2. 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.

3. 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

4. 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.

5. 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

7. 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

8. Wrist Hyperplasia

9. Square Head Appearance

10. Thorax Deformity: Harrison’s Groove

11. Double malleoli

12. Bowed legs

13. Curved Back

14. Bowed Legs

15. 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)

16. 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

17. 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.

18. Vitamin D Foods Serving Cals Amount DV Nutrient Foods
Size (IU) (%) Density Rating
Salmon, chinook,
4 oz-wt 261.9 411.00 102.8 7.1 excellent
baked/broiled
Shrimp,
4 oz-wt 112.3 162.39 40.6 6.5 very good
steamed/boiled
Sardines 3.25 oz 191.4 250.24 62.6 5.9 very good
Cow’s milk, 2% 1 cup 121.2 97.60 24.4 3.6 very good
Cod,
4 oz-wt 119.1 63.50 15.9 2.4 good
baked/broiled
Egg, whole,
1 each 68.2 22.88 5.7 1.5 good
boiled

19. Milk

21. 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