between occurrence of rickets and delayed teething, convulsions, bowleg, delayed standing, delayed walking, muscle flaccidity or weakness, history of easy fracture, fracture due to calcium deficiency or unknown cause, short stature and abnormal gate (P<0.05). Regarding presentation of rickets delayed teething present in 36.1%, convulsions in 19.4%, bowleg in 41.7%, delayed standing 47.2%, delayed walking 30.6%, muscle flaccidity or weakness 33.3%, easy fracture 13.9%, fracture due to calcium deficiency or unknown cause 16.7%, short stature 41.7% and abnormal gate in 30.6%. Table (6): illustrate the Relationship between rickets and related characteristics and treatment trials among studied children, northern Saudi Arabia, 2016. There is significant effect of history of hospital admission due to rickets and history of treatment of rickets (P<0.05). TABLES Table (1): Socio-demographic characteristics of studied children, northern Saudi Arabia, 2016 Parameter Frequency (n=400) Percent (%) Child age group in months Less than 13 68 17.0 13 – 24 101 25.2 25 – 36 144 36.0 More than 36 87 21.8 Sex

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Male 231 57.8 Female 169 42.2 Nationality Saudi 387 96.8 Non Saudi 13 3.2 Arrangement of the child between siblings 1st 150 37.5 2nd 81 20.2 3rd 48 12.0 More than the 3rd 121 30.2 Mother age group in years Less than 25 87 21.8 25 to 34 185 46.2 35 to 44 110 27.5 More than 44 18 4.5 Mother education Primary 12 3.0 Preparatory 25 6.2 Secondary 84 21.0 University 260 65.0 More than university 7 1.8 Illiterate 12 3.0 Mother work Working 118 29.5 Not working 282 70.5 Father age group in years Less than 25 15 3.8 25 to 34 197 49.2 35 to 44 122 30.5 More than 44 66 16.5 Father education Primary 16 4.0 Preparatory 21 5.2 Secondary 131 32.8 University 208 52.0 More than university 16 4.0 Illiterate 8 2.0 Father work Private sector 68 17.0 Governmental sector 156 39.0 Army forces 127 31.8 Businessman 18 4.5 Retired 31 7.8 Consanguinity Cousins 133 33.2 Relatives of the same family 88 22.0 Non relatives of the same family 67 16.8 No relation 112 28.0

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Table (2): Prevalence of rickets and suspicious cases of rickets among studded children, northern Saudi Arabia, 2016 Parameter Frequency (n=400) Percent (%) Already diagnosed rickets Yes 36 9.0 No 364 91.0 Delayed teething Yes 64 16.0 No 336 84.0 Bowleg Yes 36 9.0 No 364 91.0 Delayed standing Yes 55 13.8 No 345 86.2 Delayed walking Yes 44 11.0 No 356 89.0 Abnormal gate Yes 33 8.2 No 367 91.8 Short stature Yes 55 13.8 No 345 86.2 Muscle flaccidity or weakness Yes 46 11.5 No 354 88.5 History of easy fracture Yes 19 4.8 No 381 95.2 Fracture due to calcium deficiency or unknown cause Yes 12 3.0 No 388 97.0 Convulsions Yes 18 4.5 No 382 95.5 Table (3): The relationship between socio-demographic characteristics and rickets among studded children, northern Saudi Arabia, 2016 Parameter Rickets Total (n=400) Chi- Square P value Yes (n=36) No (n=364)

• No. (%)
• No. (%)

No.(%) Sex Male 25 206 231 2.217 0.093 69.4% 56.6% 57.8% Female 11 158 169 30.6% 43.4% 42.2%

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Child age group in months Less than 13 5 63 68 0.965 0.810 13.9% 17.3% 17.0% 13 – 24 9 92 101 25.0% 25.3% 25.2% 25 – 36 12 132 144 33.3% 36.3% 36.0% More than 36 10 77 87 27.8% 21.2% 21.8% Arrangement of the child between siblings 1st 10 140 150 4.819 0.186 27.8% 38.5% 37.5% 2nd 12 69 81 33.3% 19.0% 20.2% 3rd 5 43 48 13.9% 11.8% 12.0% More than the 3rd 9 112 121 25.0% 30.8% 30.2% Nationality Saudi 35 352 387 0.028 0.670 97.2% 96.7% 96.8% Non Saudi 1 12 13 2.8% 3.3% 3.2% Mother age group in years Less than 25 8 79 87 1.400 0.706 22.2% 21.7% 21.8% 25 – 34 19 166 185 52.8% 45.6% 46.2% 35 – 44 7 103 110 19.4% 28.3% 27.5% More than 44 2 16 18 5.6% 4.4% 4.5% Mother educational level Primary 1 11 12 5.023 0.413 2.8% 3.0% 3.0% Preparatory 3 22 25 8.3% 6.0% 6.2% Secondary 8 76 84 22.2% 20.9% 21.0% University 21 239 260 58.3% 65.7% 65.0% More than university 7 7 .0% 1.9% 1.8% Illiterate 3 9 12 8.3% 2.5% 3.0% Mother work Working 10 108 118 0.056 0.490 27.8% 29.7% 29.5%

