MANAGING A QUALITY LIFE WITH RICKETS

Rickets is defective mineralization of the growing bone seen in infants and young children caused due to abnormal calcium and phosphorus levels. This results in soft and weakened bones and bony deformities. It is commonly seen in dark-skinned children or children with inadequate exposure to sunlight.

Bone mineralization requires a sufficient supply of the essential mineral ions, calcium, and phosphorus. Vitamin D helps in the absorption of calcium ions from the gut. With insufficient serum calcium concentration caused by either vitamin D deficiency or inadequate dietary calcium intake, parathyroid hormone (PTH) will get activated leading to bone resorption and causing the release of stored bone minerals into the bloodstream thus maintaining normal serum calcium.

Bone disease (rickets and osteomalacia) develops once elevated PTH has led to low serum phosphate levels, as a result of impaired renal phosphate conservation. Nutritional Rickets is a disorder of defective growth plate matrix mineralization in children. Osteomalacia is abnormal matrix mineralization in established bone, and although present in children with rickets, it is used to describe bone mineralization defects after completion of growth. With insufficient serum calcium concentration caused by either vitamin D deficiency or inadequate dietary calcium intake, parathyroid hormone (PTH) will get activated leading to bone resorption and causing the release of stored bone minerals into the bloodstream thus maintaining normal serum calcium.

The clinical features seen in rickets include-

1. Cranio-tabes(softening of the skull around suture lines)

2. Frontal bossing(forehead bulges out)

3. Wide-open anterior fontanelle

4. Wide wrist

5. Delayed dentition

6. Harrison sulcus visible( Visible retraction of muscles at lower ribs)

TREATMENT FOR RICKETS

Treatment for rickets is essential to manage a quality life.

Treatment may be given gradually over several months or in a single-day dose of 6,00,000 IU of Vitamin D. If the gradual method is chosen 5000-10,000 IU is given daily for 2-3 months until healing is well established and the alkaline phosphatase concentration reaches the reference range

If the vitamin D dose is administered in a single day, it is usually divided into 4 or 6 oral doses. An intramuscular injection is also available. Vitamin D is well stored in the body and is gradually released over many weeks.

The single-day therapy avoids problems with compliance and may be helpful in differentiating nutritional rickets from familial hypophosphatemic rickets(FHR). In nutritional rickets, the phosphorus levels rise in 96 hours and radiographic healing is visible in 6-7 days. Neither happens with FHR.

A study conducted found that a daily calcium intake of 1000mg resulted in more radiographic healing than 500 mg per day dosing. The study also found that complete healing of nutritional rickets may sometimes take more than 24 weeks.

Human milk has little vitamin D and very little phosphorus. Infants who are weighing less than 1500gms need special supplementation (Vitamin D, Calcium, Phosphorus) if breast milk is their primary dietary source. Recommending a vitamin D supplement from the first week of life for susceptible infants is safe and effective.

The upper level of recommended daily allowance for 0-6 months and 6-12 months infants is 1000 IU/day and 1500 IU/day. However, an adequate intake of 400 IU/day has been suggested for infants 0-12 months while post that 600 IU/day has been recommended.

PREVENTION OF RICKETS

The three-pronged prevention strategy is employed-

1. A healthy balanced diet having adequate vitamin D sources like fish, cod liver oil, egg yolks, mushrooms, soy milk, almond milk, and orange juices among others can be used in older children.

2. Sunlight exposure- Exposing 12%-18% of body surface area to unprotected sunlight for 30-45 mins is equivalent to taking 600-1000 IU(for older children) of vitamin D which is the dose recommended by experts for the fortification of food. Vitamin D synthesized in the skin lasts twice as long. We as humans can get Vitamin D from abundant sunshine.

3. Vitamin D supplementation-It is used to meet the recommended daily allowance of vitamin D for the individual. RDA for vitamin D is as follows-

4. <1 year- 400 IU

5. 1-70 years- 600 IU

6. >70 years- 800IU