RICKETS IN CHILDREN
BY
ABDUL-RAHMAN ISSAH MUSTAPHA
GROUP 4 3RD YEAR
MEDICAL INSTITUTE
• 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