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Not working 26 256 282 72.2% 70.3% 70.5% Father age group in years Less than 25 2 13 15 0.837 0.841 5.6% 3.6% 3.8% 25 – 34 19 178 197 52.8% 48.9% 49.2% 35 – 44 9 113 122 25.0% 31.0% 30.5% More than 44 6 60 66 16.7% 16.5% 16.5% Father educational level Primary 16 16 4.364 0.498 .0% 4.4% 4.0% Preparatory 2 19 21 5.6% 5.2% 5.2% Secondary 12 119 131 33.3% 32.7% 32.8% University 18 190 208 50.0% 52.2% 52.0% More than university 2 14 16 5.6% 3.8% 4.0% Illiterate 2 6 8 5.6% 1.6% 2.0% Father work Private sector 6 62 68 5.377 0.251 16.7% 17.0% 17.0% Governmental sector 10 146 156 27.8% 40.1% 39.0% Army forces 13 114 127 36.1% 31.3% 31.8% Businessman 4 14 18 11.1% 3.8% 4.5% Retired 3 28 31 8.3% 7.7% 7.8% Consanguinity Cousins 9 124 133 2.603 0.457 25.0% 34.1% 33.2% relatives of the same family 7 81 88 19.4% 22.3% 22.0% non relatives of the same family 6 61 67 16.7% 16.8% 16.8% no relation 14 98 112 38.9% 26.9% 28.0%

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Table (4): relationship between rickets and daily exposure to sunlight, rickets related child feeding and supplementations and other related characteristics among studded children, northern Saudi Arabia, 2016 Parameter Rickets Total (n=400) Chi-Square P value Yes (n=36) No (n=364)

• No. (%)
• No. (%)

No.(%) Exposure to sunlight Yes 8 93 101 0.192 0.417 22.2% 25.5% 25.2% No 28 271 299 77.8% 74.5% 74.8% Child feeding Natural 8(22.2) 61 69 2.128 0.345 22.2% 16.8% 17.2% Artificial 11 156 167 30.6% 42.9% 41.8% Both 17 147 164 47.2% 40.4% 41.0% Vitamin D supplementation Yes 18 150 168 1.039 0.199 50.0% 41.2% 42.0% No 18 214 232 50.0% 58.8% 58.0% Egg eating Yes 24 242 266 0.00 0.571 66.7% 66.5% 66.5% No 12 122 134 33.3% 33.5% 33.5% Diary milk Yes 31 329 360 0.665 0.284 86.1% 90.4% 90.0% No 5 35 40 13.9% 9.6% 10.0% Presence of chronic diseases Yes 5 16 21 5.935 0.031 13.9% 4.4% 5.2% No 31 348 379 86.1% 95.6% 94.8% Family history of rickets Yes 6 10 16 16.529 0.001 16.7% 2.7% 4.0% No 30 354 384 83.3% 97.3% 96.0% Skin color Faint 26 266 26 .053 .974 72.2% 73.1% 72.2% Not faint 9 90 9 25.0% 24.7% 25.0%

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Dark 1 8 1 2.8% 2.2% 2.8% Table (5) : Relationship between presence of rickets and presence of rickets manifestations among studied children, northern Saudi Arabia, 2016 Parameter Rickets Total (n=400) Chi-Square P value Yes (n=36) No (n=364)

• No. (%)
• No. (%)

No.(%) Delayed teething Yes 13 51 64 11.905 0.002 36.1% 14.0% 16.0% No 23 313 336 63.9% 86.0% 84.0% Convulsions Yes 7 11 18 20.559 0.00 19.4% 3.0% 4.5% No 29 353 382 80.6% 97.0% 95.5% Bowleg Yes 15 21 36 51.545 0.00 41.7% 5.8% 9.0% No 21 343 364 58.3% 94.2% 91.0% Delayed standing Yes 17 38 55 37.374 0.00 47.2% 10.4% 13.8% No 19 326 345 52.8% 89.6% 86.2% Delayed walking Yes 11 33 44 15.453 .001 30.6% 9.1% 11.0% No 25 331 356 69.4% 90.9% 89.0% Muscle flaccidity or weakness Yes 12 34 46 18.529 0.00 33.3% 9.3% 11.5% No 24 330 354 66.7% 90.7% 88.5% History of easy fracture Yes 5 14 19 7.303 0.020 13.9% 3.8% 4.8% No 31 350 381 86.1% 96.2% 95.2% Fracture due to calcium deficiency or unknown cause Yes 6 6 12 25.392 0.00 16.7% 1.6% 3.0% No 30 358 388

