Rickets
What is rickets?
Rickets is a bone disease that develops in growing individuals due to the insufficiency of minerals such as calcium and phosphorus in the development of bones. The mineralization defect that develops after the completion of bone growth is called osteomalacia.
Rickets is a disease of many systems, mainly bone tissue. Vitamin D deficiency is the most common vitamin deficiency in our country. Since vitamin D is not absorbed sufficiently, calcium cannot be utilized sufficiently and ossification is impaired.
Rickets is a disease of developing countries. Turkey is a prevalence of between 5-6 percent; but in some regions this rate is much higher. It has been reported that this ratio has decreased below 1% as a result of the rickets prevention program initiated by the Ministry of Health in recent years. Although it occurs at any age, rickets is often associated with vitamin D deficiency in children. Although it can be seen at any age, it usually occurs in children aged 3 months to 2 years.
Vitamin D deficiency develops especially in brown-fed infants who are fed with milk and during periods of rapid growth. In premature infants, vitamin D deficiency is seen in the early period because they are born with incomplete storage and grow rapidly.
What are the causes of rickets?
The reasons are varied. Rickets is the most common form of rickets in infancy due to vitamin D deficiency.
Vitamin D provides sufficient amounts of calcium and phosphorus, which are the main minerals that provide bone mineralization, in body fluids and tissues. Vitamin D is made in the skin with the help of sunlight as well as being taken with foods unlike most other vitamins. This vitamin D made in the skin is the main source that meets the needs of the body. Vitamin D, which is taken with food or made in the skin, goes through a series of processes in the liver and kidneys and becomes the most effective vitamin D form.
Vitamin D deficiency may develop due to a problem in any of the stages of active vitamin D formation. Not to take nutrients rich in vitamin D and calcium, not drink enough milk, to eat a large amount of floury foods, not enough sun to live in unsanitary, humid, dark and flat-ceilinged houses, to be a mother child who is not fed during the pregnancy and the sun does not benefit from the intestinal absorption disorder Causes rickets such as liver or kidney failure, disrupting the activation of vitamin D. In addition, some long-term medications may also affect vitamin D metabolism, leading to rickets. Diphenylhydantoin (epdantoin) and phenobarbital (luminal) used in the treatment of epilepsy (epilepsy) are among these drugs.
In addition to vitamin D, deficiencies of calcium and phosphorus minerals negatively affect bone development.
What foods does Vitamin D contain?
Vitamin D is found in animal foods such as butter, milk, cheese, eggs, fish and liver. Vitamin D is also found in plants in the form of vitamin D 2 . However, only vitamin D 3 taken from animal food is stored in the body.
Enriched nutrients are needed to get enough of this vitamin. If nutrients are not specifically enriched with vitamin D, an ordinary diet is often not sufficient to meet daily needs. In addition to fish products and fish oil, vitamin D is not present in every diet.
Is there enough vitamin D in breast milk?
The amount of vitamin D in breast milk is around 12-60 IU. This amount is small compared to 400 IU which needs daily vitamin D.
Although it has been suggested that vitamin D in breast milk is more easily absorbed and therefore more effective, it is now believed that breast milk alone will not meet the vitamin D requirement of the infant. In infants breastfed, this vitamin should be given in addition. This is especially important if the mother has vitamin D deficiency. The unborn baby needs the vitamin D from the mother. The fetus stores vitamin D in various tissues as well as it can manage itself for a while after birth. If vitamin D stores are not sufficient in the mother, the baby is born either deficient in vitamin D or stored insufficient vitamin D. In this case, if not enough vitamin D is taken after the birth or if it is not exposed to enough sunlight, it will be easier to develop rickets due to vitamin D deficiency.
Congenital rickets is a form of rickets that occurs in the first three months after birth in infants of undernourished mothers.
What are the symptoms of rickets?
The symptoms of rachitism vary according to age. Symptoms in the first age, which is the most common period, depend on low levels of calcium and phosphorus in the blood. These symptoms range from ambiguous symptoms such as unexplained restlessness to transfer. Hypotonia is prominent in infants with rickets, the muscles are loose and weak; therefore, their bellies are swollen and common to the sides (frog's belly), they sit late, crawl late and walk late. Intelligence developments are not affected. Another symptom of unknown origin and its association with the disease has not been clearly shown, but is frequently said by mothers is excessive sweating, especially at the beginning.
Other signs of rickets are due to insufficient calcium accumulation in the bones. In rickets, bone symptoms first appear in the rib cage at the age of 4-10 months, and in the arms and legs after six months. This is because the effect of vitamin D deficiency is more pronounced in fast-growing bones. Head bones are soft; therefore, the baby's head is held on the sides, and some areas are collapsed by pressing the fingertips from behind. Their foreheads are wide and prominent; The head is larger than the body; flattening according to the lying direction. Bılgıldak is wider than age and closes late (after 18 months). Wrists and ankles are wider than normal (painless and after six months); the bone-cartilage junctions of the ribs are enlarged (rib rosary); a groove-like collapse may occur at the bottom of the rib cage where the diaphragm adheres to the chest. Chest anterior or inward exit anomalies such as shoemaker's chest and bird's chest are encountered. Teeth come out late and decay early. The most important finding after the child begins to walk is the curvature of the legs (O or V leg). Humpback, curvature of the back bone. The angle of the femur's neck with the body of the femur narrows, causing distortion of the hip and causing the child to walk gibi like a duck.. If the disease is left untreated, growth slows down and after a while, the child stays back according to their peers.
