Rickets- brief view

with homoeopatic approach

Presented By: Dr. SANDEEP ANWANE
Govt. Homoeo. Medical College, Bhopal

Alternative Names:

 Osteomalacia in children; Vitamin D
deficiency; Renal rickets

 Rickets is a constitutional disease of infancy
and childhood, characterized by impairment of the general health, arrested growth, abnormal proliferation of classification of the developing bone.  Rickets is a disorder primarily caused by lack of vitamin D, calcium, or phosphate, which leads to softening and weakening of the bones.

 The most common cause of osteomalacia is a
deficiency of vitamin D. Vitamin D insufficiency can cause osteomalacia because vitamin D facilitates calcium absorption and other minerals in the gastrointestinal tract necessary for bone building. Lack of vitamin D, calcium and other minerals aren’t absorbed efficiently, so they are not available for mineralization in the bone building process. This then result in soft bones.

 Insufficient sunlight exposure - Sunlight
makes vitamin D in your skin. Therefore osteomalacia can develop in people who spend little time in the sunlight, wear very strong sunscreen, live in areas where sunlight hours are short, or where the air is smoggy.  Insufficient vitamin D intake -A diet low in vitamin D is the most common cause seen worldwide. Is less common in the U.S. because many foods, such as milk and cereals are fortified with vitamin D.

 Certain Surgeries - The removal of part or all of
your stomach known as gastrectomy, can lead to this disease because the stomach breaks down foods to release vitamin D and other materials, which are then absorbed by your intestines. Surgery removing or bypassing your small intestine can lead to osteomalacia.  Chronic pancreatitis - Pancreatitis is the longstanding inflammation of your pancreas, an organ that makes digestive enzymes and hormones. If the pancreas is inflamed enzymes in charge of breaking down food and releasing nutrients do not flow as freely into your intestines.

 Chronic sprue - In this autoimmune disorder,
the lining of the small intestine is damaged by consuming foods having gluten, a protein found in wheat, barley, and rye. Damaged intestinal lining doesn’t absorb nutrients, such as vitamin D, as well as a healthy one would.

Mechanism of Vitamin –D:
 The National Institutes of Health has stated
that the following amounts of total calcium intake per day are useful to prevent rickets: 400 mg until six months of age 600 mg from six to twelve months 800 mg from one year through age five 800–1,200 mg from age six until age ten

 Vitamin D helps the body properly control calcium

and phosphate levels in the body. When the body is deficient in vitamin D, it is unable to properly control calcium and phosphate levels. If the blood levels of these minerals become too low, the body may produce other body hormones to stimulate release of calcium and phosphate from the bones. This leads to weak and soft bones.  Vitamin D may be absorbed from food or may be produced by the skin when the skin is exposed to sunlight. Lack of vitamin D production by the skin may occur in people who must stay indoors, work indoors during the daylight hours, or live in climates with little exposure to sunlight.

 Because vitamin D is a fat-soluble vitamin,

malabsorption disorders that reduce digestion or absorption of fats will decrease the ability of vitamin D to be absorbed into the body.  You may not get enough Vitamin D from your diet if you follow a vegetarian diet, do not drink milk products, or are lactose intolerant (have trouble digesting milk products). Infants who are exclusively breastfed may develop vitamin D deficiency. Human breast mil does not supply the proper amount of vitamin D. This can be a particular problem for darkerskinned children in winter months (when there are lower levels of sunlight).

 Not getting enough calcium and phosphorous
in your diet can also lead to rickets. Rickets caused by a dietary lack of these minerals is rare in developed countries because calcium and phosphorous are found in milk and green vegetables.

Risk Factor:
Those at higher risk for developing rickets include: • Breast-fed infants whose mothers are not exposed to sunlight • Breast-fed infants who are not exposed to sunlight • Individuals not consuming fortified milk, such as those who are lactose intolerant • Individuals with red hair have been speculated to have a decreased risk for rickets due to their greater production of vitamin D in sunlight.

• Your genes may increase your risk of rickets.

Hereditary rickets is form of the disease that is passed down through families. It occurs when the kidneys are unable to retain the mineral phosphate. Rickets may also be caused by kidney disorders that involve renal tubular acidosis.  Occasionally, rickets may also occur in children who have disorders of the liver, or cannot convert vitamin D to its active form.

Incidence and Prevalance:
 In the United States it is estimated that 20 to 25
million people suffer from osteomalacia, including 25 percent of women beyond menopause  Incidence of 1 per 1000 people in the United States  Rickets: In the U.S., severe nutritional rickets has become rare, although the mild disorder continues in the high-risk population (eg, individuals with dark skin, persons who live in inner-city areas). Breastfed infants who receive no vitamin D supplementation also are at risk.

 Rickets: Incidence in Europe is similar to that

in the U.S. In sunny areas, such as in the Middle East, rickets may occur when infants are bundled in clothing and are not exposed to sunlight. In some parts of Africa, deficiency of calcium and/or phosphorous in the diet may lead to rickets.  Rickets is rare in the United States. It is most likely to occur during periods of rapid growth, when the body demands high levels of calcium and phosphate. Rickets may be seen in young children 6 to 24 months old and is uncommon in newborns.

