Rickets in young children: prevention and treatment

Our website continues to receive questions related to the incidence of rickets in young children: is it necessary to give vitamin D in the summer, is late teething always a sign of rickets, is vitamin D recommended for every child and what form is best to choose... We introduce you to the classic point of view on this problem.

Rickets (from the Greek “rhahis” - spinal ridge, spine) is a disease of infants and young children with a disorder of bone formation and insufficient bone mineralization, caused by a violation of phosphorus-calcium metabolism due to a deficiency of vitamin D and its active metabolites.

A little history, rickets has been known since the times of Soranus of Ephesus (98-138 BC) and Galen (131-211 AD). In 1650, rickets was first described by the English orthopedist F. Glisson and for some time rickets was called “the English disease " It is curious that at present, according to English pediatricians, vitamin D deficiency rickets occurs only in people from Asia (the British call it “Asian disease”) precisely in connection with dietary traditions of late introduction of complementary feeding with animal protein and preventive administration of vitamin D. B At the beginning of the twentieth century, our compatriot I. Shabad discovered that cod fish oil is quite effective for the prevention and treatment of rickets. In 1920, the American scientist Mellanby established that the active substance in fish oil is a fat-soluble vitamin, and isolated vitamin D Mc Collum in 1922, after which they began to actively study the effect of vitamin D on bones, muscles, intestines and kidneys.

Rickets occurs in all countries, but is especially common in northern regions where there is a lack of sunlight. Children born in autumn and winter suffer from rickets more often and more severely. The frequency of rickets in recent years in Russia among young children ranges from 54 to 66%; for example, in Bulgaria, where there are many sunny days, the prevalence of rickets is about 20%. Rickets develops in children who have certain predisposition factors, the spectrum of which is individual for each child. The combination of various factors determines the timing of the onset and severity of rickets. On the maternal side - these are ages under 17 and over 35 years, toxicosis of pregnancy, metabolic diseases, pathology of the gastrointestinal tract, kidneys, nutritional defects during pregnancy and lactation (diet deficient in protein, calcium, phosphorus, vitamin D, B1 , B2, B6, physical inactivity, insufficient insolation, complicated childbirth, unfavorable socio-economic conditions.

On the part of the child - this is the time of birth (children born from June to December are more often ill), prematurity, children of twins, morphofunctional immaturity, large fetus (more than 4 kg), rapid weight gain during the first 3 months of life, feeding breast, but “old” donor milk, early artificial and mixed feeding with non-adapted milk formulas, late introduction of complementary foods (1 liter of human milk contains 40-70 IU of vitamin D3, and cow’s milk 5-40 IU, 1 g of chicken egg yolk contains 140-390 IU vitamin D3), children receiving predominantly vegetarian complementary foods (cereals, vegetables), insufficient exposure to fresh air, insufficient or limited motor mode (tight swaddling, plaster splints, wearing splints, lack of exercise therapy and massage), perinatal encephalopathy with damage to the third ventricle, diseases of the skin, liver, kidneys, malabsorption syndrome, frequent acute respiratory viral infections and intestinal infections, taking hormones and anticonvulsants.

It has now been established that vitamin D3 (cholecalciferol) is formed in the skin under the influence of ultraviolet rays (rays with a wavelength between 290-310 mm - Dorno rays - have the greatest antirachitic effect). Solar irradiation of the skin for 10-30 minutes promotes the formation of 200 IU of vitamin D. Under favorable conditions, the required amount of vitamin D is formed in the child’s skin.

In addition to vitamin D, the regulation of phosphorus-calcium metabolism is carried out by parathyroid hormone and calcitonin. Let's imagine a general scheme for the exchange of calcium and phosphorus. Physiological fluctuations in Ca and P are maintained within fairly narrow limits (blood Ca - 2-2.8 mmol/l). A decrease in Ca in the blood immediately activates the synthesis of parathyroid hormone, which enhances the excretion of Ca from bone tissue into the blood, as well as the release of phosphorus by the kidneys, as a result of reducing its reabsorption in the renal tubules and thus maintaining the normal Ca:P ratio (the product of Ca x P is a constant value). With a decrease in Ca in the blood, vitamin D3 temporarily increases the leaching of Ca from the bone, while simultaneously enhancing the absorption of Ca from the intestine. After restoring Ca in the blood to normal, vitamin D improves the quality of bone tissue: it helps to increase the number of bone cells-osteoblasts and bone mineralization.

It should be taken into account that changes in bone tissue can be caused by primary genetically determined and secondary diseases of organs involved in the metabolism of vitamin D: parathyroid glands, gastrointestinal tract, kidneys, liver, skeletal system. In such cases, the disease is characterized as a rickets-like syndrome of the underlying disease (hypoparathyroidism, renal tubular acidosis, De-Toni-Debreu-Fanconi syndrome, etc.). Disturbances in Ca-P metabolism also occur with long-term use of certain medications (glucocorticoids, thyroid hormones, anticonvulsants, heparin, tetracycline, etc.). In these diseases, bone disorders, as a rule, occur later, in the 2nd year of life, and are more severe.

