Rickets / Osteomalacia

Introduction

Ricktes

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Rickets is the softening of the bones in children, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries. The predominant cause is Vitamin D deficiency, but lack of adequate calcium in the diet may also lead to rickets. Although it can occur in adults, the majority of cases occur in children suffering from severe malnutrition, usually resulting from famine or starvation during the early stages of childhood. Infants who are born prematurely or who have dark skin, and babies who are breast-fed by poorly nourished mothers or who are unexposed to the sun, are all at higher risk for developing rickets.

Osteomalacia is the term used to describe a similar condition occurring in adults, generally due to a deficiency of Vitamin D. The origin of the word "rickets" is unknown. The Greek-derived word "rachitis" (meaning "inflammation of the spine") was later adapted as the scientific term for rickets, due chiefly to the words' similarity in sound.

Vitamin D is needed in absorption of calcium and phosphorus from the intestines. Calcium and phosphorous is needed for development of healthy bones and teeth.

The principal function of Vitamin D is to maintain serum calcium and phosphorus concentration within the range that supports neuromuscular function, bone calcification and other cellular processes.Vitamin D is also capable of influencing differentiation in some cancer cells, such as skin, bone, and breast cancer cells. Indeed, adequate Vitamin D status hs been linked to reduced risk of developing breast,colon and prostrate cancers.

Causes of Rickets and Osteomalacia

 Without adequate calcium and phosphorus in the blood available for deposition in the bone,  the skeleton fails to mineralize properly and bones weaken and bow under pressure. When these effects occur in a child, the disease is called rickets.

• Lack of adequate sunlight exposure. In this category, include:
  • Breast-fed infants whose mothers are not exposed to sunlight 
  • Breast-fed infants who are not exposed to sunlight 
  • Those who work indoors during daylight hours or are bed-ridden for long periods

 Causes of osteomalacia

• Gallbladder disease
• Following certain surgical procedures of the stomach and intestines
• Certain diseases of the intestines like celiac disease
• Some kidney problems like renal tubular acidosis
• Hereditary cases of rickets

Symptoms of Rickets and Osteomalacia

Severe deformity

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Symptoms of Rickets

• Bone pain or tenderness 
• Dental problems such as delayed tooth eruption, dental caries, soft easily broken teeth 
• Muscle weakness which can lead to baby being floppy 
• Frequent fractures or breakage of bones
• Skeletal deformity 
• Toddlers: Bowed legs 
• Older children: Knock-knees 
• Cranial, spinal, and pelvic deformities 
• Growth disturbance - child has short stature
• Irritability 
• Uncontrolled muscle spasms all over the body (tetany) and even seizures
• Soft skull
• Chest deformities 
• Widening of wrist raises early suspicion
• Deformed pelvis and Bow legs
• Harrison's groove(pigeon chest)
• Spinal deformity 
• Beading of the ribcage (rachitic rosary) 

Problems such as spinal deformities, bow legs, knock-knees, a deformed chest, changes in the skull causing a distinctive "square headed" appearance may persist into adult life if not treated

Symptoms of osteomalacia

• Fractures in the hip, spine and other bones
• Diffuse bone pain, especially in the hips 
• Muscle weakness
• Symptoms associated with low calcium
• Numbness around the mouth
• Numbness of extremities
• Spasms of hands or feet

Prevention and treatment

• Use of supplements :vitamin D and calcium can be given as dietary supplements
• Sunshine exposure: there is however, a genuine risk of skin cancer with excessive amount of unprotected sunshine exposure. Use of special sunscreens which filter the harmful rays whilst allowing for good rays to reach your skin is a good option. Ideally, sun exposure in the tropics is best done when the sun is not intense - the so-called 'morning and evening sun' as opposed to midday sun.
• Diet rich in vitamin D and calcium 
• Treat any other underlying factor like kidney disease
• For bone deformities such as bowlegs and some spinal deformities, braces may be used but in severe cases, surgery may be required. 

  Sources of vitamin D

• Sunlight: Your skin produces vitamin D when it's exposed to sunlight. Some people may not receive enough sun exposure to generate sufficient active Vitamin D for the body's needs they need to pay attention to dietary sources. Few foods contain appreciable amounts of vitamin D, 
• Dietary: Foods rich in vitamin D include fatty fish (e.g salmon and sardines), fortified milk and some fortified breakfast cereals. Although eggs, butter, liver and few brands of margarine contain some vitamin D, large servings must be eaten to obtain an appreciable amount of vitamin; thus these foods are not considered significant sources.

Getting enough calcium 

Calcium and phosphorus consumption are also important for bone formation in childhood. Breast milk is a good source of calcium, as are most commercially available formulas. 

Recommended daily intake of calcium is as follows (serving sizes vary with age): 

Recommended daily intake of calcium

• 1 to 3 years of age   - 500 milligrams (mg) (two servings of dairy products a day) 
• 4 to 8 years of age    - 800 mg (two to three servings of dairy products a day)
• 9 to 18 years of age  - 1,300 mg (four servings of dairy products a day)
• 19 to 50 years of age - 1,000 mg a day (three servings of dairy products a day)
• Older than 50             - 1,200 mg a day (nearly four servings of dairy products daily)

Milk and dairy products are common sources of calcium. Other sources of calcium include leafy green vegetables (for example, spinach), fortified orange juices, fortified breakfast cereals and calcium supplements. 

Recommended daily intake of Vitamin D

Vitamin D rich foods

The majority of non-severe cases of both rickets and osteomalacia respond well to treatment and improvement is seen within 3-6 months.

With adequate treatment and follow up, most individuals lead normal lives. 

The main problem encountered is reoccurrence mainly due to poor diet issues.

Information Source LInks

• ADA reports (2001). Position of the American Dietetic Association: Food fortification ad dietary supplements. Journal for the American Dietetic Association 101: 115
• Holick MF (1999). Vitamin D. In shils Me and Others (eds): Modern nutrition in Health and disease. 9^th ed. Baltimore,Md Williams & Wilkins