Rickets

What is rickets?
Rickets is a condition of softening of the bones that occur in growing children. It happens when the bones cannot take up enough calcium and
phosphorus to make hard, healthy bones. The most common cause is a lack of vitamin D. This is also called nutritional rickets.

What is vitamin D?
Vitamin D is a substance that the body needs to help absorb calcium from the gut and regulate how much calcium and phosphorus get stored in the bone. Vitamin D can primarily be obtained only from sunlight. Considering the limited outdoor exposure of children these days combined with heavy levels of air pollution that prevent the good ultraviolet rays of the sun from reaching the skin, most children today are Vitamin D deficient.

What are the symptoms of rickets?
The most classic symptom of rickets is bending or “bowing” of the bones of the legs. This happens because of the stress of walking on “soft” bones that do not have enough minerals. Infants who are crawling but not walking yet can get a widening of the area just above the wrists for the
same reason. In more severe cases, one can see swelling of the ends of the ribs as well. Sometimes the blood level of calcium can become so low that seizures can develop.

How is rickets diagnosed?
A physician can diagnose rickets from a combination of the physical exam findings, x-rays (which show widening and “fraying” of the ends of certain long bones), and blood tests that can show low levels of phosphorus and normal or low calcium with an elevated level of an enzyme called alkaline phosphatase. Levels of “25 hydroxy” vitamin D may also be checked which would be low. On occasion, further blood testing is necessary to diagnose other forms of rickets.

Who is at risk for nutritional rickets?
Infants who are breastfed and who are not given extra vitamin D are at the highest risk. The risk is even greater if the baby’s mother is also vitamin D deficient. Vitamin D deficiency among women of childbearing age is quite common. It occurs even more often in dark-skinned people and people who do not expose themselves to much sunlight.

How can rickets be prevented?
All breastfed infants should receive 400 international units of vitamin D daily. This can be obtained in a standard dose of infant vitamin drops
(which usually contain vitamins A, D, and C). Nursing women should make sure that they take in at least 600 units of vitamin D daily. Many
sources recommend 1500 to 2000 units daily.

How is nutritional rickets treated?
Treatment requires high doses of vitamin D to build up the body stores of the vitamin. This may be given as weekly mega doses or high daily doses. Supplemental calcium is also needed to keep the blood calcium level normal and heal the bones if the dietary intake of calcium is not sufficient. If the treatment is adequate, the x-ray changes start to re- solve and the blood alkaline phosphatase normalizes in about 6 to 8 weeks. If the bowing of the legs has developed, it can take many months to straighten out, but it usually does improve.