What are the other Names for this Condition? (Also known as/Synonyms)

• Nutritional Rickets
• Osteomalacia in Children
• Vitamin D Deficiency Rickets

What is Rickets? (Definition/Background Information)

• Rickets is generally caused by a deficiency of vitamin D, calcium, and phosphate, which leads to weakening and softening of the bone
• Although both genders and all ages are susceptible to Rickets, children suffering from malnutrition are affected the most. Rickets could lead to bone and dental abnormalities, pain in the bones, and stunted growth
• Vitamin D deficiency as a result of malnutrition, exposure to some chemicals, or lack of exposure to sunlight, etc. are some of the known risk factors for Rickets. The condition may occur as a result of lack of vitamin D, kidney disorders such as tubular acidosis, malabsorption of fat in the body, and liver dysfunction
• Rickets is treated by increasing the consumption of vitamin D, by consuming supplements rich in or fortified with vitamin D. With suitable and early treatment, the prognosis of the condition is excellent

There are various types of Rickets that include:

• Nutritional Rickets
• Vitamin D Resistant Rickets
• Congenital Rickets
• Newborn Rickets
• Vitamin D Dependant Rickets (Type I and Type II)

Who gets Rickets? (Age and Sex Distribution)

• Any individual may be susceptible to Rickets. However, most commonly, children suffering from malnutrition during early childhood, are affected the most
• Rickets usually occurs in children during periods of their rapid growth, i.e. between 3-24 months. It is uncommon in newborns though
• This nutritional deficiency disorder is found worldwide and affects all racial and ethnic groups

What are the Risk Factors for Rickets? (Predisposing Factors)

The risk factors associated with Rickets include:

• Exclusively breastfeeding in infants (especially beyond 6 months), since:
  • Human milk does not contain enough vitamin D
  • The mother may not get enough exposure to sunlight
  • When the mother’s diet does not contain enough vitamin D or calcium
• Older infants and toddlers who are fed with milk substitutes and weaning foods that are not vitamin D fortified
• Use of sunscreen lotions on children, which blocks skin synthesis of vitamin D
• Individuals, who generally cover all exposed areas of the skin
• Those with dark-colored skins: Dark-skinned individuals (especially of Asian origin) have a reduced ability to synthesize vitamin D
• Elderly individuals, who also have a reduced capacity to absorb vitamin D 
• Institutionalized adults not supplemented with adequate vitamin D
• Individuals with inflammatory bowel disease, fat malabsorption syndromes, those who are underweight and malnourished
• Those suffering from obesity, whose access to vitamin D stored in the body fat is diminished
• Living in multi-storied buildings that obstruct direct sun rays
• Living in a metropolis with heavy atmospheric pollution causing sun obstruction
• Wearing heavy clothes, which obstruct the ultraviolet rays
• Vitamin D deficiency in pregnant women

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Rickets? (Etiology)

• When there is a lack of vitamins and minerals, such as vitamin D, calcium, and phosphate, in the body, it results in weak and soft bones causing Rickets. Vitamin D is absorbed from the food or produced by the skin when exposed to sunlight
• Rickets is a deficiency disorder in which bone tissue does not properly mineralize, leading to soft bones and skeletal deformities
• Since vitamin D regulates the levels of calcium and phosphate in the body, a lack of vitamin D could lead to reduced circulating levels of both calcium and phosphate. The body, sensing this drop in mineral levels, eventually starts leaching the minerals from the bones, which leads to weak and soft bones.

Some known and established causes of Rickets are as follow:

• Vitamin D deficiency in dietary nutrition
• Vitamin D deficiency arising from insufficient exposure to sunlight owing to:
  • Use of strong sun blocks (topical creams and ointments)
  • Too much ‘covering up’ in sunlight (covering exposed body areas with dress material)
  • Inadequate or lack of sun exposure
  • Maternal shortage of vitamin D (low levels of vitamin D during pregnancy)
• Rickets may also develop due to certain health conditions:
  • Lactose intolerance: When an individual has difficulties in digesting milk products
  • Those who do not take milk or milk products
  • Individuals follow a strict vegetarian diet
• Breastfed infants who are not supplemented with other foods after 6-9 months (human breast milk alone does not supply the required amount of vitamin D)
• Malnutrition: Insufficient phosphates and calcium in the diet is a major cause of Rickets
• Family history (hereditary) of the condition
• Kidney disorders that involve renal tubular acidosis
• Disorders that reduce digestion or absorption of fats, such as those of the liver, when vitamin D cannot be converted into its active form

What are the Signs and Symptoms of Rickets?

