Do you think you or your child are not getting inadequate sun exposure or lack vitamin D, that’s why you have been diagnosed with rickets or osteomalacia.
Are you wondering about treatment and what foods to eat rich in vitamin D.
I have seen a few children who come to x-ray with rickets here in the United Kingdom. Thou studies show a significant number of people in the UK having low levels of vitamin D in their blood.
Here, I compile what I find relevant based on my radiography knowledge and findings from international medical publications about the subject.
Happy reading!😃
Any questions? remarks? Let’s meet in the comments section at the end of this article.🙏
Last updated: Oct 2024. Written by Juliet Semakula a diagnostic radiographer
Disclaimer: no affiliate links.
▶️What do we understand by the term rickets or osteomalacia?
Rickets is a condition that affects bone development in children. It causes bone pain, poor growth and soft, weak bones that can lead to bone deformities.
Adults can experience a similar condition, which is known as osteomalacia or soft bones.
In children, the changes of rickets can be seen at the growth plate of rapidly growing bones.
In the upper limbs, the changes are most prominent at the distal ulna, while in lower limbs the changes are most prominent at the metaphysis above and below the knees. As projected in the x-ray image below
This anteroposterior radiograph shows typical radiographic bony appearances of normal and rickets image.
There is widening of the epiphyseal plate due to unmineralized osteoid and loss of definition of the zone of provisional calcification at the epiphyseal/metaphyseal junction.
Being in a cold country you would expect to see so many people with rickets or osteomalacia because of the inadequate sunshine but Rickets is a global problem even in countries with adequate sun exposure like Africa.
▶️What really causes rickets or osteomalacia?
The causes of rickets or osteomalacia are categorised into three:
1️⃣ Nutritional deficiency, especially poor dietary intake of vitamin D and calcium.
Rickets can occur despite adequate vitamin D levels if the calcium intake is very low.
Rickets will only occur if the calcium intake is very low because vitamin D increases intestinal calcium absorption.
2️⃣Non-nutritional causes include hypophosphatemia rickets primarily due to renal phosphate losses and rickets due to renal tubular acidosis
Some children are born or develop medical conditions such as celiac disease, inflammatory bowel disease, cystic fibrosis and kidney problems.
These can affect the absorption of vitamins and minerals causing rickets.
3️⃣ Genetic factors: some varieties are due to inherited defects in vitamin D metabolism and are called vitamin D dependent rickets.
Hypophosphatemia rickets is a genetic disorder where the kidneys and bones deal abnormally with phosphate.
Phosphate binds to calcium and is what makes bones and teeth hard. This leaves too little phosphate in the blood and bones, leading to weak and soft bones
▶️How do you know if the cause of your rickets is due to one of these causes.?
How are rickets diagnosed
When you or your child go to the doctor, a full body examination will be done to check for abnormalities on the skull, legs, chest and wrist and ankle
✅ Physical examination.
️ ♦️Your baby’s skull will be checked to feel for any softness and delay in the closure of the fontanels.
♦️Legs for any exaggerated bowing of the legs seen in rickets.
♦️Your child’s chest will be checked for any abnormalities in the rib cages
♦️When your child has rickets the wrists and ankles will be larger or thicker than normal
✅ X-rays and imaging studies such as bone densitometry will be done to check any abnormalities in your legs, ribs, wrist and ankle. X-ray can show metaphyseal fraying and widening of growth plates.
✅Blood tests to determine the levels of vitamin D, calcium and phosphate in the blood. These also confirm a diagnosis of rickets and monitor the progress of treatment.
The diagnosis of rickets is based on the presence of these typical clinical symptoms and radiological findings on X-rays of the wrist or knee. Only when you have had these checks then can you confirm your diagnosis.
▶️What are some of the symptoms that might indicate you are suffering from rickets or osteomalacia.
Our normal bone growth and mineralization depends on the availability of adequate calcium and phosphate in our body.
If you lack these minerals in your daily diet and you do not get inadequate sunshine your bones can become soft and weak leading to rickets in children or osteomalacia in adults.
With rickets in children there is usually a deficient mineralization at the growth plate, whereas osteomalacia in adults refers to impaired mineralization of the bone matrix.
Rickets occur if the growth plates are open as in children and osteomalacia occurs after the growth plates have fused as seen in adults.
Identifying what bothers you most is important because the symptoms can manifest in various ways.
Here are some of the symptoms you must be on the lookout for.
♦️Muscle weakness
♦️Pain in the spine, pelvis, wrist and legs
♦️Delayed motor skills
♦️Delayed growth and hypoplasia with dental enamel
♦️Increased sweating.
♦️Hypercalcaemic seizures are frequent in the first year of life
♦️Pot belly sometimes and waddling gait.
