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INTRODUCTION-
Rickets is a childhood bone condition wherein the bones soften and become prone to fractures and irregularities. The main cause of rickets is a lack of vitamin D, but people can also inherit a certain type of rickets.
Rickets is a skeletal disorder that’s caused by a lack of vitamin D, calcium, or phosphate. These nutrients are important for the development of strong, healthy bones. People with rickets may have weak and soft bones, stunted growth, and, in severe cases, skeletal deformities.
Vitamin D helps your body absorb calcium and phosphate from your intestines. You can get vitamin D from various food products, including milk, eggs, and fish. Your body also produces the vitamin when you’re exposed to sunlight.
A vitamin D deficiency makes it difficult for your body to maintain sufficient levels of calcium and phosphate. When this occurs, your body produces hormones that cause calcium and phosphate to be released from your bones. When your bones lack these minerals, they become weak and soft.
Rickets is most common in children who are between 6 and 36 months old. Children are at the highest risk of rickets because they’re still growing. Children might not get enough vitamin D if they live in a region with little sunlight, follow a vegetarian diet, or don’t drink milk products. In some cases, the condition is hereditary.
Rickets is rare in the United States. Rickets used to be more common, but it mostly disappeared in developed countries during the 1940s due to the introduction of fortified foods, such as cereals with added vitamin D.
Rickets is the softening and weakening of bones in children, usually because of an extreme and prolonged vitamin D deficiency. Rare inherited problems also can cause rickets.
Vitamin D helps your child’s body absorb calcium and phosphorus from food. Not enough vitamin D makes it difficult to maintain proper calcium and phosphorus levels in bones, which can cause rickets.
Adding vitamin D or calcium to the diet generally corrects the bone problems associated with rickets. When rickets is due to another underlying medical problem, your child may need additional medications or other treatment. Some skeletal deformities caused by rickets may require corrective surgery.
Rare inherited disorders related to low levels of phosphorus, the other mineral component in bone, may require other medications.
Rickets is rare in populations whose governments require certain foods to have added vitamin D. However, there are concerns that the number of cases has risen in the United States since 2000.
Vitamin D plays a vital role in calcium absorption, so very low vitamin D levels can lead to low calcium levels.
As a result, developing bones can become weak and may form irregularly. People may also experience bone pain. The resulting symptoms can persist into adulthood. A severe vitamin D deficiency in adulthood can lead to osteomalacia, which is similar to rickets.
A vitamin D deficiency may result from a low dietary intake of vitamin D or low exposure to or absorption of ultraviolet (UV) rays. This means that children who spend a lot of time indoors may be at risk of vitamin D deficiency and rickets.
Rickets can also result from some metabolic and genetic conditions.
Taking vitamin D supplements may help protect those at risk.
CAUSES-
There are several causes of rickets, including:
Lack of vitamin D
The human body needs vitamin D to absorb calcium from the intestines. UV rays from sunlight help the skin cells convert a precursor of vitamin D from an inactive to an active state.
Children who don’t get enough vitamin D from these two sources can develop a deficiency:
- Sunlight. Your child’s skin produces vitamin D when it’s exposed to sunlight. But children in developed countries tend to spend less time outdoors. They’re also more likely to use sunscreen, which blocks the sun’s rays that trigger the skin’s production of vitamin D.
- Food. Fish oil, egg yolks and fatty fish such as salmon and mackerel contain vitamin D. Vitamin D has also been added to some foods and beverages, such as milk, cereal and some fruit juices.
If a person does not make or consume enough vitamin D, their body may not absorb sufficient calcium from the food they eat, causing low levels of calcium in the blood.
Low calcium levels result in irregularities of the bones and teeth, as well as nerve and muscle problems.