Rickets

The initial period of rickets occurs in the 2-3rd month of life, and in premature infants in the middle - the end of the 1st month of life. Early signs of rickets are changes in the nervous system: tearfulness, fearfulness, anxiety, hyperexcitability, shallow, anxious sleep, frequent startlings during sleep. The child's sweating increases, especially in the scalp and back of the head. Sticky, sour-smelling sweat irritates the skin, causing persistent diaper rash. Rubbing your head against a pillow leads to the formation of bald spots on the back of your head. The musculoskeletal system is characterized by the appearance of muscle hypotonia (instead of physiological muscle hypertonicity), compliance of the cranial sutures and edges of the fontanel, thickenings on the ribs (“rachitic rosary”). The duration of the initial period of rickets is 1–3 months.

During the height of rickets, which usually occurs in the 5-6th month of life, the process of osteomalacia progresses. The consequence of the acute course of rickets can be softening of the cranial bones (craniotabes) and unilateral flattening of the back of the head; deformation of the chest with depression (“cobbler’s chest”) or bulging of the sternum (keeled chest); the formation of kyphosis (“rachitic hump”), possibly lordosis, scoliosis; O-shaped curvature of tubular bones, flat feet; formation of a flat-rachitic narrow pelvis. In addition to bone deformities, rickets is accompanied by an enlarged liver and spleen, severe anemia, muscle hypotonia (“frog” belly), and loose joints.

In the subacute course of rickets, hypertrophy of the frontal and parietal tubercles, thickening of the interphalangeal joints of the fingers (“strings of pearls”) and wrists (“bracelets”), and costochondral joints (“rachitic rosaries”) occur.

Changes in the internal organs during rickets are caused by acidosis, hypophosphatemia, microcirculation disorders and may include shortness of breath, tachycardia, loss of appetite, unstable stool (diarrhea and constipation), pseudoascites.

During the period of convalescence, sleep normalizes, sweating decreases, static functions, laboratory and radiological data improve. The period of residual effects of rickets (2-3 years) is characterized by residual skeletal deformation and muscle hypotonia.

In many children, rickets occurs in a mild form and is not diagnosed in childhood. Children suffering from rickets often suffer from acute respiratory viral infections, pneumonia, bronchitis, urinary tract infections, and atopic dermatitis. There is a close connection between rickets and spasmophilia (infantile tetany). Subsequently, children who have suffered from rickets often experience a violation of the timing and sequence of teething, malocclusion, and enamel hypoplasia.

Why does the disease develop?

The main cause of rickets in children is a lack of vitamin D. This substance performs two important functions: it helps the absorption of calcium in the small intestine and reduces its leaching in the kidneys. Vitamin D comes in small quantities from food, but its main share (up to 80%) is produced in the layers of the epidermis under the influence of solar ultraviolet radiation. Vitamin D comes through the intestines in an inactive form, and to participate in calcium metabolism it must be activated by passing through the liver and kidneys.

Most often, signs of rickets are observed in children living in large cities with unfavorable environmental conditions, where it is difficult to find a suitable area for daily walks with the child. In dysfunctional and low-income families, children with this pathology are more common than in families that do not experience financial difficulties. In addition, risk factors are:

• mother’s age: either too young (under 18 years old) or mature (after 40 years old);
• limited maternal exposure during pregnancy;
• insufficient nutrition of the mother during pregnancy, unreasonable dieting, lack of physical activity;
• chronic maternal illnesses;
• third and subsequent pregnancies;
• premature pregnancy;
• birth of twins;
• frequent births (less than two years between births);
• artificial feeding of a child with incomplete absorption of necessary substances from the nutritional mixture;
• incorrect nutritional choices that are not appropriate for the child’s age;
• underfeeding or overfeeding;
• intrauterine development disorders;
• diseases of the nervous system;
• digestive disorders, insufficient absorption of nutrients in the intestines.

Boys suffer from rickets more often than girls, dark-skinned children more often than light-skinned children. In addition, the child’s second blood group is an additional risk factor.

Preventive measures

Prevention of rickets in an infant should begin in the last months of pregnancy and should only be carried out under the supervision of a specialist.

A pregnant woman needs to eat well, walk in nature, and take vitamins in recommended doses.

It is important for the baby to provide rational feeding, going for walks, exercise and massage.

All children under three years of age are prescribed vitamin D in prophylactic doses depending on age, type of feeding and region of residence.

Victoria Druzhikina

Neurologist, Therapist

For information on the symptoms and treatment of rickets in infants, watch the video “Doctor Komarovsky’s School”:

This article has been verified by a current qualified physician, Victoria Druzhikina, and can be considered a reliable source of information for site users.