• Bone pain or tenderness

Signs and Symptoms:

Arms Legs Spine Pelvis • Skeletal deformities Bowlegs Forward projection of the breastbone (pigeon chest) Bumps in the rib cage (rachitic rosary) Asymmetrical or odd-shaped skull Spine deformities (spine curves abnormally, including scoliosis or kyphosis) Pelvic deformities

• Increased tendency toward bone fractures • Dental deformities
Delayed formation of teeth Defects in the structure of teeth, holes in the enamel Increased incidence of cavities in the teeth (dental caries) Progressive weakness Decreased muscle tone (loss of muscle strength)

• Muscle cramps • Impaired growth • Short stature (adults less than 5 feet tall)

Exams and Tests:
A physical exam reveals tenderness or pain in the bones, rather than in the joints or muscles.  The following tests may help diagnose rickets: Blood tests (serum calcium) may show low levels of calcium. Tetany (prolonged muscle spasm) may occur if serum levels of calcium are low. Chvostek's sign may be positive (a spasm of facial muscles occurs when the facial nerve is tapped) indicating low serum levels of calcium. Serum phosphorus may be low. Serum alkaline phosphatase may be high.

 Arterial blood gases may reveal metabolic
acidosis.  Bone x-rays may show loss of calcium from bones or changes in the shape or structure of the bones.  A bone biopsy is rarely performed but will confirm rickets.

• PTH • Urine calcium • Calcium (ionized) • ALP (alkaline phosphatase) isoenzyme

Other tests and procedures include the following:

 The treatment goals are to relieve symptoms and  
correct the cause of the condition. The underlying cause must be treated to prevent recurrence. The symptoms disappear with the replacement of deficient calcium, phosphorous, and/or vitamin D. Biologically active form of vitamin D could be used in people who have difficulty in converting vitamin D to its active form. Including fish, liver and processed milk, which are rich sources of vitamin D in the diet. Exposure to moderate amounts of sunlight. Skeletal deformities could be corrected by maintaining a good posture and bracing could help in reducing the deformities.

 

Outlook (Prognosis):
 The disorder may be corrected with
replacement of deficient minerals and vitamin D. Laboratory values and x-rays usually improve after about 1 week, although some cases may be resistant and require large doses of minerals and vitamin D.  If rickets is not corrected while children are still growing, skeletal deformities and short stature may be permanent. If it is corrected while the child is young, skeletal deformities often diminish or disappear with time.

Possible Complications:
• Chronic skeletal pain • Skeletal deformities • Skeletal fractures, may occur without cause

 Osteomalacia caused by inadequate sun exposure and
a diet low in vitamin D can be prevented.  Spend a few minutes in the sun Direct exposure in the sun to the arms and legs for five to ten minutes daily is sufficient for adequate vitamin D production. If a person lives in cold climate and don’t get enough sun exposure during the winter, they can build enough vitamin D stores in the skin during warmer months. Although regular use of sunscreen helps prevent skin cancer and premature aging of the skin, there is concern that the frequent use of strong sunscreen can increase the risk of developing ostemalacia.

 Spend a few minutes in the sun Direct exposure in the
sun to the arms and legs for five to ten minutes daily is sufficient for adequate vitamin D production. If a person lives in cold climate and don’t get enough sun exposure during the winter, they can build enough vitamin D stores in the skin during warmer months. Although regular use of sunscreen helps prevent skin cancer and premature aging of the skin, there is concern that the frequent use of strong sunscreen can increase the risk of developing ostemalacia.  Take supplements If a person doesn’t get enough vitamins and minerals in their diet or if they have a medical condition affecting the ability of their digestive system to absorbing nutrients, they are recommended to ask a doctor about taking vitamin D and calcium supplements.

 Exercise Exercise such as walking helps

strengthen bones, but if a patient has slight fractures due to osteomalacia, they should avoid strenuous activity until their bones heal.  Renal (kidney) causes of vitamin D malabsorption should be treated promptly. Levels of calcium and phosphorus should be monitored regularly in people who have renal disorders.  Genetic counseling may help people with a family history of inherited disorders that can cause rickets.

Homoeopathic Treatment:
 Calcarea phos
In delicate children, caused by soft sponginess of the bone, from want of phosphate of lime molecules. Skull soft and thin, with crackling noise when pressed upon, delayed closure of fontanelles, sallow, earthy complexion, face pimpled, retarded dentition, emaciation, lateral curvature, swollen condyles in both extremities, spina bifida, non-union of broken bones, systematic dyscrasias. Potts\' disease, shrunken children, hard lumps on the cranium, diarrhoea during dentition with much flatus, cold tremors, child cannot hold head upright. Its principal indications are the fontanelles which remain wide open, the diarrhoea and the emaciation of the child.

Kali phos Atrophy of the bones, with putrid-smelling discharge from the bowels. Indigestion with nervous depression.

Natrum mur Particularly useful when the thighs are notably emaciated and the disease is in its early stages, with slight pliability of the bones. (Gilchrist.)

 Silicea
Open fontanelles, head too large and rest of body emaciated, with pale face, abdomen swollen, hot; ankles weak, profuse head sweat and body dry, likes wrapping up warmly, offensive diarrhoea, stools contain undigested food, with great exhaustion, but painless; inflammation, swelling and suppuration of glands and bones, ulceration and necrosis, cellular inflammation, boils. Abscess, etc., with tardy recovery and subsequent induration.

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