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Rickets

Osteomalacia in children; Vitamin D deficiency; Renal rickets; Hepatic rickets

 

Rickets is a disorder caused by a lack of vitamin D, calcium, or phosphate. It leads to softening and weakening of the bones.

Causes

 

Vitamin D helps the body control calcium and phosphate levels. If the blood levels of these minerals become too low, the body may produce hormones that cause calcium and phosphate to be released from the bones. This leads to weak and soft bones.

Vitamin D is absorbed from food or produced by the skin when exposed to sunlight. Lack of vitamin D production by the skin may occur in people who:

  • Live in climates with little exposure to sunlight
  • Must stay indoors
  • Work indoors during the daylight hours

You may not get enough vitamin D from your diet if you:

  • Are lactose intolerant (have trouble digesting milk products)
  • DO NOT drink milk products
  • Follow a vegetarian diet

Infants who are breastfed only may develop vitamin D deficiency. Human breast milk does not supply the proper amount of vitamin D. This can be a particular problem for darker-skinned children in winter months. This is because there are lower levels of sunlight during these months.

Not getting enough calcium and phosphorous in your diet can also lead to rickets. Rickets caused by a lack of these minerals in diet is rare in developed countries. Calcium and phosphorous are found in milk and green vegetables.

Your genes may increase your risk of rickets. Hereditary rickets is a form of the disease that is passed down through families. It occurs when the kidneys are unable to hold onto the mineral phosphate. Rickets may also be caused by kidney disorders that involve renal tubular acidosis.

Disorders that reduce the digestion or absorption of fats will make it more difficult for vitamin D to be absorbed into the body.

Sometimes, rickets may occur in children who have disorders of the liver. These children cannot convert vitamin D to its active form.

Rickets is rare in the United States. It is most likely to occur in children during periods of rapid growth. This is the age when the body needs high levels of calcium and phosphate. Rickets may be seen in children ages 6 to 24 months. It is uncommon in newborns.

 

Symptoms

 

Symptoms of rickets include:

  • Bone pain or tenderness in the arms, legs, pelvis, and spine 
  • Decreased muscle tone (loss of muscle strength) and weakness that gets worse
  • Dental deformities, including delayed tooth formation, defects in the tooth structure, holes in the enamel, and increased cavities (dental caries)
  • Impaired growth
  • Increased bone fractures
  • Muscle cramps
  • Short stature (adults less than 5 feet or 1.52 meters tall)
  • Skeletal deformities such as an odd-shaped skull, bowlegs, bumps in the ribcage (rachitic rosary), breastbone that is pushed forward (pigeon chest), pelvic deformities, and spine deformities (spine that curves abnormally, including scoliosis or kyphosis)

 

Exams and Tests

 

A physical exam reveals tenderness or pain in the bones, but not in the joints or muscles.

The following tests may help diagnose rickets:

  • Arterial blood gases
  • Blood tests (serum calcium)
  • Bone biopsy (rarely done)
  • Bone x-rays
  • Serum alkaline phosphatase (ALP)
  • Serum phosphorus

Other tests and procedures include the following:

  • ALP isoenzyme
  • Calcium (ionized)
  • Parathyroid hormone (PTH)
  • Urine calcium

 

Treatment

 

The goals of treatment are to relieve symptoms and correct the cause of the condition. The cause must be treated to prevent the disease from returning.

Replacing calcium, phosphorus, or vitamin D that is lacking will eliminate most symptoms of rickets. Dietary sources of vitamin D include fish liver and processed milk.

Exposure to moderate amounts of sunlight is encouraged. If rickets is caused by a metabolic problem, a prescription for vitamin D supplements may be needed.

Positioning or bracing may be used to reduce or prevent deformities. Some skeletal deformities may require surgery to correct them.

 

Outlook (Prognosis)

 

The disorder may be corrected by replacing vitamin D and minerals. Laboratory values and x-rays usually improve after about 1 week. Some cases may require large doses of minerals and vitamin D.

If rickets is not corrected while the child is still growing, skeletal deformities and short stature may be permanent. If it is corrected while the child is young, skeletal deformities often improve or disappear with time.

 

Possible Complications

 

Possible complications are:

  • Long-term (chronic) skeletal pain
  • Skeletal deformities
  • Skeletal fractures, may occur without cause

 

When to Contact a Medical Professional

 

Call your child's health care provider if you notice symptoms of rickets.

 

Prevention

 

You can prevent rickets by making sure that your child gets enough calcium, phosphorus, and vitamin D in the diet. Children who have digestive or other disorders may need to take supplements the child’s provider prescribed.

Kidney (renal) diseases, that may cause poor vitamin D absorption, should be treated right away. If you have renal disorders, monitor calcium and phosphorus levels regularly.

Genetic counseling may help people who have a family history of inherited disorders that can cause rickets.

 

 

References

Greenbaum LA. Rickets and hypervitaminosis D. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, eds. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:chap 51.

Whiting SJ, Calvo MS. Nutrition and lifestyle effects on vitamin D status. In: Feldman D, Pike JW, Adams JS, eds. Vitamin D. 3rd ed. Philadelphia, PA: Elsevier; 2011:chap 54.

 
  • X-ray

    X-ray - illustration

    X-rays are a form of ionizing radiation that can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel.

    X-ray

    illustration

    • X-ray

      X-ray - illustration

      X-rays are a form of ionizing radiation that can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel.

      X-ray

      illustration

    Tests for Rickets

     

       

      Review Date: 8/31/2016

      Reviewed By: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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