There is a predisposition to respiratory infections. Some suffer from constipation and others have diarrhea. Sleep disorders, restlessness and anemia are seen. Anemia is common in rickets and can reach important measures; red blood cells can fall down to 2 million or even more. Anemia is often associated with spleen growth. All these symptoms regress with vitamin treatment.
Vitamin D requirement should also be emphasized in pre-puberty individuals. During this period, mostly vitamin treatment is required.
Is it possible for rickets to occur other than vitamin D deficiency?
Rickets may also occur in rare cases. These conditions are due to either kidney disease or genetic / familial disorders that have been present since birth and present with symptoms later. Since the outcomes and treatment of these diseases are unique to each, it is important to differentiate them from rickets due to vitamin D deficiency.
How is rickets diagnosed?
In every child who has been deprived of adequate sunbathing and preventive rickets treatment, a combination of symptoms is sufficient for diagnosis. Hand-wrist radiography, blood calcium, phosphorus, alkaline phosphatase and parathyroid hormone levels are required for definitive diagnosis. Blood calcium levels are normal or low, phosphorus levels are low, alkaline phosphatase and parathyroid hormone levels are high. X-ray shows that the ends of long bones are swollen, concave in the middle and irregular edges. Mineral loss in the bones is sometimes severe enough to cause spontaneous fractures (green tree fractures) under the bone membrane. Chest films show that the front ends of the rib springs expand in the form of champagne cork and sometimes have broken lines on the back of the ribs. In these bone disorders, bronchial lung appearance disorders, which are called «rickets lung» are added; Increased bronchial-vascular network, emphysema in the hills, and aeration disorders with transparency around the hilum of the lung are observed.
How is rickets treated?
Rickets is not difficult to treat. The basis of the treatment consists of supplying enough vitamin D to fill the deficiencies and fill the tanks. Treatment is given orally except in very rare cases. Sometimes injected intramuscularly. One of these two treatments is preferred depending on the condition of the patient. Vitamin D is given daily at 5-12 times the daily requirement (2000-5000 IU / day) and for two to three months. Another treatment is to administer high-dose vitamin D (150,000-300 000 IU) orally. Both treatments have their own advantages and disadvantages and the decision of which treatment to choose should be made by the physician. If symptoms of calcium deficiency are severe and calcium levels are low, oral calcium is added to the treatment.
With treatment, biological and X-ray symptoms resolve more quickly than clinical symptoms. Blood calcium and phosphorus levels return to normal in three weeks; this is followed by normalization of the alkaline phosphatase level. In terms of X-ray symptoms, bones begin to re-mineralize very quickly. Re-mineralization first begins with a linear condensation in the growth cartilage and the re-emergence of ossification nuclei at the bone tip. At 3-6 weeks, the sharpness of the bone borders reappears. The general condition improves and muscle laxity disappears. When treatment is started early enough, the child heals rapidly and leaves no trace of the disease. If treatment is started later, deformities will resolve much longer. Once rickets has improved, a normal dose of treatment should be followed.
As a general rule, deformities relieve themselves after treatment with rickets. Orthopedic interventions should generally be avoided unless growth ceases. Surgery is applied to permanent abnormalities.
Are there any risky aspects of rickets treatment?
If vitamin D is used unnecessarily and overdose or overdose, it can lead to a condition called vitamin D poisoning that can lead to hypercalcemia, renal failure and death. Therefore, vitamin D treatment should be administered under the supervision of a physician.
How can rickets develop?
Prevention of rickets is based on a balanced diet, sun exposure and oral vitamin D administration.
Since vitamin D is not present in sufficient amounts in foods and the best source of vitamin D is sun, the basic condition of protection from rickets is to ensure that pregnant and lactating mothers and children are exposed to sufficient sunlight. The child should be taken to the sun every day; however, since the ultraviolet ray that makes vitamin D does not pass through the window glass, direct exposure to sunlight is necessary to achieve the desired benefit; ie sunbathing should not be from behind the glass.This time is 20 minutes a day with the head open, hands and feet naked during the hours when sunlight does not come upright. It should be kept in mind that mothers are the most important source of vitamin D in babies, and pregnant or lactating women should try to be exposed to sunlight similarly. The vitamin D level in the newborn baby is 80 percent of that of the mother. If the store of the mother is empty, the baby is born with an incomplete level. Therefore, vitamin D supplementation is recommended to the mother during pregnancy.
Regardless of the diet, 400 IU (3 drops) of vitamin D should be given orally to each baby born for at least one year. Vitamin D should be given to children up to 6 years of age if they are not fed adequately and balanced. The dose of vitamin D that should be given to premature babies can be up to 800 IU per day. Vitamin D supplements under the supervision of a doctor is recommended during periods of rapid growth.
Another important way of protection is the enrichment of the most commonly consumed nutrients in vitamin D while still in preparation. Enrichment of not only milk and bread in terms of vitamin D will serve to reduce not only rickets but also the risk of bone loss (osteoporosis) and fracture associated with vitamin D deficiency in older ages.
The child should be provided with calcium-containing foods every day. The best source of calcium is milk and products such as yoghurt, cheese and precipitate. Molasses is also a good source of calcium.
Are there false beliefs about vitamin D?
Vitamin D deficiency may delay the emergence of teeth. Therefore, it is common to believe that vitamin D is beneficial in all children with delayed ejection. High-dose vitamin D injections, other than those recommended by a doctor under the name “Toothbrush”, can have serious consequences, such as vitamin D poisoning. There may be various reasons for delayed tooth emergence. Vitamin D deficiency is just one of them. It is wrong to give a high dose of vitamin D to every child who has delayed out without knowing the underlying cause.
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