Rickets

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For the surname, see Ricketts. Rickets_sentence_0

Rickets_table_infobox_0

RicketsRickets_header_cell_0_0_0
PronunciationRickets_header_cell_0_1_0 Rickets_cell_0_1_1
SpecialtyRickets_header_cell_0_2_0 Pediatrics, rheumatologyRickets_cell_0_2_1
SymptomsRickets_header_cell_0_3_0 Bowed legs, stunted growth, bone pain, large forehead, trouble sleepingRickets_cell_0_3_1
ComplicationsRickets_header_cell_0_4_0 Bone fractures, muscle spasms, abnormally curved spine, intellectual disabilityRickets_cell_0_4_1
Usual onsetRickets_header_cell_0_5_0 ChildhoodRickets_cell_0_5_1
CausesRickets_header_cell_0_6_0 Diet without enough vitamin D or calcium, too little sun exposure, exclusive breastfeeding without supplementation, celiac disease, certain genetic conditionsRickets_cell_0_6_1
Diagnostic methodRickets_header_cell_0_7_0 Blood tests, X-raysRickets_cell_0_7_1
Differential diagnosisRickets_header_cell_0_8_0 Fanconi syndrome, scurvy, Lowe syndrome, osteomalaciaRickets_cell_0_8_1
PreventionRickets_header_cell_0_9_0 Vitamin D supplements for exclusively-breastfed babiesRickets_cell_0_9_1
TreatmentRickets_header_cell_0_10_0 Vitamin D and calciumRickets_cell_0_10_1
FrequencyRickets_header_cell_0_11_0 Relatively common (Middle East, Africa, Asia)Rickets_cell_0_11_1

Rickets is a condition that results in weak or soft bones in children. Rickets_sentence_1

Symptoms include bowed legs, stunted growth, bone pain, large forehead, and trouble sleeping. Rickets_sentence_2

Complications may include bone fractures, muscle spasms, an abnormally curved spine, or intellectual disability. Rickets_sentence_3

The most common cause of rickets is a vitamin D deficiency. Rickets_sentence_4

This can result from eating a diet without enough vitamin D, dark skin, too little sun exposure, exclusive breastfeeding without vitamin D supplementation, celiac disease, and certain genetic conditions. Rickets_sentence_5

Other factors may include not enough calcium or phosphorus. Rickets_sentence_6

The underlying mechanism involves insufficient calcification of the growth plate. Rickets_sentence_7

Diagnosis is generally based on blood tests finding a low calcium, low phosphorus, and a high alkaline phosphatase together with X-rays. Rickets_sentence_8

Prevention for exclusively breastfed babies is vitamin D supplements. Rickets_sentence_9

Otherwise, treatment depends on the underlying cause. Rickets_sentence_10

If due to a lack of vitamin D, treatment is usually with vitamin D and calcium. Rickets_sentence_11

This generally results in improvements within a few weeks. Rickets_sentence_12

Bone deformities may also improve over time. Rickets_sentence_13

Occasionally surgery may be done to correct bone deformities. Rickets_sentence_14

Genetic forms of the disease typically require specialized treatment. Rickets_sentence_15

Rickets occurs relatively commonly in the Middle East, Africa, and Asia. Rickets_sentence_16

It is generally uncommon in the United States and Europe, except among certain minority groups. Rickets_sentence_17

It begins in childhood, typically between the ages of 3 and 18 months old. Rickets_sentence_18

Rates of disease are equal in males and females. Rickets_sentence_19

Cases of what is believed to have been rickets have been described since the 1st century, and the condition was widespread in the Roman Empire. Rickets_sentence_20

The disease was common into the 20th century. Rickets_sentence_21

Early treatments included the use of cod liver oil. Rickets_sentence_22

Signs and symptoms Rickets_section_0

Signs and symptoms of rickets can include bone tenderness, and a susceptibility for bone fractures, particularly greenstick fractures. Rickets_sentence_23