Bibliography

1. https://sevgb6.ru/doc/klinicheskie-rekomendacii/raxit.pdf
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Diagnostics

An accurate diagnosis can only be made using laboratory tests:

1. Biochemical analysis of blood and urine will help determine the content of phosphorus, calcium and alkaline phosphatase.
2. Urinalysis - Sulkovich's test shows the amount of calcium excreted from the body.
3. Diagnostic radiography and bone ultrasound may be prescribed.

Interpretation of test results allows you to accurately determine the cause and source of negative phenomena.

If you suspect rickets in your baby, be sure to consult a pediatrician. Some residual effects of the disease may remain with the child for life.

How is rickets treated in children?

Currently, the treatment of rickets is complex. It includes:

• organizing a daily routine with daily long walks in the fresh air;
• providing adequate nutrition that satisfies the child’s need for calcium and other minerals;
• drug therapy - taking vitamin D in a dosage sufficient to compensate for the deficiency;
• non-drug therapy - massage, therapeutic exercises, ultraviolet baths, balneotherapy.

If clinical recommendations are followed, rickets is cured quickly enough and without long-term consequences, but only if measures were taken in the initial stages of the disease. In severe forms of the disease, it is not always possible to overcome skeletal deformation; delays in physical development, as well as the negative impact of the disease on the nervous system, are not without consequences. For three years after recovery, the child remains under clinical supervision with quarterly medical examinations.

Treatment

There are two therapeutic approaches: specific treatment and nonspecific. The ideal option is their combination – complex treatment:

• balanced diet;
• walk outdoors;
• gymnastics, massage, water treatments;
• symptomatic treatment of other diseases;
• prescribing medications containing vitamin D and calcium.

It happens that rickets appears for other reasons not related to calcium and vitamins. For example, in case of impaired absorption of calcium in the gastrointestinal tract, pathology of the parathyroid glands or pituitary gland. These forms of rickets are much more difficult to treat.

FAQ

Does rickets occur in breastfed children?

Yes, a baby whose mother is breastfeeding may develop rickets if the mother's diet or lifestyle does not provide her body with enough of this vitamin. Therefore, pediatricians prescribe vitamin D preparations prophylactically to all children, including those who are breastfed.

What are the consequences of rickets?

The most severe consequences of the disease are skeletal deformities, including:

• incorrect bite and, as a result, difficulty chewing, impaired diction, jaw deformation, caries;
• rachiocampsis;
• curvature of the pelvis, especially dangerous for girls;
• mental deficiency due to cranial deformation.

These are just some of the adverse effects. Therefore, even with minor symptoms of rickets, the child should be shown to a doctor.

Does a child need to take calcium with rickets?

The need to prescribe calcium supplements becomes clear from the results of laboratory tests. With severe hypocalcemia, the child may need pharmaceutical drugs, which must be combined with an increase in the proportion of calcium-rich foods in the diet - dairy products, legumes, almonds and pistachios.

Postnatal prevention in the 1st – 2nd year of life

Postnatal prevention of rickets is not limited to the first year of a child’s life. The need of a child's body for vitamin D exceeds that of adults. This can be easily explained by the active growth of the musculoskeletal system and the development of internal organs, intensive consumption of organic and mineral food components. It is generally accepted that a healthy child needs vitamin D supplementation up to 4 years of age. The preventive dosage of the drug for a healthy child is on average 500-1000 IU per day. Dose adjustment is carried out in the presence of risk factors for hypovitaminosis. Children born prematurely, children from multiple pregnancies, children with low height and weight, children with diagnosed pathology or morpho-functional immaturity - they should all receive a larger dose of the drug.

Therapy for already developed rickets is prescribed taking into account the degree of bone damage and varies from 2000 to 5000 IU per day. The course of therapy must be limited. And also, calcium-phosphorus metabolism is controlled by monitoring biochemical blood parameters.

Do not forget that each case is unique and requires an individual approach. This is exactly how specialists at the CELT multidisciplinary clinic work. Contact us for a consultation and we will help you raise a strong and healthy baby!

Make an appointment through the application or by calling +7 +7 We work every day:

• Monday—Friday: 8.00—20.00
• Saturday: 8.00–18.00
• Sunday is a day off

The nearest metro and MCC stations to the clinic:

• Highway of Enthusiasts or Perovo
• Partisan
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What are the consequences?

The most severe consequences are associated with changes in the shape of the skeleton, namely:

• curvature of the jaw and, as a result, difficulty chewing, malocclusion, caries and problems with diction;
• deformation of the pelvis and spine;
• mental retardation.

Rickets is a dangerous disease that can leave a mark for life. To prevent this, you need to be attentive to any changes in the child’s behavior and report them to the doctor. You can consult with a specialist and make an appointment by phone or through the online form on our clinic’s website.

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