Submitted to thewingars by
PROF SAMIYA NAEEMULLAH
Diplomat American Board Of Pediatrics,
Head of department of pediatrics
Islamic International Medical College Trust
• Identify cases of rickets clinically
• Explain Lab Diagnosis
• X-ray findings
• Enumerate preventive measures
• Define osteomalacia
A disease of growing bones
occurs in children
before fusion of epiphysis
un mineralized matrix
at the growth plates.
Failure of mature bones to mineralize
dietary lack of vitamin D
lack of ultraviolet rays of sun.
VITAMIN D METABOLISM
Maintenance of normal plasma levels of
Calcium & phosphorus.
Two forms of Vit D are present
1 Vit D2 (ergocalciferol)
2.Vit D3 (cholecalciferol)
Types of Rickets
• Vitamin D Deficient Rickets(nutritional)
• Vitamin D Dependent rickets
• Vitamin D Resistant Rickets
• Renal Rickets
• Hepatic Rickets
• Congenital Rickets
Normal bone development
• Bone consists of protein matrix –osteoid
• Mineral phase-calcium and phosphorus.
• Intramembranous ossification-flat bones
mesenchymal cells differentiate into
• Enchondral ossification –long tubular
• Growing cartilage at the epiphyseal plates
is mineralized and resorbed
replaced by osteoid matrix
which undergoes mineralization
to create bone.
Mineralization is delayed or inadequate
osteoid thickens and increase in
circumference of growth plate.
Softening of the bones-----Deformities
• Peak incidence 6 months – 2 years
• profuse sweating while asleep
• frequent respiratory infections.
• Failure to thrive
• Delay in walking,delayed dentition
• Larger than normal.
• Frontal bossing (due to excess osteoid)
Craniotabes (ping pong ball sensation)
due to thinning of outer table of skull.
• Delayed closure of anterior fontanel
• caput quadratum (square like head)
• Rachitic Rosery (prominent costochondral
• Harrison’s sulcus (depression above the
subcostal margin at the site of diaphragm)
Pulling of softened ribs by the diaphragm during
• Pigeon chest deformity.(The weakened ribs
bend inwards due to the pull of respiratory
musclesand ,causing anterior protrusion of
1. Widening of wrists and ankles
2. Bending of long bones
knock knees,(genu valgum)
3. Green stick fractures
Widening of wrist joints
Widening of ankle joints
1.Serum Calcium low (normal 9-11mg/dl)
2.Serum phosphorus low (normal-5-7mg/dl
3.Alkaline phosphatase is raised.
This is the most striking feature,shows
increased but ineffective activity of
4. 25-(OH) D levels less than 20 ng/dl
Confirms of Vitamin D deficiency
• STOSS THERAPY
• 300,000-600,000 units i/m
• Indrop D 200,000 units
• Repeat x-ray after 3 weeks
• Another dose
• HIGH DOSE VITAMIN D THERAPY
• 2000-5000 IU/day over 4-6 weeks
• Followed by intake o 400 I/U daily
VITAMIN D DEPENDENT
• Inborn error of vitamin D metabolism
• Autosomal Recessive
• Type 1 and 2
• TYPE 1
• Defect in 1 alpha-hydroxylase responsible for
the synthesis of 1-25-dihydroxy vit D
• Symptoms in the 1st year of life
• Tetany,convulsions,musle weakness andgrowth
TYPE 2 VIT D DEPENDENT
• End Organ resistance to effects to
• 1-25(OH) VIT D is high
• Physiological doses of one alpha Leo
• 1-2 micrograms per day.
VITAMIN D RESISTANT RICKETS
• X linked dominant
• Males are more severely effected than
• Vitamin D activation & tubular
reabsorption of phosphate are impaired
resulting in hypophosphatemia .
• Oral Phosphate and 1 ,25-(OH)2 –D3
• To prevent rickets, health experts
• a child should be breast-fed
• weaned and put on to cow's milk and
other foods rich in vitamin D and calcium,
like eggs and dairy products such as
butter and leafy vegetables.
1.Exposure to sunlight (ultraviolet light)
Early morning and evening 30 minutes per
week or 2 hours per week maintains
adequate sun exposure.
2.Food fortified with Vit A and Vit D
specially butter,ghee and milk.
Children under 5 should 500ml of milk
daily or youghart or cheese daily.
• Daily intake of 400 i.u.vitamin D by
• Lactating mothers should receive
supplemention with milk or vitamin D to
ensure prevention of rickets in their
• Sun exposure to mothers.
• Calcium supplements such as lime can
also be added to staple foods like rice and
bread. Plenty of sunlight, fresh air and
exercise are also necessary to ensure
sufficient Vitamin D intake.
• A meeting of international experts on
rickets held in Dhaka in 2006 identified
community-based awareness as one of
the most effective measures against the
spread of rickets. Experts at the meeting
said efforts to boost rice production over
the years had influenced diets: there was
less emphasis on calcium-rich foods such
as dairy products and leafy green
• In liver it is hydroxylated into 25-
• Converted in the kidney into 1-25-(OH)2-D
• The most active metabolite of Vit D
• It acts on GIT to increase calcium
• On bone to increase calcium resorption
• Parathyroid hormone activates Alpha-1
hydroxylase enzyme in the kidney.