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Published by Bupa's health information team, August 2008.
This factsheet is for parents of children with rickets, or those who would like information about it.
Rickets is a disease which affects bone development in children. It causes their bones to become soft and weak, and can lead to deformities. Rickets is most common in children aged three to 18 months, and is usually caused by a lack of vitamin D and/or calcium.
Bone development in children
During childhood, bones continually grow and develop. Often this growth is at its peak in infancy and puberty. Growth stops once your child's bones and skeleton are fully developed.
The strength of your child's bones depends on the amount of minerals that are laid down in them. This is done through a process called mineralisation. Minerals such as calcium and phosphorus are taken from the food your child eats and deposited in their bones. This process is assisted by vitamin D, which helps the body to absorb calcium and makes sure it gets to where it's needed. During childhood, mineralisation ensures that bones grow and develop, whereas in adulthood it maintains and repairs them.
Rickets is a disease which affects how your child's bones grow and develop. It causes them to become soft and weak. As your child grows, his/her increased body weight can cause soft, weak bones to become bowed and deformed.
Soft bones can also affect adults (after their bones have stopped growing); this condition is called osteomalacia.
Symptoms of rickets
The symptoms of rickets may include:
- soft skull bones
- delayed closing of the soft spot at the top of your babies head (the anterior fontanelle)
- poor growth (your child may be short for his or her age)
- floppiness in the limbs and body due to muscle disease or weakness
- teeth taking longer to come through
- weak tooth enamel which may lead to tooth decay
- bone pain in the arms, legs, spine and pelvis (but this is rare)
- fractures, as the result of a fall
Your child may also have skeletal deformities, such as:
- thickening of their ankles, wrists or knees ("knock-knees")
- legs that curve outwards ("bow legs")
- a breast bone that sticks out ("pigeon chest")
- ribs that stick out - this may look like a set of beads on their chest ("rachitic rosary")
- an asymmetrically shaped skull
- spinal deformities (eg a hunched back)
- pelvic deformities (eg a beaked pelvis)
If your child has any of these symptoms or skeletal deformities, you should see your GP.
Complications of rickets
If your child has very low levels of calcium in his/her body, they may develop hypocalcaemia. Hypocalcaemia can make the symptoms of rickets much worse and cause fractures. Symptoms include:
twitching in the body
tingling in hands and feet
If your child has any of these symptoms, you should take him/her to see your GP.
Causes of rickets
Nutritional rickets is the most common type of rickets. It's caused by a lack of vitamin D or calcium (or both) in your child's diet. Both these minerals are essential for forming strong, healthy bones.
It's not known how many children have nutritional rickets. It had been largely wiped out in the UK. However, in recent years it has re-emerged, especially in children from ethnic groups (eg Asian, African Caribbean and Middle Eastern).
Vitamin D comes from two main sources - sunlight and diet. About 80 percent of the vitamin D your child needs comes from sunlight, and the rest comes from diet.
Rickets is more common in children from Asian, African Caribbean and Middle Eastern origin because dark skin needs to be in the sun for much longer than light skin to get enough vitamin D. However, children with light skin can also be at risk if they don't go outside in the sunlight very often, are frequently covered up or wear sunscreen.
Children who have diets that limit certain food groups (for example vegetarians, vegans or macrobiotics) may also be at risk of developing rickets. This is because they may not be getting enough calcium or vitamin D in their diet. Also, breast milk contains very little vitamin D, so babies who are exclusively breastfed are at risk of developing rickets. However, it's important to remember that breast milk is the best source of nutrition for your baby, containing everything he or she needs to grow and develop.
This is a rare inherited form of rickets. If you child has this form of rickets, he/she will be unable to absorb enough of the vitamins and minerals needed to build strong, healthy bones.
These can make it difficult for your child to process and absorb vitamin D, and can include vitamin D dependent rickets type I (a rare inherited condition) or vitamin D dependent rickets type II.
Rickets can be due to other conditions such as liver disease, kidney disease or kidney failure.
Diagnosis of rickets
Your GP will ask about your child's symptoms and carry out an examination. He or she may also ask you about your child's medical history.
