Rickets

1. Prepared by the assistant
of the Department of
Propedeutics of Childhood
Diseases Smagulova A.E.

2. Rickets- is a group of diseases of the child’s body associated
with insufficient intake of vitamin D or a disruption of its
metabolic processes, leading to a disruption of many types of
metabolism, primarily calcium phosphorus, which causes
damage to many organs and systems, but mainly the skeleton.
(Maidannik V.G., 2014)

3. Vitamin D
Helps the body control
calcium and phosphorus levels;
stimulates the absorption of calcium in
intestines;
contributes to raising the level
serum calcium and phosphorus
blood and mineral deposits
bone component;
stimulates bone deposits
mineral;
affects bone resorption
increases phosphate reabsorption
kidneys and reduces their excretion with
urine

5. Aaetiology
Exogenous causes Endogenous causes
 Lack of intake of Vit D with food (yolk,
oil, liver);
 Lack of intake of phosphates, calcium;
 Inadequate sun exposure;
 Impaired absorption in the intestines (diarrhea,
malabsorption);
 Violation of the processes of turning Vit D into an
active form (liver, kidney, genetic pathology);
 Violation of the functional activity of receptors for vit
D (genetic pathology);
 Fast growth, increased needs
 Use of drugs (antacids, anticonvulsants, loop diuretics,
glucocorticoids)

8. Clinical classification
•
Severity Course Period
• I mild
• II medium
• III severe
• Acute
• Subacute
• Recurrent
• Initial
manifestations
• height of the
disease
• Reconvalescence
• Residual changes

9. Diagnostic criteria
1. Complaints: anxiety, timidity, irritability, hyperesthesia, decreased
appetite, sleep disturbance, trembling when falling asleep, loud
sound, flash of light; excessive sweating, the child rubs his head on a
pillow, baldness of the head; deformation of the bones of the head,
chest, spine, limbs; lag in physical development, delayed teething
2. Anamnesis: the disease is detected from 3-4 months of age,
although the first symptoms may appear in 1 - 1.5 months.
Identification of risk factors

10. • Symptoms of osteomalacia (softening, calcium depletion of bone - prevail
in acute rickets) - compliance of the bones of the skull, the edges of the
fontanel, craniotabes, brachycephaly, deformation of the bones of the skull,
limbs, clavicles, flat pelvis, erosion and tooth decay.
craniotabes deformity of the limbs

11. erosion and tooth decay

12. • Symptoms of osteoid hyperplasia (prevail in the subacute course of
rickets) - frontal and parietal tubercles, costal “rosary”, supracondylar
thickening of the legs, “bracelets” on the forearms, “pearls” on the fingers.
"Olympic" forehead

13. • Symptoms of bone tissue hypoplasia - growth retardation with a characteristic
"short-legged", late eruption of milk and permanent teeth, late closure of the
fontanel.

14. • Symptoms of muscular hypotension - curvature of the spine with lumbar
kyphosis, scoliosis, chest deformity with a developed lower aperture, weakness
and sagging muscles, loose joints, "frog" abdomen.

15. • Delay of static and locomotor functions.

16. The severity of the process distinguishes:
1 - mild - corresponds to the initial period of rickets.
Minor disturbances in the general condition: nervous excitability,
anxiety, trembling with a sharp sound, a flash of light, sleep rhythm
disturbances, a superficial "disturbing" sleep.
Sweating (sticky sweat with a sour smell), itchy skin, the child rubs
the back of the head on the pillow, which leads to baldness of the back
of the head.
 From the skeletal system: softening the edges of the large fontanel.
 Laboratory confirmation of rickets of the I degree is a slight
hypophosphatemia and an increase in the activity of alkaline
phosphatase in the blood.

17. II - moderate severity - moderate changes in the skeletal system and
internal organs, distinct deformations of the skull, chest, slight enlargement
of the liver and spleen, moderate anemia;
X-ray marked expansion of metaphyses of tubular bones, their cup-shaped
deformation.
With a biochemical blood test - a decrease in phosphates and calcium, an
increase in the activity of alkaline phosphatase in the blood.

18. III - severe - damage to several parts of the skeletal system, severe
damage to the internal organs and nervous system, lag in physical and
mental development, deformation of the lower extremities - O-shaped
(genuvarum), X-shaped (genuvalgum) and others (coxavara,
genurecurvatum). Spinal curvature in the form of scoliosis, lordosis,
lumbar kyphosis.
During X-ray examination, a rough restructuring of the pattern and
bone rarefaction, expansion and blurring of the metaphysis zone are
noted, fractures without displacement are possible (like the "green
branch").
A pronounced decrease in the level of phosphates and calcium is
determined in the blood.