Early skeletal deformities can arise in infants such as soft, thinned skull bones – a condition known as craniotabes, which is the first sign of rickets; skull bossing may be present and a delayed closure of the fontanelles. Rickets_sentence_24

Young children may have bowed legs and thickened ankles and wrists; older children may have knock knees. Rickets_sentence_25

Spinal curvatures of kyphoscoliosis or lumbar lordosis may be present. Rickets_sentence_26

The pelvic bones may be deformed. Rickets_sentence_27

A condition known as rachitic rosary can result as the thickening caused by nodules forming on the costochondral joints. Rickets_sentence_28

This appears as a visible bump in the middle of each rib in a line on each side of the body. Rickets_sentence_29

This somewhat resembles a rosary, giving rise to its name. Rickets_sentence_30

The deformity of a pigeon chest may result in the presence of Harrison's groove. Rickets_sentence_31

Hypocalcemia, a low level of calcium in the blood can result in tetany – uncontrolled muscle spasms. Rickets_sentence_32

Dental problems can also arise. Rickets_sentence_33

An X-ray or radiograph of an advanced sufferer from rickets tends to present in a classic way: the bowed legs (outward curve of long bone of the legs) and a deformed chest. Rickets_sentence_34

Changes in the skull also occur causing a distinctive "square headed" appearance known as "caput quadratum". Rickets_sentence_35

These deformities persist into adult life if not treated. Rickets_sentence_36

Long-term consequences include permanent curvatures or disfiguration of the long bones, and a curved back. Rickets_sentence_37

Cause Rickets_section_1

Maternal deficiencies may be the cause of overt bone disease from before birth and impairment of bone quality after birth. Rickets_sentence_38

The primary cause of congenital rickets is vitamin D deficiency in the mother's blood, which the baby shares. Rickets_sentence_39

Vitamin D ensures that serum phosphate and calcium levels are sufficient to facilitate the mineralization of bone. Rickets_sentence_40

Congenital rickets may also be caused by other maternal diseases, including severe osteomalacia, untreated celiac disease, malabsorption, pre-eclampsia, and premature birth. Rickets_sentence_41

Rickets in children is similar to osteoporosis in the elderly, with brittle bones. Rickets_sentence_42

Pre-natal care includes checking vitamin levels and ensuring that any deficiencies are supplemented. Rickets_sentence_43

Also exclusively breast-fed infants may require rickets prevention by vitamin D supplementation or an increased exposure to sunlight. Rickets_sentence_44

In sunny countries such as Nigeria, South Africa, and Bangladesh, there is sufficient endogenous vitamin D due to exposure to the sun. Rickets_sentence_45

However, the disease occurs among older toddlers and children in these countries, which in these circumstances is attributed to low dietary calcium intakes due to a mainly cereal-based diet. Rickets_sentence_46

Those at higher risk for developing rickets include: Rickets_sentence_47

Rickets_unordered_list_0

  • Breast-fed infants whose mothers are not exposed to sunlightRickets_item_0_0
  • Breast-fed infants who are not exposed to sunlightRickets_item_0_1
  • Breast-fed babies who are exposed to little sunlightRickets_item_0_2
  • Adolescents, in particular when undergoing the pubertal growth spurtRickets_item_0_3
  • Any child whose diet does not contain enough vitamin D or calciumRickets_item_0_4

Diseases causing soft bones in infants, like hypophosphatasia or hypophosphatemia can also lead to rickets. Rickets_sentence_48

Strontium is allied with calcium uptake into bones; at excessive dietary levels strontium has a rachitogenic (rickets-producing) action. Rickets_sentence_49

Sunlight Rickets_section_2

Sunlight, especially ultraviolet light, lets human skin cells convert vitamin D from an inactive to active state. Rickets_sentence_50

In the absence of vitamin D, dietary calcium is not properly absorbed, resulting in hypocalcaemia, leading to skeletal and dental deformities and neuromuscular symptoms, e.g. hyperexcitability. Rickets_sentence_51

