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by Alan R

Rickets

Definition

Rickets is disease resulting from a vitamin D , calcium, or phosphate shortage in children. It causes bones to soften and weaken.
Rickets
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Causes

Rickets results when there is a vitamin D, calcium, or phosphorous shortage in a child's body. This may occur when:
  • The supply of vitamin D from diet or sun exposure is too low.
  • The way the body processes vitamin D is not typical.
  • Tissue does not respond to the action of vitamin D.
  • There is not enough calcium or phosphorous in the diet or it cannot be absorbed
  • Kidney disease is present.
Vitamin D controls how calcium is absorbed in the body. It also controls levels of calcium and phosphate in bone. Vitamin D is absorbed in the intestines from food. Vitamin D is also produced by the skin during exposure to sunlight.
Most often, rickets is caused by a shortage of vitamin D. This can result from:
  • Not enough vitamin D in the diet. In children, this may be related to:
    • Not drinking enough vitamin D-fortified milk
    • Not giving enough vitamin D supplements to children being breastfed or to children who are lactose intolerant
  • Lack of exposure to sunlight
Less often, rickets can be caused by other disorders that affect vitamin D absorption or calcium metabolism such as:
  • Kidney problems:
    • A hereditary disorder of the kidney called vitamin D-resistant rickets
    • Renal tubular acidosis—a non-hereditary kidney disorder that causes bone calcium to dissolve
    • Chronic kidney failure
    • Long-term kidney dialysis
  • Diseases of the small intestines with malabsorption
  • Disorders of the liver or pancreas disease
  • Cancer
  • Certain drugs, such as:
    • Certain seizure medications, such as phenytoin or phenobarbital
    • Acetazolamide
    • Ammonium chloride
    • Disodium etidronate
    • Fluoride treatment
  • Toxicity or poisoning from:
    • Cadmium
    • Lead
    • Aluminum
    • Outdated tetracycline

Risk Factors

Factors that may increase your child's chances of getting rickets include:
  • Lack of sun exposure
  • Age: 6 to 24 months
    • Babies who are breastfed—breast milk is low in vitamin D
    • Babies who do not drink enough formula that is fortified with vitamin D
    • Children who do not drink enough vitamin D-fortified milk
  • Lactose intolerance with low intake of vitamin D-fortified milk
  • Family history of rickets
  • Race: Black, especially in association with breastfeeding
  • Certain chronic illnesses that result in loss of or poor absorption of calcium

Symptoms

Symptoms may include:
  • Bone pain and tenderness
  • Skeletal and/or skull deformities
  • Bow legs or knock knees
  • Deformity or curvature of the spine
  • Pigeon chest—a chest that protrudes
  • Impaired growth, resulting in short stature
  • Bone fractures
  • Dental deformities
  • Delayed tooth formation
  • Defects in teeth
  • Increased cavities
  • Loss of appetite or weight loss
  • Difficulty sleeping
  • Muscle weakness
  • Delayed walking

Diagnosis

The doctor will ask about your child's symptoms and medical history. A physical exam will be done.
Your child's bodily fluid and bone may be tested. This can be done with:
  • Blood tests
  • Urine tests
  • Bone biopsy
Pictures may be taken of structures inside your child's body. This can be done with an x-ray .

Treatment

Treatment attempts to:
  • Correct the underlying cause
  • Relieve or reverse symptoms

Treating the Underlying Cause

Treatment of the underlying cause may include:
  • Adding the following to your child's diet:
    • Vitamin D-fortified dairy products
    • Foods high in vitamin D, such as fatty fish, egg yolk, and green vegetables
    • Foods high in calcium
    • Supplements of vitamin D, calcium, and other minerals
    • Biologically active vitamin D
  • Adequate, but not excessive, exposure to sunlight
  • Avoiding medication that may be causing poor calcium absorption
  • Treating underlying illnesses

Treating Symptoms

Treatment to relieve or correct symptoms may include:
  • Wearing braces to reduce or prevent bony deformities
  • In severe cases, surgery to correct bony deformities

Prevention

To help prevent rickets, your child should:
  • Drink vitamin D-fortified milk.
  • Consume enough vitamin D , calcium, and other minerals. If you think your child's diet may be lacking, talk with the doctor about other sources of vitamins and minerals.
  • Get sufficient, but not excessive, exposure to sunlight. Fifteen minutes a day is usually enough. Any longer than that requires sun protection with clothing or sunscreens, especially in fair-skinned infants and children. Children with dark skin are at increased risk for rickets and may need more sun exposure and dietary supplements with vitamin D.
  • Breastfed babies and bottle-fed babies who do not get enough vitamin-D fortified formula may need to be given a supplement starting within the first few days of life. Children not getting at least 400 units of vitamin D from their diet may also need supplements. Talk to the doctor to make sure your child is meeting the nutritional requirements for vitamin D.

RESOURCES

American Academy of Pediatrics http://www.healthychildren.org

Academy of Nutrition and Dietetics http://www.eatright.org

CANADIAN RESOURCES

About Kids Health http://www.aboutkidshealth.ca

Alberta Human Services http://humanservices.alberta.ca

References

Balk SJ; Council on Environmental Health; Section on Dermatology. Ultraviolet radiation: a hazard to children and adolescents. Pediatrics. 2011;127(3):e791-817.

Grant WB, Boucher BJ. Requirements for Vitamin D across the life span. Biol Res Nurs. 2011;13(2):120-133.

Rickets: what it is and how it's treated. American Academy of Family Physicians' FamilyDoctor.org website. Available at: http://familydoctor.org/familydoctor/en/diseases-conditions/rickets.html . Updated November 2010. Accessed July 30, 2013.

Vitamin D deficiency in children (infancy through adolescence). EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed . Updated June 5, 2013. Accessed July 30, 2013.

Wagner CL, Greer FR, American Academy of Pediatrics Section on Breastfeeding, American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122:1142-1152.

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