19. • The initial period most clearly begins to appear at the age of
3-4 months, however, the first symptoms may occur earlier -
at 1-1.5 months, but they are not specific and can often pass
by the attention of parents. Neurological and autonomic
changes come first.
Neurological changes Vegetative changes
The child shows anxiety, moodiness, sleep
disturbance - children fall asleep badly and
often wake up, shyness, irritability appears,
children often startle from a loud sound or
bright light. Noticeably declining
appetite - a child with reluctance and for a
short time takes a breast, sluggishly sucks -
sometimes there are constipation.
In addition, such vegetative manifestations
as sweating, especially in a dream, and an
increase in the vascular excitability of the
skin, which manifests itself in the form of
an increase in the intensity and duration of
red dermographism, are noteworthy. Most
intensively, causing severe itching in the
child, the scalp sweats, with which the
child constantly rubs against the pillow,
this leads to a nape of the neck that is
specific for rickets.
Bone changes in the initial period of rickets are not characteristic, however, sometimes the pliability of
the edges of the large fontanel can be detected. The initial period of the disease lasts, as a rule, from 2 to
4 weeks.

20. initial period

21. • During the height of the disease, changes in the skeletal system progress:
osteomalacia of the chest, lower extremities, excessive osteogenesis (rickets
bracelets, frontal and parietal tubercles of the skull). The child may lag behind in
physical and mental development
• With severe rickets, the functional state of the liver, gastrointestinal tract, protein, lipid metabolism are violated, there
is a deficiency of vitamins B1, B6, B5, A, E, C, copper, zinc, magnesium.
• Most children with rickets of 1 and 2 degrees are observed phenomena of hypochromic anemia.

22. • During the period of
convalescence (recovery), the
clinical and laboratory
symptoms of rickets
gradually disappear. Skeletal
deformities that arose during
rickets remain in adulthood:
impaired posture, changes in
the chest, bones of the lower
extremities. The transferred
rickets can contribute to tooth
damage (the development of
multiple caries), the
development of myopia, flat
feet, narrowing, deformation
of the pelvic bones.

23. • The acute course is the rapid development of all symptoms, vivid
neurological and autonomic disorders, significant
hypophosphatemia, high levels of alkaline phosphatase, the
predominance of osteomalacia.
• Subacute course – moderately expressed or subtle neurological
and autonomic disorders, the prevalence of osteoid hyperplasia are
characteristic.
• Recurrent course - typical changes in periods of exacerbation and
subsidence of the process with persisting residual effects. When x-
raying growth zones, several calcification bands are found in
metaphyses.

24. Diagnostic studies:
Basic (mandatory) diagnostic examinations Additional diagnostic examinations
 General blood analysis
 General urine analysis;
 determination of the level of calcium
and phosphorus in the blood ;
 serum alkaline phosphatase activity;
 test according to Sulkovich (qualitative
determination of the degree of
calciuria).
 Serum 25 (OH) D concentration (the
main test for determining the level of
vitamin D deficiency).
 X-ray of bones (with pronounced bone
changes for differential diagnosis).
 Densitometry (for differential diagnosis -
the degree of determination of
osteoporosis).

25. • Laboratory examination:
The concentration of phosphorus in the blood serum can be reduced to 0.65-0.8
mmol / L (with a norm in children under 1 year old 1.5-1.8 mmol / L).
The concentration of calcium is up to 2.0-2.2 mmol / l (with a norm of 2.2-2.7
mmol / l).
The concentration of ionized calcium is less than
1.0 mmol l.
An increase in the activity of alkaline phosphatase in blood serum by a factor of
1.5-2 (absolute values of the norm depend on the method for its determination).
A decrease in 25-OH-D in the blood (normally 20 ng / ml), a decrease to 10 ng /
ml indicates a vitamin D deficiency, and a content below 5 ng / ml indicates
vitamin deficiency (II B).

26. • Increase in the activity of alkaline phosphatase in the blood
serum by 1.5-2 times (the absolute indicators of the norm
depend on the method of its determination).
• A decrease in 25-OH-D in the blood (normally 20 ng / ml), a
decrease to 10 ng / ml indicates a vitamin D deficiency, and a
content below 5 ng / ml indicates avitaminosis (II B).
• Increased excretion of amino acids (aminoaciduria - above 10
mg / kg per day) is an early sign of rickets.
• Hyperphosphaturia and increased clearance of urine phosphates
(normally 0.1-0.25 ml / sec, with rickets up to 0.5-1.0 ml / sec).
• Increase in serum osteocalcin content up to 90-170 ng / ml.