Children may lack vitamin D if they:
- have dark skin
- spend a lot of time indoors
- always wear sunscreen when outside
- follow a lactose-free or strict plant-based diet
- have a health condition such as celiac disease, which prevents the body from making or using vitamin D
- live in a place with high levels of air pollution
Regarding infants, the Centers for Disease Control and Prevention (CDC) note that breast milk does not provide enough vitamin D. According to the CDC, the American Academy of Pediatrics recommend vitamin D supplements of 400 international units (IU) (10 micrograms [mcg]) for infants who are wholly or partially breastfed. Formula milk tends to be fortified with vitamin D.
Genetic factors
Some types of rickets result from a genetic condition. These may be hereditary.
Hypophosphatemic rickets, for example, is a rare condition in which the kidneys are unable to process phosphate properly. Low levels of phosphate in the blood lead to weak and soft bones.
The most common type affects around 1 in 20,000 newborns.
Genetic factors that affect the body’s ability to use calcium can result in rickets, including those that affect liver, kidney, and intestinal function.
Calcium is also important for bone strength. Find out which foods provide calcium here.
Problems with absorption
Some children are born with or develop medical conditions that affect the way their bodies absorb vitamin D. Some examples include:
- Celiac disease
- Inflammatory bowel disease
- Cystic fibrosis
- Kidney problems
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SYMPTOM-
Signs and symptoms of rickets can include:
- Delayed growth
- Delayed motor skills
- Pain in the spine, pelvis and legs
- Muscle weakness
Because rickets softens the areas of growing tissue at the ends of a child’s bones (growth plates), it can cause skeletal deformities such as:
- Bowed legs or knock knees
- Thickened wrists and ankles
- Breastbone projection
When to see a doctor
Talk to your doctor if your child develops bone pain, muscle weakness or obvious skeletal deformities.
RISK FACTOR-
Factors that can increase a child’s risk of rickets include:
- Dark skin. Dark skin has more of the pigment melanin, which lowers the skin’s ability to produce vitamin D from sunlight.
- Mother’s vitamin D deficiency during pregnancy. A baby born to a mother with severe vitamin D deficiency can be born with signs of rickets or develop them within a few months after birth.
- Northern latitudes. Children who live in geographical locations where there is less sunshine are at higher risk of rickets.
- Premature birth. Babies born before their due dates tend have lower levels of vitamin D because they had less time to receive the vitamin from their mothers in the womb.
- Medications. Certain types of anti-seizure medications and antiretroviral medications, used to treat HIV infections, appear to interfere with the body’s ability to use vitamin D.
- Exclusive breast-feeding. Breast milk doesn’t contain enough vitamin D to prevent rickets. Babies who are exclusively breast-fed should receive vitamin D drops.
Age
Rickets is most common in children who are between 6 and 36 months old. During this time period, children usually experience rapid growth. This is when their bodies need the most calcium and phosphate to strengthen and develop their bones.
Diet
You have a higher risk of developing rickets if you eat a vegetarian diet that doesn’t include fish, eggs, or milk. You’re also at an increased risk if you have trouble digesting milk or have an allergy to milk sugar (lactose). Infants who are only fed breast milk can become deficient in vitamin D as well. Breast milk doesn’t contain enough vitamin D to prevent rickets.
Skin color
Children of African, Pacific Islander, and Middle Eastern descent are at the highest risk for rickets because they have dark skin. Dark skin doesn’t react as strongly to sunlight as lighter skin does, so it produces less vitamin D.
Geographic location
Our bodies produce more vitamin D when they’re exposed to sunshine, so you’re more at risk for rickets if you live in an area with little sunlight. You’re also at a higher risk if you work indoors during daylight hours.
Genes
One form of rickets can be inherited. This means that the disorder is passed down through your genes. This type of rickets, called hereditary rickets, prevents your kidneys from absorbing phosphate.
COMPLICATION-
Left untreated, rickets can lead to:
- Failure to grow
- An abnormally curved spine
- Bone deformities
- Dental defects
- Seizures
DIAGNOSIS-
Your doctor may be able to diagnose rickets by performing a physical examination. They will check for tenderness or pain in the bones by lightly pressing on them. Your doctor may also order certain tests to help make a rickets diagnosis, including:
- blood tests to measure the levels of calcium and phosphate in the blood
- bone X-rays to check for bone deformities
In rare cases, a bone biopsy will be performed. This involves the removal of a very small section of bone, which will be sent to a laboratory for analysis.