♦️Develop Infection if you have calcipenic rickets
♦️Bowed legs or knock knees
Osteomalacia in adults may be asymptomatic because the growth plate is fused, and hence bony deformities are not seen.
If you have symptoms. These will be.
♦️You may start feeling aches and pains in the lumbar (lower back) region and thighs, spreading later to the arms and ribs.
♦️Tenderness to touch in the involved bones.
♦️Proximal muscles become weak, and there is difficulty in climbing up stairs and getting up from a squatting position
♦️Pathological fractures may develop due to weight bearing.
▶️What are treatment approaches for rickets?
There are several steps you can take to help you prevent rickets or osteomalacia.
🟢Dietary changes:
You should ensure you or your child are having a healthy balanced diet rich in vitamin D and calcium.
🟢Vitamin D and calcium supplementation
Dosing of vitamin D depends upon the nature and severity of the deficiency. Always consult your doctor for the actual dose.
If you are being treated for deficiency, close supervision is needed during treatment. It includes physical examination and biochemical evaluation every 2 weeks
🟢 Sunlight exposure.
You should get at least 10 to 15 minutes of sun exposure a day.
If you are from Asian, African-Caribbean and Middle Eastern origin you are more at risk of developing rickets because your skin is darker and needs more sunlight to get enough vitamin D.
🟢Orthopaedic interventions
In severe cases with significant skeletal deformities, orthopaedic interventions such as braces or surgery may be recommended to correct bone abnormalities and improve the child’s mobility.
Images showing a child in brace
Image x-ray showing a surgical procedure to correct the deformity.
X-ray should be taken at 4 weeks to see the progress of the treatment. Response is judged if the x-ray shows clear improvement and serum calcium, and phosphorus levels have normalised.
x-ray and biochemistry should be repeated after 3 months, when the growth plates should have regained a normal appearance, and biochemistry should be normal and urine calcium should become detectable.
Current vitamin D recommendations in the UK can be found in this like
The table below outlines a guide of foods rich in vitamin D. All the intakes will depend on how bad your vitamins levels are. Always fallow your doctors instructions.
| Vitamin D3 produced in the skin and D2 obtained from the diet | Intake in mg/iu |
| Sunlight | Your skin produces vitamin D when it’s exposed to the sun, and we get most of our vitamin D this way. Speeding 15 to 20 minutes a day in the sun can help. |
| Oily fish | 180 to 325 mg. |
| Eggs | 20 to 25 iu (international units)/yolk |
| Fortified breakfast cereals | (up to 8.75µg or 350 IU per 100g) USA |
| Calcium sources | Intake |
| Milk,cheese,yoghurt | Milk 1 cup 276 mg, yoghurt 275mg,285 mg cheese |
| Broccoli and cabbage, spinach | 245-266 mg |
| Dietary supplements with vitamin D | 8.5 to 10mcg of vitamin D for babies to 1 year a day for adults t (10µg or 400 IU) |
| Fortified infant formula | 400 IU/LAnd Children from the age of 1 year and adults need 10mcg of vitamin D a day. |
▶️Is rickets is reversible, can you fully recover?
Most cases of rickets go away once your child gets enough vitamin D. There may be lasting effects or defects that require further treatment, such as braces or surgery.
Your child may need therapy as a result. It is possible that your child may require a strict diet to stay healthy
If left untreated rickets can lead to:
♦️An abnormally curved spine.
♦️Failure to grow.
♦️Bone deformities
♦️Dental defeats
♦️Seizures
Vitamin D deficiency is an important cause of rickets or osteomalacia even in countries with adequate sun exposure.
Screening for vitamin D deficiency is recommended in individuals at risk to prevent rickets.
we have come to the end of this article, hope I have answered some of the frequently asked questions. Wishing you a quick recovery.🙋
📚Sources:
Sahay M, Sahay R. Rickets-vitamin D deficiency and dependency. Indian J Endocrinol Metab. 2012 Mar;16(2):164-76. doi: 10.4103/2230-8210.93732. PMID: 22470851; PMCID: PMC3313732.
Korkmaz HA, Padidela R, Ozkan B. Approach to nutritional rickets. J Pediatr Endocrinol Metab. 2023 Feb 28;36(4):335-341. doi: 10.1515/jpem-2023-0051. PMID: 36843296.
Bouillon R, Carmeliet G. Vitamin D insufficiency: Definition, diagnosis and management. Best Pract Res Clin Endocrinol Metab. 2018 Oct;32(5):669-684. doi: 10.1016/j.beem.2018.09.014. Epub 2018 Oct 3. PMID: 30449548.
Images:
Dr Irfan Merchant. MUDr, Mr Benjamin Pal Kapur. MBChB, MRCS, Dr Weisang Luo. MBChB. BSc, Miss Philippa Thorpe. MBChB, MRCS, FRCS (Orth)
Images: https://www.eurorad.org/case/12919