27. Instrumental examination:
X-ray of bones.
On the roentgenogram of bones in places of the most intensive growth, especially
enchondral ossification, osteoporosis is revealed and intensified; the calcification zone
becomes not convex, but more horizontal, gradually smoothes out, becomes uneven,
fringed; the gap between the pineal gland and the diaphysis increases due to the expanding
metaphysis; the pineal gland becomes saucer-shaped.
Ossification points of small bones are detected in a timely manner, but on the
roentgenogram they are less clearly detected.
Subperiosteal fractures of the green twig type are often detected.
In severe rickets, Loozero zones are observed - transversely located transparent zones
(stripes) several millimeters wide. In the initial period - minor osteoporosis.

28. Classical X-ray triad of rickets
A decrease in calcification leads to a thickening of the growth zones:
1. The “fringe” of the ends of metaphyses
2. “Goblet / saucer like” distal sections of the radial, ulnar, fibula
3. Expansion of the distal divisions and metaphyses

29. Treatment tactics
1. Non-drug treatment:
diet therapy:
 In the organization of nutrition in the treatment of rickets, a balanced diet is recommended for the content of
proteins, fats and carbohydrates, the predominance of foods rich in vitamins and minerals, in particular
calcium, phosphorus, magnesium, etc.
 It is necessary to limit cereals and flour products in the diet, to introduce vegetable and fruit juices, mashed
potatoes in a timely manner. Hard-boiled yolk rich in fat-soluble vitamins and B vitamins, as well as
phosphorus, calcium, microelements should be added to vegetable mashed potatoes. D in breast-milk
substitutes - adapted milk formulations. The need for calcium for a healthy baby in the first 6-12 months is
500-600 mg per day.
 massage, baths, outdoor activities:
 For rickets during the period of reparation and with pronounced residual phenomena, salt, coniferous, salt-
coniferous baths, sand, sea and sun baths are useful. Salt baths are indicated for pasty children, conifers - for
children with reduced nutrition. General massage and gymnastics are mandatory Prescribing massage before
prescribing drug therapy can have a negative effect (P.V. Novikov, 2011).
The therapeutic effect in rickets is achieved only when vitamin D-therapy is combined with the rationalization
of feeding the child, a balanced intake of calcium and phosphorus salts, normalization of sleep and wakefulness,
and prolonged stay

30. Drug treatment:
For treatment, vitamin D preparations are used
in the form of an aqueous and oily solution.
Prescribe an aqueous solution of vitamin D3
(in one drop of 500 IU) and Ergocalciferol (in
one drop of 625, 1250 IU) in a dose of 2000-
5000 IU in courses of 30-45 days.
In the absence of the possibility of determining
the level of 25 (OH) D, the selection of
therapeutic doses of vitamin D is carried out in
accordance with the peculiarities of the clinical
picture of rickets, the degree of its severity and
the dynamics of the disease. Doses and duration
of rickets therapy are variable and depend on
many factors, including the individual
characteristics of the organism.

31. It is recommended to start treatment with a dose of 2000 IU with its gradual increase
to an individual therapeutic dose under the control of the Sulkovich test (carried out
before treatment, and then every 7-10 days during the treatment). With a sharply
positive test result, vitamin D is canceled.
Depending on the severity of the disease, the daily dose of vitamin D:
with I degree of rickets - 1000-1500 IU for 30 days
with II degree - 2000-2500 IU for 30 days
at the III degree - 3000-4000 IU for 45 days
After achieving the clinical effect (manifested by the normalization of muscle tone,
the disappearance of craniotabes and autonomic disorders, the lack of progression of
bone deformities, the onset of teething) and the normalization of laboratory
parameters (alkaline phosphatase, calcium, phosphorus in the blood), they switch to
a prophylactic dose of vitamin D (400-500 IU ), which the child receives daily
during the first 2 years of life and in the winter in the 3rd year.