PREVENTION-
Exposure to sunlight provides the best source of vitamin D. During most seasons, 10 to 15 minutes of exposure to the sun near midday is enough. However, if you’re dark-skinned, if it’s winter or if you live in northern latitudes, you might not be able to get enough vitamin D from sun exposure.
In addition, because of skin cancer concerns, infants and young children, especially, are warned to avoid direct sun or to always wear sunscreen and protective clothing.
To prevent rickets, make sure your child eats foods that contain vitamin D naturally — fatty fish such as salmon and tuna, fish oil and egg yolks — or that have been fortified with vitamin D, such as:
- Infant formula
- Cereal
- Bread
- Milk, but not foods made from milk, such as some yogurts and cheese
- Orange juice
Check labels to determine the vitamin D content of fortified foods.
If you’re pregnant, ask your doctor about taking vitamin D supplements.
Guidelines recommend that all infants should receive 400 IU a day of vitamin D. Because human milk contains only a small amount of vitamin D, infants who are exclusively breast-fed should receive supplemental vitamin D daily. Some bottle-fed infants may also need vitamin D supplements if they aren’t receiving enough from their formula.
TREATMENT-
Treatment will aim to maximize the individual’s intake of calcium, phosphate, and vitamin D.
Depending on the underlying cause, a doctor will usually prescribe vitamin D supplements.
They may also recommend:
- increasing exposure to sunlight
- making dietary changes
- taking fish oil
- getting more exposure to UVB light
- consuming calcium and phosphorus
Get more information on vitamin D and joint pain here.
Dietary measures
If rickets results from a poor diet, a doctor may prescribe:
- daily calcium and vitamin D supplements
- an annual vitamin D injection (if a person cannot take supplements orally)
- a diet plan that focuses on foods rich in vitamin D
To add vitamin D to the diet, a person can consume:
- eggs
- cod liver oil
- oily fish, such as salmon, tuna, sardines, and swordfish
- vitamin D-fortified foods, such as milk, some juices, many cereals, some brands of margarine, and some soy milk products
- beef liver
Making dietary changes and spending some time outside each day can help prevent rickets in most children.
Treating medical causes
If the cause is genetic, a doctor may prescribe phosphate and calcitriol supplements to reduce bowing in the legs.
If there is an underlying medical cause, such as kidney disease, treating it may help prevent rickets.
PHYSICAL THERAPY FOR RICKETS –
Physical therapists can take a team approach with medical management through patient education on: Foods high in vitamin D; Importance of following medical recommendations for vitamin D intake; Importance of proper sun exposure with risks of overexposure. A study suggests that implementing a fall treatment protocol comprised of a multidisciplinary team of a Family Medicine (FM) physician, an Internal Medicine (IM) physician, a physical therapist, and a Home Health (HH) nurse leads to more consistent care of elderly patients who experience falls. However, there is a need for reviewing and updating the protocol based on outcomes, and subsequent research is required for improvement in the patient care.
There are no direct physical therapy interventions for vitamin D deficiency. Patient will be referred to physical therapy for treatment of impairments that may be a cause of vitamin D deficiency such as decline in muscle strength, decline in physical functioning, or falls prevention. (See Clinical Presentation). In these instances techniques could include:
Falls prevention training eg Otago program, and falls exercise classes
General muscle strengthening exercises
In older adults, there is a blunted responsiveness to resistance training and reduced muscle hypertrophy compared with younger adults. There is evidence that both exercise training and vitamin D supplementation may benefit musculoskeletal health in older adults, and it is plausible that in combination their effects may be additive. Vitamin D deficiency is associated with impaired muscle strength and performance in community-dwelling older people.
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Medicurio 