Rickets is a disease of growing bones caused by inadequate mineralization due to vitamin D deficiency or disorders of calcium and phosphorus. It occurs in children before bone growth plate fusion. Common causes include nutritional deficiencies of vitamin D, calcium, or phosphorus. Clinical features include bone softening and deformities, muscle weakness, and hypocalcemic symptoms. Diagnosis is confirmed by blood tests and radiographic findings of widened growth plates. Treatment involves high dose vitamin D supplementation along with adequate calcium and phosphorus intake.
2. RICKETS
Disease of growing bones ,occurs in children only before the fusion
of epiphyses, and due to unmineralised matrix at the growth plates.
Inadequate mineralization - Thick G.Plate
Bones become soft.
3. Causes of Rickets
VITAMIN D DISORDERS
Nutritional Vitamin D deficiency
Congenital Vitamin D deficiency
Secondary Vitamin D deficiency
Malabsorption
Increased degradation
Decreased Liver 25-hydroxylase
Vitamin D dependent ricket Type 1
Vitamin D dependent ricket Type 2
Chronic Renal Failure
PHOSPHORUS DEFICIENCY
Inadequate intake
Premature infants
Aluminium containing antacids
CALCIUM DEFICIENCY
Low intake
Diet
Premature Infant
Malabsorption
Primary Disease
Dietary inhibitors of calcium absorption
6. VITAMIN D DEFICIENCY is MC cause of Rickets Worldwide.
Most commonly occur in infancy due to poor intake and inadequate
cutaneous synthesis
Formula fed infants - receive adequate vit D even without cutaneous
synthesis
Breast fed infants rely on cutaneous synthesis or vitamin D
supplements
Cutaneous synthesis is limited due to:
Ineffectiveness of winter sun
Avoidance of sunlight
Decreased cutaneous synthesis due to increased skin pigmentation
7. Clinical Features of Rickets
GENERAL
Failure To Thrive
Listlessness
Protruding Abdomen, UMBILICAL HERNIA due to hypotonia
of abdominal wall muscles
Muscle Weakness (specially proximal)
Fractures
8. HEAD
CRANIOTABES: softening of cranial
bones
Frontal Bossing
Delayed Fontanelle Closure
Delayed Dentition, early numerous
caries, enamel hypoplasia - mostly
deciduous teeth are concerned
Craniosynostosis - early growing
together (or fusion) of two or more
bones of the skull.
9. CHEST
RACHITICROSARY widening of
costochondral junction
Harrison Groove pulling of softened ribs
by the diaphragm during inspiration,
Pectus carinatum
Thoracic asymmetry
Widening of thoracic bone
Respiratory Infections
Atelectasis impairment of air movement
12. WINDSWEPT DEFORMITY
(combination of varus deformity of 1 leg with
valgus deformity of other leg Anterior
bowing of tibia and femur)
Coxa Vara
Leg pain
14. RADIOLOGY FINDINGS
Changes are most easily visualized on PA view of wrist - although
characteristic racitic changes are seen at other growth plates
Alterations of the epiphyseal regions of the long bones - most
characteristic
Widening of the radiolucent space between end of bone shafts
(metaphyseal lines) and epiphysis
15. The edge of the metaphysis loses its sharp border, which is described as
fraying.
The edge of the metaphysis changes from a convex or flat surface to a more
concave surface. This change to a concave surface is termed cupping and is
most easily seen at the distal ends of the radius, ulna, and fibula.
16. LAB FINDINGS
Serum calcium - N, ↓
Phosphorus - ↓
Alkaline phosphatase - ↑
Parathyroid hormone(PTH) -↑
25-hydroxyvitamin D - ↓
1,25-dihydroxyvitamin D (1,25-D) - ↓, N, ↑
Urine Ca – ↓
Urine Pi - ↑
17. TREATMENT
Children with should receive vitamin D and adequate nutritional intake of
calcium and phosphorus.
With stoss therapy, 300,000-600,000 IU of vitamin D are administered
orally or intramuscularly as 2-4 doses over 1 day.
The alternative is daily, high-dose vitamin D, with doses ranging from
2,000-5,000 IU/day over 4-6 wk.
Either strategy should be followed by daily vitamin D intake of 400 IU/day if
<1 yr old or 600 IU/day if >1 yr old
18. MANGEMENT
Infants 200 - 400 IU/D (Infants daily exposed to sunlight for 15-20
min.to prevent Rickets)
Children 400 – 600 IU/D
Breast feed infants must receive vit.D supplementations because breast
milk contains only 30-40 IU/L
19. CONGENITAL VITAMIN D DEFICIENCY
Occur when there is severe maternal vitamin D
deficiency during pregnancy
Risk factors
Poor dietary intake of Vitamin D
Lack of adequate sun exposure
Clinical Features
Symptomatic hypocalcemia
IUGR
Decreased bone ossification + classic rachitic
changes
Treatment
Vitamin D supplementation
Adequate intake of calcium and
phosphorus
Use of prenatal vitamin D