Rickets

Rickets

Definition
Rickets is a disorder of growing bone caused by deficiency of vitamin D (or calcium/phosphate) which leads to soft, weak bones in children.

Causes / Etiology

• Inadequate dietary vitamin D, calcium or phosphate
• Lack of sunlight exposure (reduced skin synthesis of vitamin D)
• Renal disease causing loss of active vitamin D (renal osteodystrophy)
• Genetic defects in vitamin D metabolism (e.g., vitamin D‑dependent rickets)

Types or Classification

• Nutritional rickets – due to poor intake or absorption of vitamin D, calcium or phosphate.
• Renal rickets (renal osteodystrophy) – occurs in chronic kidney disease where active vitamin D is not formed.
• Genetic rickets – inherited defects in enzymes or receptors of the vitamin D pathway.

Pathology (step‑wise)
step 1 → Vitamin D deficiency → ↓ intestinal absorption of calcium and phosphate.
step 2 → Low serum calcium (and phosphate) → parathyroid glands release PTH (parathyroid hormone).
step 3 → PTH increases renal excretion of phosphate and mobilises calcium from bone.
step 4 → Persistent low calcium‑phosphate product → defective mineralisation of osteoid → soft, pliable bone (rickets).

Clinical Features

General

• Bone pain, especially in legs and ribs
• Muscle weakness, easy fatigue
• Delayed growth, short stature

Specific (skeletal)

• Bowed legs (genu varum) or knock‑knees (genu valgum)
• Rachitic rosary – beading of costochondral junctions (enlarged wrist/ankle joints)
• Cupping and fraying of metaphyses on X‑ray
• Dental defects – delayed eruption, enamel hypoplasia

Complications

Acute

• Hypocalcaemic tetany (muscle spasms, seizures)
• Pathological fractures due to weak bone

Chronic

• Osteomalacia in later life (soft adult bone)
• Permanent deformities of long bones and pelvis
• Stunted growth and reduced adult height

Diagnosis / Investigations

Routine tests

• Serum calcium (low or low‑normal)
• Serum phosphate (low)
• Alkaline phosphatase (markedly raised, reflects osteoblastic activity)
• Serum 25‑hydroxy‑vitamin D (deficient)

Special tests

• X‑ray of wrist/knee – shows cupping, fraying, widened growth plates
• Urine calcium/creatinine ratio – helps differentiate renal from nutritional causes
• Bone biopsy (rare) – confirms defective mineralisation

Management

General management

• Correct vitamin D deficiency: oral vitamin D3 400 IU daily for infants, higher doses (2000‑5000 IU) for deficient children as per protocol.
• Calcium supplementation: elemental calcium 500‑1000 mg/day in divided doses.
• Phosphate supplementation if severe hypophosphataemia.

Modern treatment

• Active vitamin D analogues (calcitriol) for renal or vitamin D‑dependent rickets.
• Bisphosphonates are occasionally used in refractory cases to stabilise bone turnover.

Dietary advice

• Encourage regular safe sunlight exposure (10‑15 min mid‑day).
• Include dairy products, fortified cereals, oily fish, egg yolk for calcium and vitamin D.
• Limit phosphorous‑rich soft drinks; ensure balanced protein intake.

Homeopathic Therapeutics (key remedies, brief keynote style)

Calcarea carbonica

• Bowed legs, delayed walking, weak muscles.
• Rachitic rosary, enlarged costochondral joints.
• Tendency to chill, especially in damp weather.
• Irritability, especially at night.
• Preference for cold drinks, aversion to heat.
• Slow, steady growth once corrected.

Phosphorus

• General weakness, especially in the evenings.
• Bone pain aggravated by cold, relieved by warmth.
• Tendency to bleed easily (nosebleeds, bruises).
• Restlessness, anxiety, fear of being alone.
• Craving for cold water, aversion to hot drinks.
• Sensitive to light, prefers dim rooms.

Calcarea phosphorica

• Delayed dentition, enamel defects, loose teeth.
• Slow bone development, metaphyseal cupping.
• Craving for cold, salty foods; aversion to dairy.
• Fatigue after mental work, difficulty concentrating.
• Tendency to develop rickets after illness or poor diet.
• Improvement with fresh air and moderate exercise.

Silicea

• Fragile bones, easy fractures, tendency to develop deformities.
• General debility, poor appetite for solids.
• Sensation of “sand” in the eyes, hair loss.
• Aversion to rich, fatty foods; prefers light, dry diet.
• Tendency to develop infections of skin and bone.
• Beneficial when given in the early stages of rickets.

Symphytum (St. John’s‑wort)

• Promotes bone healing, useful after fractures.
• Deep, aching bone pain, especially in long bones.
• Tendency to develop suppurative infections at wound sites.
• Craving for salty foods, aversion to sweets.
• Improves with gentle massage and warm compresses.
• Useful in convalescence to strengthen newly formed bone.