Preventable but neglected: rickets in an informal settlement Nairobi, Kenya

Nutritional rickets is a disease whose aetiology is related to a lack of vitamin D, calcium and sunlight exposure. Globally, it is one of the most common non-communicable diseases afflicting children, particularly in certain populations in developing countries.1,2 Left untreated, rickets can have chronic sequelae, including developmental delays, skeletal abnormalities and painful pathological fractures.3 Despite this burden and previous recommendations from many industrialised countries, there are no public health initiatives to address rickets prevention in resource-limited countries.4,5 Known risk factors for rickets include prolonged breastfeeding, early supplemental feeding with low vitamin D and calcium-rich foods, reduced sunlight exposure, overcrowded living situations, sex, dark skin pigmentation and air pollution.6 However, a review of rickets literature reveals a paucity of reports from sub-Saharan Africa; existing reports have mainly focused on cases seen in tertiary care settings.7–11 While populations in informal settlements in Africa are at increased risk of rickets, we are not aware of any publications from a primary care setting within an informal settlement in Africa. Medecins Sans Frontieres (MSF) operates the only large-scale primary care programme for the informal settlement of Kibera in Nairobi, Kenya, which has an estimated population of 200 000.12 In 2011–2012, the programme noted an increasing number of cases of rickets among children. While recommended for all high-risk children, and usually routine practice in industrialised countries, vitamin D supplementation was not provided by MSF or the Kenyan Ministry of Health.13 The purpose of this study was to describe 1) the demographic, social and clinical characteristics of children presenting with rickets at the MSF clinic, 2) treatment outcomes, and 3) challenges with loss to follow-up in Kibera, Nairobi, Kenya.