Disease: Rickets (Calcium, Phosphate, or
Vitamin D Deficiency)

    Rickets facts

    • Rickets is caused by a deficiency of vitamin D, calcium, or phosphate.
    • There are several different types of rickets.
    • There are different bony abnormalities associated with rickets, but all are due to poor mineralization with calcium and phosphate.
    • The active form of vitamin D is synthesized by skin cells when exposed to sunlight.
    • Vitamin D is found in small amounts in a some foods.
    • Infants who are exclusively breastfed should receive vitamin D supplements.
    • Children and adolescents who do not obtain enough vitamin D though milk and foods should receive vitamin D supplements.

    What is rickets?

    Rickets is a disorder caused by a deficiency of vitamin D, calcium, or phosphate. Rickets leads to softening and weakening of the bones and is seen most commonly in children 6-24 months of age. There are several subtypes of rickets, including hypophosphatemic rickets (vitamin-D-resistant rickets), renal or kidney rickets (renal osteodystrophy), and most commonly, nutritional rickets (caused by dietary deficiency of vitamin D, calcium, or phosphate). Classic nutritional rickets is also medically termed osteomalacia.

    What is the history of rickets?

    Roman descriptions of individuals with rickets can be found as early as the second century, and in the 1640s, the condition was well documented as a common bone ailment across England. Unfortunately, the scientifically proven cause of rickets was not identified until the 1920s, and by the 1930s, public-health initiatives recommended fortifying milk with vitamin D and cod-liver oil as a nutritional supplement for young infants and children. This led to a 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. Moreover, for a variety of reasons, rickets is seen more frequently amongst infants and children living in industrialized nations, often among more affluent populations.

    What causes rickets?

    Regardless of the type of rickets, the cause is always either due to a deficiency of vitamin D, calcium, or phosphate. Three common causes of rickets include nutritional rickets, hypophosphatemic rickets, and renal rickets.

    Nutritional rickets

    Nutritional rickets, also called osteomalacia, is a condition caused by vitamin D deficiency. 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. It occurs naturally in very small quantities in some foods such as saltwater fish (salmon, sardines, herring, and fish-liver oils). Vitamin D is also naturally synthesized by skin cells in response to sunlight exposure. It is necessary for the appropriate absorption of calcium from the gut.

    Infants and children most at risk for developing nutritional rickets include dark-skinned infants, exclusively breastfed infants, and infants who are born to mothers who are vitamin D deficient. In addition, older children who are kept out of direct sunlight or who have vegan diets may also be at risk.

    Hypophosphatemic rickets

    Hypophosphatemic rickets is 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. The individual affected is able to absorb phosphate and calcium, but the phosphate is lost in the urine. This is not caused by a vitamin D deficiency. Patients with hypophosphatemic rickets typically have obvious symptoms by 1 year of age. Treatment is generally through nutritional supplements of phosphate and calcitriol (the activated form of vitamin D).

    Renal (kidney) rickets

    Similar to hypophosphatemic rickets, renal rickets is 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. This includes calcium and phosphate, and therefore the affected individuals develop symptoms almost identical to severe nutritional rickets. Treatment of the underlying kidney problem and nutritional supplementation are recommended for these patients.

    What are rickets symptoms and signs?

    Signs and symptoms of rickets include bone pain or tenderness, dental deformities, delayed formation of teeth, decreased muscle strength, impaired growth, short stature, and a number of skeletal deformities, including abnormally shaped skull (craniotabes), bowlegs, rib-cage abnormalities (rachitic rosary), and breastbone, pelvic, and spinal deformities.

    Occasionally, in very severe rickets, patients may develop even more serious signs and symptoms associated with very low levels of calcium or phosphate. These might include tetany (involuntary muscle contractions) or seizures. These are medical emergencies and require immediate treatment.

    How is rickets diagnosed?

    Rickets is initially diagnosed clinically with a complete medical and nutritional history and with a complete physical exam by a health professional. If rickets is suspected in a child and the child has no acute symptoms such as seizures or tetany, X-rays of long bones (radius, ulna, and femur) and ribs are obtained.

    Vitamin D levels, alkaline phosphatase, parathyroid hormone (hormone involved in calcium and phosphate control), and electrolytes, including indirect measurements of kidney function (BUN and creatinine), should be evaluated if the X-rays show any of the following characteristics that are consistent with rickets:

    • Widening or abnormally shaped metaphysis (most actively growing part of the bone below the growth plate)
    • Obvious bowing of the femurs
    • Osteopenia (bones which are not as dense, a sign of decreased mineralization)
    • Rib flaring (rachitic rosary)
    • Multiple fractures at different healing stages

    Different causes of rickets will reveal different findings on laboratory tests. For the scope of this article, we will focus on vitamin D deficiency. In these cases, the active form of vitamin D will be decreased, parathyroid hormone will be increased, and calcium and phosphate will be decreased.