32. When using therapeutic doses of vitamin D, it is
necessary to constantly monitor the child's condition,
since there is a wide range of individual sensitivity to
vitamin D. Signs of hypervitaminosis D are vomiting,
abdominal pain, thirst, and hypercalciuria. For the
timely detection of hypercalcemia, a Sulkovich test is
carried out (a qualitative reaction that determines the
excretion of calcium in the urine) once a week, the
calcium content in the blood plasma is assessed - once a
month. (II B)

33. Preventive actions
Antenatal prophylaxis of rickets:
It is necessary to observe the regimen of the day of a pregnant woman,
including a sufficiently long sleep day and night.
Walking in the fresh air is recommended for at least 2-4 hours daily, in any
weather.
It is extremely important to organize a rational diet for the pregnant woman
(daily use at least 180 g of meat, 100 g of fish - 3 times a week, 100-150 g
of cottage cheese, 30-50 g of cheese, 300 g of bread, 500 g of vegetables,
0.5 l of milk or dairy products).
Pregnant women at risk (nephropathy, diabetes mellitus, hypertension,
rheumatism, etc.) starting from the 28–32th week of pregnancy should
additionally be prescribed vitamin D at a dose of 500–1000 IU for 8 weeks,
regardless of the time of year.

34. When applying therapeutic doses of vitamin D, it is necessary to
constantly monitor the condition of the child since there is a wide
range of individual sensitivity to vitamin D. Signs of hypervitaminosis
D are vomiting, abdominal pain, thirst, hypercalciuria. For the timely
detection of hypercalcemia, a Sulkovich test is performed (a
qualitative reaction that determines the excretion of calcium in the
urine) 1 time per week, and the calcium content in the blood plasma is
evaluated - 1 time per month.

35. Postnatal Prophylaxis of Rickets
It is necessary to observe the conditions for the correct feeding of the
child. The best for an infant in its first year of life is breast milk,
provided that the lactating woman is properly nourished.
 The daily diet of a woman during lactation should be diverse and
include the required amount of protein, including animal origin; fat
enriched with polyunsaturated fatty acids, carbohydrates that provide
the body with energy, as well as vitamins and minerals.
Physiotherapy exercises, massage should be carried out
systematically, regularly, for a long time, with a gradual and uniform
increase in load.

36. Postnatal specific prophylaxis of rickets: carried out by vitamin D, the
minimum prophylactic dose of which is 500 IU per day for healthy full-term
infants.
This dose is prescribed starting from the 4th-5th week of life in the autumn-
winter-spring period, taking into account the child's living conditions and
risk factors for the development of the disease.
Specific prevention of rickets in full-term children is carried out in the
autumn-winter-spring period in the first and second year of life.
Children at risk for rickets in the autumn-winter-spring period of the first
two years of life should receive vitamin D daily at a dose of 1000 IU.
Premature infants with I degree of prematurity are prescribed vitamin D
from the 10-14th day of life, 400-1000 IU daily for 2 years, excluding
summer. With prematurity of the II degree, vitamin D is prescribed at a dose
of 1000-2000 IU daily for a year, excluding the summer period, in the
second year of life, the dose of vitamin D is reduced to 400-1000 IU.

37. list of used literature:
1. Авдеева Т.Г., Коровина Н.А. Рахит.//Педиатрия. Национальное руководство. Том 1. – М: «ГЕОТАР-
Медиа». 2009, глава 11. – С.261 – 278.
2. Ершова О.Б., Белова К.Ю., Назарова А.В. Кальций и витамин D: всѐ ли мы о них знаем?// РМЖ.
Клинические рекомендации и алгоритмы для практикующих врачей. 2011, № 12. Сайт: info@rmj.ru
3. Захарова И.Н, Дмитриева Ю.А, Васильева С.В, Евсеева Е.А. Что нужно знать педиатру о витамине D:
новые данные о его роли в организме (часть 1). //Педиатрия, 2014, том 93, № 3. – С.111-117.
4. Костылева М.Н. Место препаратов, содержащих кальций в профилактике гипокальциемии у детей
(обзор литературы). // РМЖ. Педиатрия, 2008, № 6. Сайт: info@rmj.ru
5. Мальцев С.В., Зиатдинова Н.В., ФофановВ.Б. Рентгеноденситометрия костной ткани у детей с
различными формами рахита. //Казанский медицинский журнал, 2003 г, том LXXXIV (84), № 1. – С 41–
42.
6. Почкайло А.С., В.Ф. Жерносек, Э.В. Руденко, Н.В. Почкайло, Е.В. Ламеко //Современные подходы к
диагностике, лечению и профилактике рахита у детей/ учебно-методическое пособие, 2014 ,Минск 72 с.
7. Новиков, П.В. Современный рахит (классификация, методы диагностики, лечения и профилактики) :
лекция для врачей ,2-е . – издание, Москва, 2011. – 71 с. 8. ПрокопцеваН. Л. Рахит у детей. (Лекция) //
Сибирское медицинское обозрение, 2013, № 5. – С. 88 – 98.