The signs and symptoms associated with Rickets are varied and may include:

• Bone pain and tenderness in the arms, legs, pelvis, and spine
• Muscle weakness and cramps
• Short stature - adults could be less than 5 feet tall
• Rickety myopathy
• Floppy baby syndrome and slinky baby syndrome
• Increased tendency to fractures
• Skeletal deformities such as:
  • Bowed legs in toddlers
  • Knock knees or windswept knees in older children
  • Odd-shaped skull
  • Bumps in the ribcage
  • Pigeon chest - breastbone pushed forward
  • Cranial deformities
  • Pelvic deformities
  • Spinal deformities, such as lumbar lordosis (abnormal spine curvature)
• Hypocalcaemia - low level of calcium in blood
• Growth disturbances
• Tetany - uncontrolled muscle spasms all over the body
• Craniotabes (soft skull)
• Costochondral swelling (swelling of specific cartilages)
• Harrison’s groove
• Dental deformities that may include:
  • Delayed formation of teeth
  • Defects in the structure of teeth
  • Holes in the enamel
  • Increased cavities in the teeth (dental caries)
  • Progressive weakness

How is Rickets Diagnosed?

Rickets may be diagnosed through the following tests and procedures:

• Complete physical examination with comprehensive medical history
• Blood tests which include:
  • Serum calcium, which may show low levels of calcium
  • Serum phosphorus, which may be low
  • Serum alkaline phosphatase may be high
• Arterial blood gases that can reveal metabolic acidosis
• X-rays of the affected bones to check for change in bone structure
• Bone biopsy, in rare cases
• Other tests may include:
  • PTH - parathyroid hormone that is released by the parathyroid gland. This test is done to measure the amount of PTH in blood
  • Urine calcium - this test is done to measure the amount of calcium in urine

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Rickets?

The complications associated with Rickets could be:

• Chronic skeletal pain
• Skeletal deformities
• Skeletal fractures
• Delayed and stunted growth

How is Rickets Treated?

The treatment and prevention of Rickets is known by the term 'antirachitic' (meaning effective against Rickets). The common treatment options for Rickets are:

• Increased vitamin D consumption by including fish, liver, and processed milk in one’s diet
• Increased dietary intake of calcium and phosphates
• Increasing exposure to ultraviolet B light
• Increased consumption of cod liver oil, halibut-liver oil, and viosterol, which are rich in vitamin D
• Direct exposure to sunlight for a longer period
• Ultra violet light therapy for effective replacement of vitamin D
• Vitamin D supplement: 400 international units of vitamin D per day is recommended for infants and children
• Positioning or bracing could be an option to rectify dental deformities
• Surgery may be needed to address severe bone deformities

How can Rickets be Prevented?

Rickets is a preventable condition that can be prevented through:

• Ensuring that a child’s diet is rich in calcium, phosphorous and vitamin D
• Taking vitamin D supplements as recommended by the healthcare provider
• Prompt treatment of kidney conditions that lead to poor absorption of vitamin D
• Periodic monitoring calcium and phosphorus levels in those with renal disorders
• Genetic counseling may help in case of a family history of Rickets

What is the Prognosis of Rickets? (Outcomes/Resolutions)

• Promptly understanding the underlying conditions and adopting corrective measures, such as supplementing vitamin D and minerals, may help address Rickets
• Replenishing vitamin D generally leads to the patient’s improving within a week or so. In some cases, a longer period of mineral and vitamin D replacement may be required
• Prompt treatment for Rickets is advisable in growing children, in order to avoid permanent deformities

Additional and Relevant Useful Information for Rickets:

Rickets is also known as Osteomalacia in Children (or Pediatric Osteomalacia); osteomalacia indicates a weakening of bones due to nutritional deficiency of vitamin D or calcium.