Foods that contain vitamin D include butter, eggs, fish liver oils, margarine, fortified milk and juice, portabella and shiitake mushrooms, and oily fishes such as tuna, herring, and salmon. Rickets_sentence_52

A rare X-linked dominant form exists called vitamin D-resistant rickets or X-linked hypophosphatemia. Rickets_sentence_53

Cases have been reported in Britain in recent years of rickets in children of many social backgrounds caused by insufficient production in the body of vitamin D because the sun's ultraviolet light was not reaching the skin due to use of strong sunblock, too much "covering up" in sunlight, or not getting out into the sun. Rickets_sentence_54

Other cases have been reported among the children of some ethnic groups in which mothers avoid exposure to the sun for religious or cultural reasons, leading to a maternal shortage of vitamin D; and people with darker skins need more sunlight to maintain vitamin D levels. Rickets_sentence_55

Rickets had historically been a problem in London, especially during the Industrial Revolution. Rickets_sentence_56

Persistent thick fog and heavy industrial smog permeating the city blocked out significant amounts of sunlight to such an extent that up to 80 percent of children at one time had varying degrees of rickets in one form or the other. Rickets_sentence_57

It is sometimes known "the English Disease" in some foreign languages (e.g. German: 'Die englische Krankheit', Dutch: 'Engelse ziekte', Hungarian: "angolkór"). Rickets_sentence_58

Evolutionary considerations Rickets_section_3

Vitamin D natural selection hypotheses: Rickets is often a result of vitamin D3 deficiency. Rickets_sentence_59

The correlation between human skin color and latitude is thought to be the result of positive selection to varying levels of solar ultraviolet radiation. Rickets_sentence_60

Northern latitudes have selection for lighter skin that allows UV rays to produce vitamin D from 7-dehydrocholesterol. Rickets_sentence_61

Conversely, latitudes near the equator have selection for darker skin that can block the majority of UV radiation to protect from toxic levels of vitamin D, as well as skin cancer. Rickets_sentence_62

An anecdote often cited to support this hypothesis is that Arctic populations whose skin is relatively darker for their latitude, such as the Inuit, have a diet that is historically rich in vitamin D. Since these people acquire vitamin D through their diet, there is not a positive selective force to synthesize vitamin D from sunlight. Rickets_sentence_63

Environment mismatch: Ultimately, vitamin D deficiency arises from a mismatch between a population's previous evolutionary environment and the individual's current environment. Rickets_sentence_64

This risk of mismatch increases with advances in transportation methods and increases in urban population size at high latitudes. Rickets_sentence_65

Similar to the environmental mismatch when dark-skinned people live at high latitudes, Rickets can also occur in religious communities that require long garments with hoods and veils. Rickets_sentence_66

These hoods and veils act as sunlight barriers that prevent individuals from synthesizing vitamin D naturally from the sun. Rickets_sentence_67

In a study by Mithal et al., Vitamin D insufficiency of various countries was measured by lower 25-hydroxyvitamin D. 25(OH)D is an indicator of vitamin D insufficiency that can be easily measured. Rickets_sentence_68

These percentages should be regarded as relative vitamin D levels, and not as predicting evidence for development of rickets. Rickets_sentence_69

Asian immigrants living in Europe have an increased risk for vitamin D deficiency. Rickets_sentence_70

Vitamin D insufficiency was found in 40% of non-Western immigrants in the Netherlands, and in more than 80% of Turkish and Moroccan immigrants. Rickets_sentence_71

The Middle East, despite high rates of sun-exposure, has the highest rates of rickets worldwide. Rickets_sentence_72

This can be explained by limited sun exposure due to cultural practices and lack of vitamin D supplementation for breast-feeding women. Rickets_sentence_73

