Vitamin D Deficiency Rickets
Vitamin D deficiency rickets is a common clinical manifestation of advanced vitamin D deficiencies, characterized by a disorder of bone mineralization, mainly encountered during growth. Daily need of vitamin D is 400-800 IU, with an average of 500 IU / day, regardless of age, depending on the growth, sun exposure and individual factors.
Vitamin D deficiency rickets occurs most frequently in the first two years of life but the disease can affect any period of childhood. In adults, in advanced forms of vitamin D deficiency, osteomalacia is installed. There are forms of rickets, where the genetic component is involved:
- Vitamin-dependent rickets (Prader hereditary rickets).
- Vitamin D resistant rickets (Albright hereditary rickets).
Causes Of Vitamin D Deficiency Rickets
The main cause of vitamin D deficiency rickets is represented by a insufficient intake of endogenous or exogenous vitamin D:
- Absence of vitamin D prophylaxis.
- Insufficient sun exposure or ineffective sun exposure due to pollution, season or skin pigmentation.
- Nutritional deficiency of calcium and phosphorus (common in premature infants).
- Nutritional deficiency of vitamin D.
Risk Factors Of Vitamin D Deficiency Rickets
- Age 3-6 months – 2 years.
- Artificial feeding, without vitamin D supplementation.
- Malnutrition, malabsorption.
- Frequent infections, diarrhea.
- Neonatal septicemia.
- Intranatal trauma.
- Corticotherapy for a long period.
- Antiepileptic treatment.
- Extrahepatic biliary atresia.
- Abandoned, institutionalized children.
- Kidney failure.
- Pregnancy disorders.
- Ecological factors.
Signs And Symptoms Of Vitamin D Deficiency Rickets
- Manifestations of mild hypocalcemia events: anxiety, night sweats, unmotivated irritability, feeling of breathlessness, muscle cramps, numbness of extremities, feeling of lump in throat.
- Palpitations, abdominal pain, bloating, loss of appetite, early satiety, asthenia, emotional volatility, reduced ability to concentrate.
- Manifestations of sever hypocalcemia: seizures, muscle contractures, screaming for no apparent reason, glottis spasm, tremor, signs of intracranial hypertension (in newborns).
- Delay of growth, short stature, bone changes, thickening of the extremities, thickening of the condro-costal joints, deformations of the chest (sternum out in relief, and distant lower ribs – pigeon breast), the appearance of Harrison subcostal groove, cranial deformation (asymmetric prominence of the frontal and parietal bose, occipital flattening) craniotabes – occipital bone softening, at palpation it has the consistency of a celluloid ball.
- Fontanels are open after the age of 18 months or, sometimes, craniosynostosis.
- Delayed appearance of the first incisors (after 10 months) or incomplete tooth eruption after 3 years.
- The abdomen is relaxed due to the low muscle tone.
- Liver and spleen are pushed down, due to chest deformity.
- Limb deformities and bone fractures.
Diagnosis Of Vitamin D Deficiency Rickets
Diagnosis of vitamin D deficiency rickets is based on clinical examination and paraclinical investigations
- Low or normal serum calcium.
- Phosphorus – low or normal.
- Low elimination of calcium in the urine.
- Increased alkaline phosphatase.
- Increased phosphaturia.
- Increased levels of parathyroid hormone.
- Demineralization of the skeleton.
- Proliferation of osteoid tissue in the growth areas of the bones.
- Magnesium levels.
- Total proteins levels.
- Investigation of liver and kidney function.
- Radiography of the extremities:
- Enlargement of the epiphysis cartilage enlargement and irregular calcification of the metaphyseal extremity.
- Shaft head looks like a cup;
- Osteo-cartilaginous junction looks fringe, with a vague contour.
- Chest radiography: anterior extremities of the ribs are enlarged.
Treatment And Prophylaxis Of Vitamin D Deficiency Rickets
- Exposure to sun at minimum 15 minutes a day.
- Correct diet, rich in vitamin D, A, calcium and phosphorus.
- Until the recovery of vitamin D deficiency rickets, will not be encouraged sitting position and walking of the baby, in order to prevent bone deformations.
- Will be avoided the abuse of flour.
- White fish, because is rich in vitamin D, which can be used after the age of 10-12 months, are indicated, in the absence of intolerance, milk, cream, egg yolk, liver, beef, veal or pork and butter.
- Is required a high calcium and phosphorus intake (400-800 mg / day).
- Foods rich in vitamin D: cod liver oil, cod liver and tuna liver, oysters, fish oil, egg yolk, liver and veal.
- Diet will ensure adequate amounts of vitamin A and vitamin F.
Attention!!! Vitamin D is toxic in high doses.
Prophylaxis is based on vitamin D supplementation in the form of drugs.
- Antenatal prophylaxis should be started by administration of vitamin D, 1000 – 1200 IU / day and calcium preparations in the last trimester of pregnancy.
- Vitamin D supplementation will continue in the first days after birth, for 18-24 months continuously and then up to age of 5 years, during the cold seasons of the year.
- 500 – 800 IU vitamin D daily.
- 1000 -1500 IU vitamin D daily during the first months of life: in twins, in the absence of prenatal prophylaxis, in anticonvulsant therapy, in corticosteroids therapy and in other high-risk groups of children.
- In premature newborns, in underweight newborns, 160 IU / kg / day of vitamin D, daily is recommended. Premature infants are more susceptible to vitamin D deficiency rickets and require high doses of vitamin D, until the third quarter of life (period required for calcium stocks recovery).
- In premature infants and infants who receive less than 400 ml of milk per day is required addition of calcium, 50 mg / kg / day.