Rickets

Rickets: Excerpt from The 5-Minute Pediatric Consult

Alisha J. Rovner, PhDMaria Mascarenhas, MBBS

Rickets - BASICS

Rickets - description

• Failure or delay in the mineralization of growing bone, caused primarily by a deficiency of vitamin D, calcium, or phosphorus
• See for classification of rickets and vitamin D metabolite levels

Rickets - description_causes

• See table “Causes and Management of Rickets.”

Causes and Management of Rickets

Rickets - epidemiology

Children at risk for rickets:

• Low-birth-weight and/or premature infants
• Breast-fed infants who do not receive supplemental vitamin D
• Chronic renal insufficiency
• Cholestatic liver disease
• Circulating vitamin D metabolites (25-hydroxyvitamin D, 1,25-dihydroxyvitamin D)
• Serum Ca, P, Mg, alkaline phosphatase, and total COUrinary Ca, P, Mg, pH, creatinine, and amino acids, exclude Fanconi syndrome and proximal renal tubular stenosis.

Rickets - epidemiology_classification

See table “Classification of Rickets and Vitamin D Metabolite Levels.”

Rickets - pathophysiology

Overproduction and deficient calcification of osteoid tissue, with associated osseous deformities; alterations in growth patterns

Rickets - DIAGNOSIS

Rickets - signs & symptoms

• Anomalies of osteoid tissue
• Skeletal deformities
• Growth disturbances
• Hypocalcemia
• Tetany
• Irritability
• Listlessness
• Generalized muscular weakness

Rickets - history

• Symptoms of hepatic, renal, or gastrointestinal disease
• Prolonged breast-feeding without vitamin D supplementation:
  • Little or no sunlight exposure (or being covered up when exposed to sunlight)
  • Born to mother who is vitamin D deficient
• Calcium intake
• Lactose intolerance
• Strict vegetarian diet
• Factors influencing calcium absorption:
  • Vitamin D intake
  • Steatorrhea
  • Antacids
  • Anticonvulsants
  • Diet high in foods containing oxalic acid
• Vitamin D–fortified milk in children >1 year of age
• Adequate exposure to sunlight
• Prolonged use of cholestyramine
• Factors influencing calcium excretion: Diuretics, polyuria, or glycosuria suggests renal tubular dysfunction.
• Bone pain
• Delayed standing or walking
• Anorexia
• Seizures
• Pathologic fractures
• Tetany
• Familial history of rickets

Rickets - physical exam

• Failure to thrive
• Long-bone deformities (i.e., varus or valgus deformity)
• Fractures following minimal trauma
• Skull abnormalities (i.e., delay in closure of anterior fontanelle, craniotabes, and frontal bossing)
• Chest deformities (i.e., enlargement of costochondral junctions leading to rachitic rosary)
• Muscular hypotonia
• Waddling gait

Rickets - tests

Rickets - lab

See “Classification of Rickets and Vitamin D Metabolite Levels.”

• Circulating vitamin D metabolites (25-hydroxyvitamin D, 1,25-dihydroxyvitamin D)
• Circulating levels of parathyroid hormone
• Serum calcium, phosphorous, magnesium, alkaline phosphatase, and total COUrinary calcium, phosphorous, magnesium, pH, creatinine, and amino acids, to rule out Fanconi syndrome and proximal renal tubular acidosis

Rickets - imaging

• Order one view because rickets is symmetrical
• Knee or wrist films (the earliest sign at the wrist is a loss of clear demarcation between the growth plate and the metaphysic, with loss of the provisional zone of calcification)
• Radiographic findings: Irregular cortices and bony margins, widened metaphyses, widened growth plates, osteopenia

Rickets - differencial diagnosis

• Blount’s disease
• Fanconi syndrome
• Metastatic bone disease
• Neurofibromatosis type 1
• Proximal renal tubular acidosis

Rickets - therapy

See table “Causes and Management of Rickets.”

Rickets - FOLLOW UP

• Monitor serum calcium, alkaline phosphatase, and phosphorus levels every 2–4 weeks; re-image bones radiographically monthly until stabilized.
• One early radiographic sign of healing is the appearance of the provisional zone of calcification at the boundary between the physis and metaphysis.

Classification of Rickets and Vitamin D Metabolite Levels

N, normal; ↓, decreased; ↑, increased.

Rickets - bibliography

1. Gartner LM, Greer FR; Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency: New guidelines for vitamin D intake. Pediatrics. 2003;111:908–910.
2. Jewell JA, McElwain LL, Blake AS. Nutritional rickets. Arch Pediatr Adolesc Med. 2006;160:983–985.
3. Weisberg P, Scanlon K, Li R, et al. Nutritional rickets among children in the United States: Review of cases reported between 1986 and 2003. Am J Clin Nutr. 2004;80(6 Suppl):1697S–1705S.

Rickets - CODES

Rickets - icd9

• 268.0 Rickets, active
• 275.3 Disorders of phosphorus metabolism
• 588.0 Renal osteodystrophy

Rickets - FAQ

• Q: What is the best way to diagnose rickets?
• A: Laboratory investigation and x-rays are the best ways to make the diagnosis. The most common biochemical findings of children with vitamin D–deficient rickets are hypocalcemia, hypophosphatemia, low 25-(OH)-D concentrations, and elevated levels of parathyroid hormone and alkaline phosphatase. The classic radiographic findings occur at the growth plate of long bones and are best seen at the distal end of the radius and ulna or at the tibia and femoral growth plates around the knee. Widening of the physis, with fraying, cupping, and splaying of the metaphyses and underdevelopment of the epiphysis are common findings.
• Q: What are the recommendations for vitamin D supplementation in infants and children?
• A: To prevent rickets and vitamin D deficiency in healthy infants and children, and acknowledging that adequate sunlight exposure is difficult to determine, the American Academy of Pediatrics recommends a supplement of 200 IU/d for the following:

  All breast-fed infants unless they are weaned to at least 500 mL/d of vitamin D–fortified formula or milk

  All non–breast-fed infants who are ingesting <500 mL/d of vitamin D–fortified formula or milk

  Children and adolescents who do not get regular sunlight exposure, do not consume at least 500 mL/d of vitamin D–fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D
• Q: What are the distinguishing features of vitamin D–deficient and calcium-deficient rickets?
• A: The biochemical features (e.g., hypocalcemia, high alkaline phosphatase, and high parathyroid hormone) and radiographic (i.e., growth-plate changes) are similar. The distinguishing feature is the difference in vitamin D status. In vitamin D–deficient rickets, 25-(OH)-D levels are low. Typically, in calcium-deficient rickets, 25-(OH)-D levels are normal (>10 ng/mL) and 1,25-(OH)2-D levels are high.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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