Consequences of a non-supplemented pediatric vegan diet: Nephrolithiasis & nutritional calcipenic rickets

Abstract

Rickets and other nutritional deficiencies have largely been eradicated in the industrialized world. However, strict adherence to modern diet trends such as veganism may leave individuals vulnerable to nutritional deficiencies if proper supplementation is not followed. The effects of such deficiencies due to diet trends, particularly in children, is not well documented as occurrences are rare. Here we present a case of a 3-year-old female fed a strict vegan diet which led to the development of nutritional calcipenic rickets, failure to thrive, and nephrolithiasis.

Highlights

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Rickets is exceedingly rare in the United States.
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This case demonstrates consequences of un-supplemented pediatric vegan diet.
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Diet resulted in nutritional calcipenic rickets and failure to thrive.
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Additional finding of nephrolithiasis likely due to dietary complications.

1 Introduction

Rickets is a metabolic disorder of childhood characterized by impaired bone mineralization and disrupted microarchitecture at the growth plate. It is most often caused by severe vitamin D deficiency causing nutritional calcipenic rickets, although there are other metabolic and genetic causes. Through the fortification of food with vitamin D, rickets has been largely eradicated in the modern world. However, in areas with poor food access, nutritional deficiencies leading to nutritional rickets, such as diets low in calcium or vitamin D, still occur. Plant-based foods in particular are low in calcium, vitamin D, and vitamin B12. Accordingly, vegetarian and vegan diets have also been associated with vitamin D deficiency. While vegetarian and vegan diets are not homogeneous, they tend to exclude all meat and fish, with the added exclusion of animal products, including dairy, for vegans. Ready access to dietary supplements should preclude vitamin deficiencies, especially those severe enough to cause rickets, in those following plant-based diets in the United States (US). Yet, strict adherence, lack of proper supplementation, and lack of medical care can lead to severe nutritional deficiencies. Such a diet is uncommon, and it is therefore rare to see a case of nutritional rickets in the US. Here we present a case of a 3-year-female fed a non-supplemented vegan diet who presented with nutritional calcipenic rickets and failure to thrive complicated by nephrolithiasis.

2 Case presentation

A 3-year-old female presented to an outside hospital for a possible seizure and was found to be febrile with acute hypoxic hypercapnic respiratory failure. She was subsequently intubated and transferred to our hospital. Her medical history included a full-term birth with no NICU stay. She had received no vaccinations and was not previously seen by any pediatrician. Her family followed a strict vegan diet. While she was within normal millstones with crawling at 1 year, she did not start walking until 2 years of age and was not yet running at 3 years. She only had an estimated 200 words per family reporting. Initial laboratory findings were notable for low vitamin D (<7 ng/ml), calcium (5.4 mg/dl), and phosphorus (3.9 mg/dl), and high PTH (1050.9 pg/ml), alkaline phosphatase (2404 U/L), and WBC (15.2 thous/mm ³ ) with a neutrophil predominance. She also had deficiencies in vitamin B12 and iron. Bone imaging revealed a clavicular fracture and findings consistent with rickets including diffuse osteopenia, metaphyseal cupping, poor mineralization of epiphyseal center, and age-inappropriate mineralization ( Fig. 1 ). Her findings and history were consistent with failure to thrive and calcipenic rickets. Renal ultrasound demonstrated grade 1 hydronephrosis and a 7 mm stone in the right urinary collecting system ( Fig. 2 ). On hospital day 2, her urinalysis was notable for turbidity, brown color, blood, protein (200), and RBCs (TNTC). By hospital day 3, the stone had progressed to the ureterovesical junction (UVJ) and hydronephrosis was grade 2 ( Fig. 2 ). The stone was spontaneously passed by hospital day 5, though not collected, with resulting resolution of hydronephrosis. No evidence of UTI or AKI developed during progression or resolution of her nephrolithiasis.