Up to 70% and 80% of adolescent girls in Iran and Saudi Arabia, respectively, have vitamin D insufficiency. Rickets_sentence_74

Socioeconomic factors that limit a vitamin D rich diet also plays a role. Rickets_sentence_75

In the United States, vitamin D insufficiency varies dramatically by ethnicity. Rickets_sentence_76

Among males aged 70 years and older, the prevalence of low serum 25(OH) D levels was 23% for non-Hispanic whites, 45% for Mexican Americans, and 58% for non-Hispanic blacks. Rickets_sentence_77

Among women, the prevalence was 28.5%, 55%, and 68%, respectively. Rickets_sentence_78

A systematic review published in the Cochrane Library looked at children up to three years old in Turkey and China and found there was a beneficial association between vitamin D and rickets. Rickets_sentence_79

In Turkey children getting vitamin D had only a 4% chance of developing rickets compared to children who received no medical intervention. Rickets_sentence_80

In China, a combination of vitamin D, calcium and nutritional counseling was linked to a decreased risk of rickets. Rickets_sentence_81

With this evolutionary perspective in mind, parents can supplement their nutritional intake with vitamin D enhanced beverages if they feel their child is at risk for vitamin D deficiency. Rickets_sentence_82

Diagnosis Rickets_section_4

Rickets may be diagnosed with the help of: Rickets_sentence_83

Rickets_unordered_list_1

  • Blood tests:Rickets_item_1_5
    • Serum calcium may show low levels of calcium, serum phosphorus may be low, and serum alkaline phosphatase may be high from bones or changes in the shape or structure of the bones. This can show enlarged limbs and joints.Rickets_item_1_6
  • A bone density scan may be undertaken.Rickets_item_1_7
  • Radiography typically show widening of the zones of provisional calcification of the metaphyses secondary to unmineralized osteoid. Cupping, fraying, and splaying of metaphyses typically appears with growth and continued weight bearing. These changes are seen predominantly at sites of rapid growth, including the proximal humerus, distal radius, distal femur and both the proximal and the distal tibia. Therefore, a skeletal survey for rickets can be accomplished with anteroposterior radiographs of the knees, wrists, and ankles.Rickets_item_1_8

Types Rickets_section_5

Rickets_unordered_list_2

Differential diagnosis Rickets_section_6

Osteochondrodysplasias also known as genetic bone diseases may mimic the clinical picture of rickets in regard to the features of bone deformities. Rickets_sentence_84

The radiologic picture and the laboratory findings of serum calcium, phosphate and alkaline phosphatase, are important differentiating factors. Rickets_sentence_85

Blount's disease is an important differential diagnosis because it causes knee defomities in a similar fashion to rickets namely bow legs or genu varum. Rickets_sentence_86

Infants with rickets can have bone fractures. Rickets_sentence_87

This sometimes leads to child abuse allegations. Rickets_sentence_88

This issue appears to be more common for solely nursing infants of black mothers, in winter in temperate climates, suffering poor nutrition and no vitamin D supplementation. Rickets_sentence_89

People with darker skin produce less vitamin D than those with lighter skin, for the same amount of sunlight. Rickets_sentence_90

Treatment Rickets_section_7

The most common treatment of rickets is the use of vitamin D. However, orthopedic surgery is occasionally needed. Rickets_sentence_91

Diet and sunlight Rickets_section_8

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. Rickets_sentence_92

A sufficient amount of ultraviolet B light in sunlight each day and adequate supplies of calcium and phosphorus in the diet can prevent rickets. Rickets_sentence_93

Darker-skinned people need to be exposed longer to the ultraviolet rays. Rickets_sentence_94

The replacement of vitamin D has been proven to correct rickets using these methods of ultraviolet light therapy and medicine. Rickets_sentence_95

Recommendations are for 400 international units (IU) of vitamin D a day for infants and children. Rickets_sentence_96

Children who do not get adequate amounts of vitamin D are at increased risk of rickets. Rickets_sentence_97

