Rickets: Causes, Symptoms & Treatment

Rickets is a disease that is almost extinct in Germany and is also fondly referred to as “softening of the bones“. It is a disease that occurs in childhood but, if left untreated, can have effects into adulthood.

What is rickets?

The word rickets is derived from the Greek term “rhachis,” which means “spine.” Before the Industrial Revolution, rickets was very common in Europe because children in particular worked as cheap labor in factories and mines and saw little sunlight. The air in the cities was stuffy and polluted, sunlight hardly reached the people. It was not until much later that doctors found the link between rickets and sunlight. Rickets is a metabolic disease caused by vitamin D deficiency. Vitamin D is absolutely necessary for the blood to absorb calcium and phosphate and transport them to the bones. In the case of vitamin D deficiency, the vitamin can no longer be converted into its effective level in the skin. The bones that are growing do not calcify properly in rickets, they remain soft and become crooked under stress. In rickets, the spine is mainly affected, but also the legs.

Causes

As mentioned above, in rickets, vitamin D metabolism does not function properly. This is caused either by a protein deficient diet, too little exposure to sunlight, or faulty absorption of nutrients in the gastrointestinal tract. There is also a special form of rickets that is not caused by vitamin D deficiency. The body needs vitamin D to properly incorporate calcium and phosphate into the bones. Vitamin D also ensures that calcium and phosphate can be absorbed from the intestines and recovered from the kidneys. In the case of vitamin D deficiency, this absorption is disturbed. The bones become soft and deformed. The human body produces vitamin D itself in the skin with the help of ultraviolet radiation from sunlight. A small part of the vitamin D requirement is taken up with food. However, intake from food is not sufficient for rickets prophylaxis.

Symptoms, complaints, and signs

Rickets is a bone disease in children usually caused by vitamin D deficiency. It is also known as English disease. The petant of the disease occurring in adults is osteomalacia. It is generally referred to as calcium deficiency rickets. Far less common is phosphate deficiency rickets, which is often inherited. The disorder is caused by a loss of phosphate via the kidneys. Around the second month of the child’s life, the first symptoms of the disease appear. Children generally become restless and startle easily. In addition, there is sweating and an itchy skin rash. This is caused by the increased sweating. After another four weeks, general muscle weakness and the characteristic soft “frog belly” become noticeable. The children are prone to constipation and muscle cramps. Softening of the skull bone results in a severely flattened back of the head, with the typical appearance of a “square skull.” The thorax and the joints of the extremities widen. Defects are also noticeable in the jawbone. The children teethe late, the enamel shows defects and an open bite can develop. Rickets is accompanied by various bone deformities. A typical sign is bow legs. These result from the curvatures of the long bones. Adults do not show bone deformities in rickets caused by vitamin D deficiency because bone growth is already complete.

Disease progression

Symptoms of rickets begin to appear as early as the second or third month of life. Restlessness, jumpiness, and profuse sweating at the back of the head are among the early symptoms. This is accompanied by an itchy skin rash. Constipation, a flabby abdominal wall, cramps and changes in the skeleton are symptoms that are added in the third to fourth month of life. Still open cranial sutures close only with delay, skull bones soften. The ribs show the typical rachitic rosary. These are distensions at the bone-cartilage border of the ribs, which look like strings of pearls. Tooth eruption is delayed, enamel formation is disturbed, and children are prone to tooth decay. Typically, in rickets, the thigh bones become deformed and the children have severe bow legs.

Complications

Complications are not to be expected in case of prompt and adequate treatment. Therapy based on high-dose vitamin D in combination with calcium usually causes the symptoms to subside very quickly. However, failure to treat the condition can lead to a number of complications. Rickets is a disorder that occurs in childhood but can severely affect the quality of life of those affected in adulthood if it is not treated or not treated adequately. The bones that are growing in children do not calcify properly in the case of a vitamin D metabolic disorder; they remain soft and bend when they are loaded. In severe cases and with delayed therapy, so-called “greenstick fractures” are to be expected, especially in children. This is an incomplete bone fracture in which the elastic periosteum surrounding the bone remains uninjured. However, patients usually still have to wear a cast for a long time, which is usually very difficult for children in particular. If severe bone deformities have occurred as a result of rickets, these can usually only be corrected by surgery. This is not possible in all cases. The patient may then suffer lifelong deformities that reduce the quality of life and develop other disorders, for example, constant shortness of breath with a curvature of the thorax, which accompany him into adulthood.

When should one go to the doctor?