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83.3% 98.4% 97.0% Short stature Yes 15 40 55 25.997 0.00 41.7% 11.0% 13.8% No 21 324 345 58.3% 89.0% 86.2% Abnormal gate Yes 11 22 33 26.003 0.00 30.6% 6.0% 8.2% No 25 342 367 69.4% 94.0% 91.8% Table (6): Relationship between rickets and treatment trials among studded children, northern Saudi Arabia, 2016 Parameter Rickets Total (n=400) Chi-Square P value Yes (n=36) No (n=364)

• No. (%)
• No. (%)

No (%) History of hospital admission due to rickets Yes 7 7 72.038 0.00 19.4% .0% 1.8% No 29 364 393 80.6% 100.0% 98.2% History of treatment of rickets Yes 21 21 2.241E2 0.00 58.3% .0% 5.2% No 15 364 379 41.7% 100.0% 94.8% DISCUSSION Nutritional Rickets is a common disease among our children and numbers of individuals suffering from it arising every year. It's distinct from other types of rickets in that it's caused by a simple deficiency in vitamins and nutrition and thus can be easily corrected if detected early [25]. This is a cross-sectional study carried out on children in Arar city by personal interview with the child and his/her mother using pre designed questionnaire to estimate the prevalence of those affected in northern Saudi Arabia, to show the risk factors associated with this disease, to show the presenting features of the cases and to show the previous treatment trials in northern Saudi Arabia. Our study found that 36% of the cases aged between 25 – 36 months. These results didn't agree with Holick MF. Study [1] that showed rickets was mostly observed before 18 months

• f age, with maximum frequency between the ages of 4 and 12 months. In Maria C. study

[26] the results said the mean age of presentation was 20 months. Another study was carried

• ut in Riyadh [27] showed that 54% of children aged between (6-9) months and the rest aged

(10-14) months. The total prevalence of rickets disease among diagnosed children in this study was 9%. Prevalence of nutritional rickets in developed countries appears to be rising [28, 29, 30, 31,

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32, 33]. A study in Qatar [29] showed that 23.9% of the studied children were found to have

• NR. The incidence of rickets associated with VDD in infants aged 0−3 years was found to be

6% in a study in Turkey [34]. Low stature in the family, alopecia, dental deformities,

• rthopedic abnormalities, and consanguineous marriage should be investigated for

differential diagnosis. This study showed muscle weakness 11.5%, delayed teething 16%, bowleg 9%, delayed standing 13.8%, abnormal gates 8.2% and convulsions 4.5%. While

• ther study in Kuwait [35] came out with other percentages of manifestations like delayed

milestones 39.8%, skeletal deformities 80.6%, pallor 67%, racketic rosary 81.7% and open fontanel 72.8%. In a study in Al-Madinah, Saudi Arabia [17] it was found that the presenting features of the 136 cases of rickets seen were, diarrhea and vomiting or cough and fever in 48, convulsions in 11 infants (8.1% of the total and 33.3% of those aged less than 1 year), bow legs in 78, delayed dentition in 33, delayed standing in 38, hypotonia in 25, abnormal gait in 54 and sweating in 33. Many factors can influence Vit D level. According to many studies factors were; lack of exposure to sunlight, prolonged breast feeding without supplementation and inadequate weaning practices are important. Maternal education is important as it can influence all of the above factors. 65% of mothers in this study were highly educated (University) while only 3% were illiterate. This study found no relationship between rickets and exposure to sunlight (with a P value = 0.417). Other study in Saudi Arabia [36] showed that lack of exposure to sunlight was recorded in 90% of children with rickets and in 37% of the controls. Twelve studies provided information on sunlight exposure, but they varied greatly in how they reported exposure [37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48]. Breast milk is indisputably the ideal food for infants; however, breast milk typically contains insufficient amount of vitamin D for rickets prevention. Babies who drink an adequate amount of infant formula to achieve normal growth typically receive sufficient vitamin D to prevent rickets. However; there was no significant effect of child feeding on NR in our study (P value = 0.345). Other study in Saudi got (70%) was exclusively on breast-feeding (127 males, 69 females) with no

• supplementation. In 79 infants (23%) the breast-feeding extended until the end of their first

year [27]. While DeLucia MC study [26] concluded that over 96% (32 of 33) of children with a history of breastfeeding had been breastfed for more than 6 months. In conclusion, this study revealed that nutritional rickets is highly prevalent among children in Saudi Arabia. However, several factors seem to make important contributions. Appropriate preventive measures should include strategies such as health education, stressing the importance of exposure to sunlight, good quality weaning food and the right starting age for

• weaning. Mothers should be supplemented during pregnancy through food containing with

vitamin D and infants may be supplemented after birth.

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