Vitamin D is essential for allowing the body to uptake calcium for use in proper bone calcification and maintenance. Rickets_sentence_98

Supplementation Rickets_section_9

Sufficient vitamin D levels can also be achieved through dietary supplementation and/or exposure to sunlight. Rickets_sentence_99

Vitamin D3 (cholecalciferol) is the preferred form since it is more readily absorbed than vitamin D2. Rickets_sentence_100

Most dermatologists recommend vitamin D supplementation as an alternative to unprotected ultraviolet exposure due to the increased risk of skin cancer associated with sun exposure. Rickets_sentence_101

Endogenous production with full body exposure to sunlight is approximately 250 µg (10,000 IU) per day. Rickets_sentence_102

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. Rickets_sentence_103

Surgery Rickets_section_10

Occasionally surgery is needed to correct severe and persistent deformities of the lower limbs, especially around the knees namely genu varum and genu valgum. Rickets_sentence_104

Surgical correction of rachitic deformities can be achieved through osteotomies or guided growth surgery. Rickets_sentence_105

Guided growth surgery has almost replaced the use of corrective osteotomies. Rickets_sentence_106

The functional results of guided growth surgery in children with rickets are satisfactory. Rickets_sentence_107

While bone osteotomies work through acute/immediate correction of the limb deformity, guided growth works through gradual correction. Rickets_sentence_108

Epidemiology Rickets_section_11

In developed countries, rickets is a rare disease (incidence of less than 1 in 200,000). Rickets_sentence_109

Recently, cases of rickets have been reported among children who are not fed enough vitamin D. Rickets_sentence_110

In 2013/2014 there were fewer than 700 cases in England. Rickets_sentence_111

In 2019 the number of cases hospitalised was said to be the highest in 50 years. Rickets_sentence_112

Rickets occurs relatively commonly in the Middle East, Africa, and Asia. Rickets_sentence_113

History Rickets_section_12

Greek physician Soranus of Ephesus, one of the chief representatives of the Methodic school of medicine who practiced in Alexandria and subsequently in Rome, reported deformation of the bones in infants as early as the first and second centuries AD. Rickets_sentence_114

Rickets was not defined as a specific medical condition until 1645, when an English physician Daniel Whistler gave the earliest known description of the disease. Rickets_sentence_115

In 1650 a treatise on rickets was published by Francis Glisson, a physician at Caius College, Cambridge, who said it had first appeared about 30 years previously in the counties of Dorset and Somerset. Rickets_sentence_116

In 1857, John Snow suggested rickets, then widespread in Britain, was being caused by the adulteration of bakers' bread with alum. Rickets_sentence_117

German pediatrician Kurt Huldschinsky successfully demonstrated in the winter of 1918–1919 how rickets could be treated with ultraviolet lamps. Rickets_sentence_118

The role of diet in the development of rickets was determined by Edward Mellanby between 1918 and 1920. Rickets_sentence_119

In 1923, American physician Harry Steenbock demonstrated that irradiation by ultraviolet light increased the vitamin D content of foods and other organic materials. Rickets_sentence_120

Steenbock's irradiation technique was used for foodstuffs, but most memorably for milk. Rickets_sentence_121

By 1945, rickets had all but been eliminated in the United States. Rickets_sentence_122

Etymology Rickets_section_13

The word rickets may be from the Old English word wrickken ('to twist'), although because this is conjectured, several major dictionaries simply say "origin unknown". Rickets_sentence_123

The name rickets is plural in form but usually singular in construction. Rickets_sentence_124

The Greek word "rachitis" (ῥαχίτης, meaning "in or of the spine") was later adopted as the scientific term for rickets, due chiefly to the words' similarity in sound. Rickets_sentence_125

See also Rickets_section_14

Rickets_unordered_list_3


Credits to the contents of this page go to the authors of the corresponding Wikipedia page: en.wikipedia.org/wiki/Rickets.