The condition usually occurs in children. The first signs of irregularity can be seen from the second month of life. If left untreated, long-term sequelae can occur and persist into adulthood. Therefore, parents, relatives and guardians should react as early as possible to changes in the child’s health and consult a doctor. Noticeable changes in the appearance of the skin, itching or sweating indicate an impairment of health. There is a need for action as soon as the complaints persist for several days or weeks. An increase in irregularities is cause for concern. In these cases, a visit to the doctor is required as soon as possible. In case of disturbances of the digestive tract, constipation or a general feeling of illness, medical help is needed. Cramps or loss of control over the muscular system are considered a distinguishing feature of rickets. If abnormalities of the body structure are evident during the growth process, a physician should be consulted. In the case of a square skull shape, O-shaped legs or widening of the chest, observations should be discussed with a doctor. Deformities or curvatures of the skeletal system as well as peculiarities of the jaw should be examined and clarified. Abnormalities of the teeth, enamel or delayed tooth growth are signs of a disease. If an open bite occurs, a check-up visit with a doctor should take place so that a cause investigation can be initiated.

Treatment and therapy

In the past, rickets was treated with cod liver oil, because cod liver oil contains vitamin D. Today, children with the disease receive vitamin D for three weeks and, if calcium is deficient, calcium in high doses. Treatment of vitamin D deficiency rickets should be done up to age 4 LW with 1000 IU vitamin D3 and additional calcium administration (40-80 mg/kg per day) for about 12 weeks. This should be followed by implementation of prevention with 500 IU vitamin D3 until the end of 1 year of age. Babies from 4 weeks of age to 12 months of age receive 3000 IU of vitamin D3 and additional calcium administrations (40-80 mg/kg per day) for a period of 12 weeks. Thereafter, prevention should be treated with 500 IU vitamin D3 until the end of the 1st year of life. Children and adolescents from the age of 1 year are treated with 5000 IU vitamin D3 and additional calcium administrations (40-80 mg/kg per day) for a period of 12 weeks. Thereafter, adequate exposure to sunlight and calcium intake through a balanced diet (e.g. milk) should be ensured. (Source: Guidelines of the Society for Pediatrics and Adolescent Medicine (DGKJ))

Since lack of sunlight is also a cause, sunlight or high-altitude sun exposure is also part of the therapy. Following drug therapy, a calcium-rich diet must be maintained. Regular sunlight is also necessary. In the case of phosphate deficiency symptoms, phosphate must be substituted with medication. The bone deformities usually heal with this treatment.However, severe thigh deformities due to the disease rickets often need to be corrected with splints.

Prevention

Rickets is almost extinct in Germany today. Newborns and infants are prophylactically given a 500 IU vitamin D tablet every day for the first year of life, since breast milk and even cow’s milk do not contain enough vitamin D. Infant milk is usually fortified with vitamin D. Actually, 100-200 IU per day is recommended for children of this age, with the higher dosage of the tablet is to absorb fluctuations and also occasional forgetting to give the tablet. In most cases nowadays the administration is done in combination with fluorine for caries prophylaxis. The tablets are soluble in milk and water and can therefore be administered with infant milk or tea to prevent rickets. Playing outside or in the sun also ensures a healthy vitamin D balance. However, parents should be careful, especially in the summer, that their children do not get sunstroke, heat stroke or sunburn while doing so.

Aftercare

In most cases, there are no special or direct aftercare measures available to those affected by rickets, so they should see a doctor early if they become ill. In most cases, there may also be no self-healing, so a visit to a physician is always necessary for the patient. The sooner a doctor is contacted, the better the further course of the disease usually is. Most of those affected are dependent on a surgical intervention, through which the complaints can be permanently alleviated. In any case, those affected should rest and take it easy on their bodies after such an operation. Physical exertion and stressful activities should be avoided in any case. The further course of the disease depends very much on the type and also on the severity of the malformations, so that a general prediction is usually not possible. It is also possible that the life expectancy of the child is significantly limited or reduced as a result of this disease. Further aftercare measures are not available to those affected by this disease and are usually not necessary. In many cases, rickets thereby reduces the life expectancy of the affected person.

What you can do yourself

In the case of rickets, bed rest and warmth are important. At the same time, the sufferer should provide the body with plenty of sunlight and air. In summer, sleeping with the window open can be done. Hot compresses relieve the pain and help in a speedy recovery. Warm milk with honey also helps rickets with sore throat and difficulty swallowing. Other effective natural remedies are heather, willow rod, thyme and lady’s mantle. These remedies can be drunk as a tea or applied to the skin in the form of a decoction. In consultation with the family doctor, the sick person can start a diet of vegetables, honey and milk products. First and foremost, a diet rich in iron and other minerals and vitamins is important. Moderate sports and exercises from yoga and Pilates can support physiotherapy and contribute to recovery. Since rickets is usually chronic, aids such as walking aids or a wheelchair must also be organized in the long term. For this, the affected person should contact the family doctor directly, who can clarify further details with the health insurance company. Finally, the cause of the rickets must be found and treated. If this succeeds early, only few complications occur and the mentioned home remedies are sufficient for a quick improvement of the health condition. If, despite all measures, the symptoms become more severe, the family doctor must be informed.