If your GP suspects your child has rickets, your child will be asked to take a blood test. This will measure the amount of vitamin D, calcium and phosphorous in your child's blood. Your child may also be referred to the hospital for an X-ray, usually of the wrist.
If rickets is diagnosed, your child will be referred to a paediatrician (a doctor who specialises in treating conditions in children) for treatment and monitoring.
Treatment for rickets
Rickets is treated with daily vitamin D and calcium supplements. However, sometimes a vitamin D injection may be given once a year instead of daily vitamin D supplements.
It's very important that you give your child the correct dose of supplements as specified by your GP. If your child has too much vitamin D, they can develop a vitamin D toxicity which causes an excess of calcium in their body (hypercalcaemia).
For hypophosphataemic rickets and vitamin D dependent rickets, your child will have specialist treatment from their paediatrician.
If there are any other underlying conditions related to your child's rickets, such as metabolic disorders or kidney disease, these will also be treated.
If you are pregnant or breastfeeding, it's important to make sure you get enough vitamin D. In the womb, your baby will get all the vitamin D it needs directly from you. This will be stored up and used over the first few months after birth. After this, unless your baby gets vitamin D from another source, these stores will begin to run out.
If you feed your baby formula milk, this won't be a problem as it's fortified with vitamin D so your baby will be getting a constant supply. However, breast milk contains very little vitamin D, so there is a risk that your baby may not get enough. However, it's important to remember that breast milk is the best source of nutrition for your baby, containing everything he or she needs to grow and develop.
The Department of Health recommends that pregnant and breastfeeding women take 10 micrograms of vitamin D supplements every day to prevent their baby from getting rickets.
Prevention of rickets
There are several measures you can take to prevent your child from getting rickets.
Give your child plenty of foods that are rich in calcium and vitamin D.
Good sources of calcium include:
dairy products (eg milk, yoghurt and cheese)
bread made with fortified flour
beans and pulses (eg kidney beans and lentils)
green vegetables (eg broccoli and cabbage)
Not many foods contain enough of the vitamin D your child needs, the main source is sunlight. However, it can be found in:
eggs (cooked, not raw)
breakfast cereals fortified with vitamin D
Your child's main source of vitamin D is sun exposure to their skin. In the UK, children with light skin only need about 15 minutes of sunlight on their hands or face, two or three times a week during the spring and summer months, to get enough vitamin D.
However, you need to be careful as babies and young children have very sensitive skin and can burn easily. It's important to keep your child out of the sun between 11am and 3pm, use sunscreen and keep them mostly covered.
The Department of Health recommends that all children under the age of five should take supplements containing seven micrograms of vitamin D a day, and women who are pregnant or breastfeeding should take 10 micrograms a day. This is especially important for babies being breastfed or children in at risk groups (eg Asian, African Caribbean and Middle Eastern).
Some families may be eligible for free vitamin D supplements from the government run Welfare Foods Scheme (see Further information for more details).
See our answers to common questions about rickets, including:
- Pettifor, JM, Nutritional rickets: deficiency of vitamin D, calcium, or both. The American Journal of Clinical Nutrition, 2004. 80(6): 1725-1729.
- Rickets. GP Notebook. http://gpnotebook.co.uk, accessed 18 March 2008
- Simon, C, Everitt, H, and Kendrick, T, Oxford Handbook of General Practice. 2nd ed. Oxford: Oxford University Press, 2007
- Primary vitamin D deficiency in adults. Drug and Therapeutics Bulletin, 2006. 44: 25-29.
- Hypocalcaemia. GP Notebook. http://gpnotebook.co.uk, accessed 20 March 2008
- Allgrove, J, Is nutritional rickets returning? Archives of Disease in Childhood, 2004. 89: 699-701.
- When you're pregnant. Food Standards Agency. www.eatwell.gov.uk, accessed 25 March 2008
- Healthy eating for under fives. Department of Health. www.direct.gov.uk, accessed 25 March 2008
This information was published by Bupa's health information team and is based on reputable sources of medical evidence. It has been peer reviewed by Mr Roger Tillman, Royal Orthopaedic Hospital, Birmingham, and by Bupa doctors. The content is intended for general information only and does not replace the need for personal advice from a qualified health professional.
Publication date: August 2008.