History of Rickets?• Roman descriptions of individuals with rickets found as early as the second century• Documented in the 1640s as a common bone ailment across England.• Scientifically proven cause of rickets was not identified until the 1920s• In the 1930s, public-health initiatives recommend fortifying milk with vitamin D and cod-liver oil as a nutritional supplement for young infants and children.• This led to near eradication of rickets in the United States and other industrialized nations.• Unfortunately, rickets has made a comeback and is still common in less-developed nations.
What causes Rickets?• Decreased calcium absorption from the intestine and abnormalities in formation of skeletal bones.• Genetic disorders affecting vitamin D absorption can also cause rickets.• Not consuming enough milk and dairy products, which are high in vitamin D and calcium• Less common causes of rickets are liver and kidney diseases and cancer.• Darker skinned children require more sunlight to make vitamin D and are more at risk if sunlight exposure is limited• Exclusively breastfed infants• Infants who are born to mothers who are vitamin D deficient.• Older children who are kept out of direct sunlight• Vegan Diets
Types of Rickets• Nutritional Rickets (Osteomalacia): Vitamin D is a fat-soluble vitamin that is essential for the normal formation of bones and teeth and necessary for the appropriate absorption of calcium and phosphorus from the bowels.• Hypophosphatemic Rickets: Caused by low levels of phosphate. The bones become painfully soft and pliable. This is caused by a genetic dominant X-linked defect in the ability for the kidneys to control the amount of phosphate excreted in the urine.• .• Renal (kidney) Rickets: Caused by a number of kidney disorders. Individuals suffering from kidney disease often have decreased ability to regulate the amounts of electrolytes lost in the urine.
Signs & Symptoms• Bone pain or tenderness• dental problems: Delayed teeth formation, deformatiies• muscle weakness : Floppy baby syndrome" or "slinky baby"• increased tendency for fractures (easily broken bones), especially greenstick fractures• Impaired Growth: Short Statue• Enlargement of the liver and spleen
Signs & Symptoms (Cont)• Skeletal deformity – Toddlers: Bowed legs (genu varum) : Bowing of the femurs – Ribcage abnormalities : Costochondral swelling , Rib Flaring: rachitic rosary – Thorax Deformity (Harrison’s Groove): a horizontal groove along the lower border of the thorax – Pelivic and spinal deformities – Older children: Knock-knees (genu valgum) or "windswept knees" – Cranial: Soft skull, square head appearance. – Hypocalcemia (low level of calcium in the blood) – Osteopenia : Bones which are not dense, a sign of decreased mineralization – Multiple fractures in different healing stages – Tetany: Uncontrolled muscle spasms all over the body – Ankle: Double malleoli sign due to metaphyseal hyperplasia – Wrist widening . due to cartilage hyperplasia. – Curve Back and disfiguration of long bones
How Diagnosed!• Complete medical and nutritional history• Complete physical exam by a health professional• X-rays of long bones (radius, ulna, and femur) and ribs are obtained.• Vitamin D levels, alkaline phosphatase, parathyroid hormone , calcium level• Electrolytes, including indirect measurements of kidney function (BUN and creatinine)
Treatment for Rickets• Correcting any abnormal levels with supplemental calcium or phosphate• Initiation of vitamin D supplementation (calcitriol) . Vitamin D3 (cholecalciferol) is the preferred form since it is more readily absorbed than vitamin D2.• Diet rich in calcium. This is especially important for children on vegan diets. Recommendations are for 400 international units (IU) of vitamin D a day for infants and children• Exposure to ultraviolet B light (sunshine when the sun is highest in the sky). Darker-skinned babies need to be exposed longer to the ultraviolet rays
Vitamin D Food Sources• The richest food in vitamin D is salmon – particularly wild-caught; mackerel and mushrooms exposed to UV light.• Halibut, Saltwater Fish:salmon, sardines, herring and fish-liver oils.• Cod liver oil, sardines canned in oil, tuna canned in water, beef or calf liver, cheese, egg yolks and milk or yogurt fortified with vitamin D.• Most milk in the United States is fortified with vitamin D, just as numerous brands of margarine, yogurt, orange juice and breakfast cereals.
Vitamin D Foods Serving Cals Amount DV Nutrient Foods Size (IU) (%) Density RatingSalmon, chinook, 4 oz-wt 261.9 411.00 102.8 7.1 excellentbaked/broiledShrimp, 4 oz-wt 112.3 162.39 40.6 6.5 very goodsteamed/boiledSardines 3.25 oz 191.4 250.24 62.6 5.9 very goodCow’s milk, 2% 1 cup 121.2 97.60 24.4 3.6 very goodCod, 4 oz-wt 119.1 63.50 15.9 2.4 goodbaked/broiledEgg, whole, 1 each 68.2 22.88 5.7 1.5 goodboiled
Prognosis for Rickets!• Outcomes for children with nutritional rickets are excellent, especially if diagnosed early.• Supplementation with calcium and vitamin D will lead to healing of the bony defects within days to months.• Severe bowing, seen in longer-standing cases of rickets may also resolve over a number years without requiring surgical intervention.• Patients with very advanced disease, however, the bony changes may be permanent