    What is the history of rickets?

    Roman descriptions of individuals with rickets can be found as early as the second century, and in the 1640s, the condition was well documented as a common bone ailment across England. Unfortunately, the scientifically proven cause of rickets was not identified until the 1920s, and by the 1930s, public-health initiatives recommended fortifying milk with vitamin D and cod-liver oil as a nutritional supplement for young infants and children. This led to a 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. Moreover, for a variety of reasons, rickets is seen more frequently amongst infants and children living in industrialized nations, often among more affluent populations.

    What causes rickets?

    Regardless of the type of rickets, the cause is always either due to a deficiency of vitamin D, calcium, or phosphate. Three common causes of rickets include nutritional rickets, hypophosphatemic rickets, and renal rickets.

    Nutritional rickets

    Nutritional rickets, also called osteomalacia, is a condition caused by vitamin D deficiency. 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. It occurs naturally in very small quantities in some foods such as saltwater fish (salmon, sardines, herring, and fish-liver oils). Vitamin D is also naturally synthesized by skin cells in response to sunlight exposure. It is necessary for the appropriate absorption of calcium from the gut.

    Infants and children most at risk for developing nutritional rickets include dark-skinned infants, exclusively breastfed infants, and infants who are born to mothers who are vitamin D deficient. In addition, older children who are kept out of direct sunlight or who have vegan diets may also be at risk.

    Hypophosphatemic rickets

    Hypophosphatemic rickets is 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. The individual affected is able to absorb phosphate and calcium, but the phosphate is lost in the urine. This is not caused by a vitamin D deficiency. Patients with hypophosphatemic rickets typically have obvious symptoms by 1 year of age. Treatment is generally through nutritional supplements of phosphate and calcitriol (the activated form of vitamin D).

    Renal (kidney) rickets

    Similar to hypophosphatemic rickets, renal rickets is 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. This includes calcium and phosphate, and therefore the affected individuals develop symptoms almost identical to severe nutritional rickets. Treatment of the underlying kidney problem and nutritional supplementation are recommended for these patients.

    What are rickets symptoms and signs?

    Signs and symptoms of rickets include bone pain or tenderness, dental deformities, delayed formation of teeth, decreased muscle strength, impaired growth, short stature, and a number of skeletal deformities, including abnormally shaped skull (craniotabes), bowlegs, rib-cage abnormalities (rachitic rosary), and breastbone, pelvic, and spinal deformities.

    Occasionally, in very severe rickets, patients may develop even more serious signs and symptoms associated with very low levels of calcium or phosphate. These might include tetany (involuntary muscle contractions) or seizures. These are medical emergencies and require immediate treatment.

    How is rickets diagnosed?

    Rickets is initially diagnosed clinically with a complete medical and nutritional history and with a complete physical exam by a health professional. If rickets is suspected in a child and the child has no acute symptoms such as seizures or tetany, X-rays of long bones (radius, ulna, and femur) and ribs are obtained.

    Vitamin D levels, alkaline phosphatase, parathyroid hormone (hormone involved in calcium and phosphate control), and electrolytes, including indirect measurements of kidney function (BUN and creatinine), should be evaluated if the X-rays show any of the following characteristics that are consistent with rickets:

    • Widening or abnormally shaped metaphysis (most actively growing part of the bone below the growth plate)
    • Obvious bowing of the femurs
    • Osteopenia (bones which are not as dense, a sign of decreased mineralization)
    • Rib flaring (rachitic rosary)
    • Multiple fractures at different healing stages

    Different causes of rickets will reveal different findings on laboratory tests. For the scope of this article, we will focus on vitamin D deficiency. In these cases, the active form of vitamin D will be decreased, parathyroid hormone will be increased, and calcium and phosphate will be decreased.

    Source: http://www.rxlist.com

    Rickets is initially diagnosed clinically with a complete medical and nutritional history and with a complete physical exam by a health professional. If rickets is suspected in a child and the child has no acute symptoms such as seizures or tetany, X-rays of long bones (radius, ulna, and femur) and ribs are obtained.

    Vitamin D levels, alkaline phosphatase, parathyroid hormone (hormone involved in calcium and phosphate control), and electrolytes, including indirect measurements of kidney function (BUN and creatinine), should be evaluated if the X-rays show any of the following characteristics that are consistent with rickets:

    • Widening or abnormally shaped metaphysis (most actively growing part of the bone below the growth plate)
    • Obvious bowing of the femurs
    • Osteopenia (bones which are not as dense, a sign of decreased mineralization)
    • Rib flaring (rachitic rosary)
    • Multiple fractures at different healing stages

    Different causes of rickets will reveal different findings on laboratory tests. For the scope of this article, we will focus on vitamin D deficiency. In these cases, the active form of vitamin D will be decreased, parathyroid hormone will be increased, and calcium and phosphate will be decreased.

    Source: http://www.rxlist.com

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