RICKETS IN CHILDREN

JINU JANET VARGHESE

GROUP :4, YEAR :6

TBILISI STATE MEDICAL UNIVERSITY

• RICKETS IS DEFECTIVE MINERALIZATION OF BONES BEFORE

EPIPHYSEAL CLOSURE IN INFANTS DUE TO DEFICIENCY OR

IMPAIRED METABOLISM OF VITAMIN D PHOSPHORUS OR CALCIUM,

POTENTIALLY LEADING TO FRACTURES AND DEFORMITY. RICKETS

LEADS TO SOFTENING AND WEAKENING OF THE BONES AND IS

SEEN MOST COMMONLY IN CHILDREN 6-24 MONTHS OF AGE.

EPIDEMIOLOGY

• AS A RESULT OF THERAPEUTIC DEVELOPMENTS IN THE 20TH CENTURY, THE

PREVALENCE OF RICKETS DECREASED, PARTICULARLY IN DEVELOPED COUNTRIES

SUCH AS THE UNITED STATES, THE UNITED KINGDOM, AND AUSTRALIA, WHERE

IT EVENTUALLY BECAME RARE. TODAY THE DISTRIBUTION AND PREVALENCE OF

RICKETS ARE ALIGNED PRIMARILY WITH RISK FACTORS. HENCE, IT IS MOST

PREVALENT IN PEOPLES WHO ARE DARK-SKINNED AND IN DEVELOPING

COUNTRIES WHERE ACCESS TO VITAMIN D-FORTIFIED FOODS IS LACKING.

AFRICA, THE MIDDLE EAST, AND PARTS OF ASIA RANK AMONG THE WORLD’S

MOST HEAVILY AFFECTED REGIONS.

SIGNS AND SYMPTOMS

• BONE TENDERNESS

• DENTAL PROBLEMS

• MUSCLE WEAKNESS (RICKETY MYOPATHY)

• INCREASED TENDENCY FOR FRACTURES (EASILY BROKEN BONES), ESPECIALLY

GREENSTICK FRACTURES

• SKELETAL DEFORMITY (BOWED LEGS, KNOCK-KNEES)

• CRANIAL DEFORMITY (SUCH AS SKULL BOSSING OR DELAYED FONTANELLE

CLOSURE)

• PELVIC DEFORMITY

• SPINAL DEFORMITY (SUCH AS KYPHOSCOLIOSIS OR LUMBAR LORDOSIS)

• GROWTH DISTURBANCE

• CHEST X RAY SHOWING CHANGES CONSISTENT WITH RICKETS. THESE CHANGES

ARE USUALLY REFERRED TO AS "ROSARY BEADS" OF RICKETS.

• HYPOCALCEMIA (LOW LEVEL OF CALCIUM IN THE BLOOD)

• TETANY (UNCONTROLLED MUSCLE SPASMS ALL OVER THE BODY)

• CRANIOTABES (SOFT SKULL)

• COSTOCHONDRAL SWELLING (AKA "RICKETY ROSARY" OR "RACHITIC ROSARY")

• HARRISON'S GROOVE

• DOUBLE MALLEOLI SIGN DUE TO METAPHYSEAL HYPERPLASIA

• WIDENING OF WRIST RAISES EARLY SUSPICION, IT IS DUE TO METAPHYSEAL

CARTILAGE HYPERPLASIA.

TYPES

• NUTRITIONAL RICKETS

• VITAMIN D-RESISTANT RICKETS

• VITAMIN D-DEPENDENT RICKETS

• TYPE I

• TYPE II

TREATMENT AND PREVENTION

• THE TREATMENT AND PREVENTION OF RICKETS IS KNOWN AS ANTIRACHITIC.

THE MOST COMMON TREATMENT OF RICKETS IS THE USE OF VITAMIN D.

HOWEVER, SURGERY MAY BE REQUIRED TO REMOVE SEVERE BONE

ABNORMALITIES.

• DIET AND SUNLIGHT: TREATMENT INVOLVES INCREASING DIETARY INTAKE OF

CALCIUM, PHOSPHATES AND VITAMIN D. EXPOSURE TO ULTRAVIOLET B LIGHT

(MOST EASILY OBTAINED WHEN THE SUN IS HIGHEST IN THE SKY), COD LIVER

OIL, HALIBUT-LIVER OIL, AND VIOSTEROL ARE ALL SOURCES OF VITAMIN D.

• SUPPLEMENTATION: SUFFICIENT VITAMIN D LEVELS CAN ALSO BE ACHIEVED

THROUGH DIETARY SUPPLEMENTATION AND/OR EXPOSURE TO SUNLIGHT.

VITAMIN D3 (CHOLECALCIFEROL) IS THE PREFERRED FORM SINCE IT IS MORE

READILY ABSORBED THAN VITAMIN D2. ACCORDING TO THE AMERICAN

ACADEMY OF PEDIATRICS (AAP), ALL INFANTS, INCLUDING THOSE WHO ARE

EXCLUSIVELY BREAST-FED, MAY NEED VITAMIN D SUPPLEMENTATION UNTIL

THEY START DRINKING AT LEAST 17 US FLUID OUNCES (500 ML) OF VITAMIN D-

FORTIFIED MILK OR FORMULA A DAY.

SUPPLEMENTATION RECOMMENDATIONS

AGE FEMALE MALE PREGNANCY

0-12 Months 400 IU ( 10 mcg)

400 IU (10 mcg)

1-13 Years 600 IU (15 mcg)

600 IU (15 mcg)

14-18 Years 600 IU(15 mcg)

600 IU(15 mcg)

600 IU(15 mcg)

19-50 Years 600 IU (15 mcg)

600 IU(15 mcg)

600 IU(15 mcg)

51-71 Years 600 IU (15 mcg)

600 IU(15 mcg)

> 70 Years 800 IU (20 mcg)

800 IU (20 mcg)

PHYSICAL THERAPY MANAGEMENT

• IF LEFT UNTREATED, THE CHILD CAN DEVELOP SPINAL CURVATURES, SEIZURES,

AND OSTEOPOROSIS. CHILDREN WHO ARE SOLELY BREAST-FED ARE MORE AT

RISK TO RICKETS DUE TO THE ABSENCE OF VITAMIN D IN BREAST MILK .

• ONCE THE CHILD BECOMES OLDER, AND STILL CANNOT ABSORB VITAMIN D, IT

IS VERY IMPORTANT FOR THEM TO TRY AND INCREASE BONE GROWTH AS

MUCH AS POSSIBLE. EXERCISES WHILE STANDING CAN HELP INCREASE BONE

GROWTH BUT DUE TO OSTEOPOROSIS MAY ALSO BE AT RISK FOR FRACTURES.

PHYSICAL THERAPY CAN HELP TO ALSO REDUCE ANY BONE OR MUSCLE PAIN

THROUGH STRETCHING AND STRENGTHENING EXERCISES AS WELL AS HANDS

ON MANUAL TECHNIQUES. TREATMENT TO RELIEVE OR CORRECT SYMPTOMS

MAY INCLUDE WEARING BRACES TO REDUCE OR PREVENT BONY DEFORMITIES

• IF A PATIENT IS ABLE, NO ACTIVITY RESTRICTIONS ARE NEEDED. AFFECTED

INDIVIDUALS OBVIOUSLY SHOULD NOT ENGAGE IN CONTACT SPORTS UNTIL RICKETS

IS COMPLETELY HEALED.

• 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)

• 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