Characteristics of Pediatric Scurvy Hospitalizations: 2006–2021

Scurvy is an uncommon disease in children caused by nutritional deficiency of Vitamin C. It can present with a variety of complaints, including joint swelling and tenderness, refusal to bear weight, rash, petechiae, bleeding, fever, and irritability,1,2 that may mimic more serious diagnoses and lead to unnecessary, costly, and potentially harmful testing. Since 2000, an increasing number of reports suggest the incidence of pediatric scurvy is rising.3–5 However, to date there has been no systematic investigation of pediatric scurvy hospitalizations across the United States. Our study aims to describe trends in pediatric scurvy hospitalizations using a large national dataset.We used the Pediatric Health Information System (PHIS) database to conduct a multicenter retrospective repeated cross-sectional study of children hospitalized with scurvy from 2006 to 2021. We restricted analyses to hospitals that submitted data to PHIS over the entire study interval. We included patients admitted to inpatient or observation units with a primary diagnosis of scurvy, ascorbic acid deficiency, or Vitamin C deficiency as classified by International Classification of Diseases, 9th and 10th revision codes. We excluded patients admitted for other primary diagnoses that affect nutrition, like cancer or short bowel syndrome, as well as emergency department and clinic encounters. We extracted data on patient demographics, diagnoses, testing, procedures, and costs. Patient demographics and clinical variables were summarized using percentages for binary measures and median (interquartile range [IQR]) for continuous variables. We calculated the frequency of hospitalizations for scurvy as primary diagnosis per 100 000 hospitalizations by calendar year and assessed trends over time using a Mann-Kendall trend test. R statistical software (version 4.1.2) was used for analysis. The CHOP Institutional Review Board deemed this nonhuman subjects research.Of the 43 hospitals with admissions for a primary scurvy diagnosis between 2006 and 2021, 33 submitted data over the entire study period and 138 unique patients were identified. Scurvy hospitalizations increased significantly over time, with marked increases after 2017 (Fig 1). Common comorbid diagnoses included autism (60%), other neurodevelopmental disorders (19%), and iron deficiency (43%). Males (78%) were more commonly affected than females (22%). Patients underwent imaging and procedures as shown in Table 1. Median length of stay was 5 days and median cost of admission was $17 082. A posthoc comparison of children admitted before and after 2017 revealed few statistically significant differences (Supplemental Table 2).Hospitalizations for pediatric scurvy increased over the last 15 years and incurred high cost and diagnostic testing burden. This rise is likely multifactorial; possible factors include decreased juice intake and increase in disordered eating.6 A review of the National Health and Nutrition Examination Survey from 1999 to 2018 showed Americans’ Vitamin C intake decreased 22.6%, with the largest drops in intake of 100% fruit juice and fruit drinks.7 In 2017, the American Academy of Pediatrics updated their recommendations to further limit juice intake.8 Notably, a sustained rise in scurvy hospitalizations occurred around this time. As caregivers appropriately restricted juice, vitamin C may not have been replaced by other sources, especially in children with already selective diets.This study redemonstrates several characteristics seen in previous research of patients with scurvy. Literature has shown selective eating is common in children with autism and other neurodevelopmental disorders.9 Iron deficiency was another common comorbidity, which may be related to overall poor nutrition or iron’s role as a cofactor in Vitamin C absorption. Male predominance was also notable. This finding may be related to autism epidemiology,10 but in post hoc analysis, males predominated in children both with and without autism or neurodevelopmental disorders (Supplemental Table 3). Identification of neurodevelopmental disorders, however, relies on accurate documentation and coding practices, which vary across hospitals.Our study has several limitations. By limiting our patient sample to those with a primary scurvy diagnosis, we likely underestimate the total number of scurvy admissions. PHIS does not include laboratory or imaging results and is composed of data from tertiary academic pediatric hospitals, which are not representative of the overall pediatric population. Data collected during 2020 and 2021 must be considered in the setting of the Covid-19 pandemic, the effects of which are unclear.The observed trend may reflect an increased incidence in the broader US pediatric population or a shift away from early outpatient diagnosis and treatment. Further research should investigate the incidence and demographics of patients with scurvy, and trends in diagnosis and treatment, in more population-based datasets.