Rickets is a condition that weakens and softens the bones in children due to a dietary deficiency or genetic problems which results in bowed legs, stunted growth, bone pain, a large forehead, and difficulty in sleeping. Rickets are usually caused by a deficiency of vitamin D. Vitamin D is necessary for the absorption of calcium and phosphate in the body. It can be prevented by consuming foods rich in vitamin D or calcium, or by taking supplements under the recommendation of your physician.
Causes of rickets
The most common cause of rickets is the lack of vitamin D, which is essential for the absorption of calcium and phosphate from food. Vitamin D can be obtained from sunlight and foods like fish, eggs, fortified cereals, or supplements. Other causes of rickets include:
- Lack of calcium in the diet
- Underlying conditions such as kidney and liver diseases, coeliac disease, and inflammatory bowel disease that affect vitamin D absorption or metabolism
- Persistent low levels of phosphate in the blood may be caused by a genetic defect (X-linked hypophosphataemic rickets) or certain medications
- Some genetic diseases interfere with how the body handles vitamin D or phosphorous and this may result in rickets
Signs and symptoms of rickets
Signs and symptoms of rickets include:
- Bone pain and tenderness in the legs, arms, ribs, and spine
- Poor development and growth (short height and low weight)
- Skeletal deformities: thickening of the ankles, wrists, and knees, bowed legs, soft skull bones, and increased curvature of the spine
- Dental problems: weak tooth enamel, delay in teeth coming through, and increased risk of cavities
- Muscle weakness and spasms
- Increased susceptibility to bone fractures
- Low levels of calcium in the blood can cause tingling in the hands and feet, seizures, and cramps
Diagnosis of rickets
Your physician can diagnose rickets based on the following methods:
- Physical examination: The doctor will conduct physical exams for signs of bone abnormalities, such as soft skull bones, bowed legs, curved spine, or enlarged joints
- Blood tests: The doctor will request a blood test to measure the levels of calcium, phosphate, alkaline phosphatase, and vitamin D in the blood. Low levels of calcium, phosphate, or vitamin D, or high levels of alkaline phosphatase can indicate rickets
- X-ray: The doctor will order an X-ray of the bones, especially the wrists or knees, to look for changes in the growth plates or bone structure. Rickets can cause metaphyseal fraying and widening of growth plates, which are areas where new bone cells are formed
- DEXA scan: It is a bone density scan, a type of X-ray that measures the amount of calcium in the bones. Rickets can cause low bone density or osteoporosis1
Management and treatment for rickets
Most cases of rickets tend to be due to vitamin D and calcium deficiency which can be treated by replacing the missing vitamin or mineral in the body, usually vitamin D or calcium. This can be done
- Consuming foods rich in vitamin D and calcium such as fish, eggs, dairy products, and leafy green vegetables
- Taking vitamin D and calcium supplements as prescribed by your doctor
- Increasing exposure to sunlight can help the skin produce vitamin D
If rickets is caused by a genetic defect then it can be treated with:
- Phosphate supplements as seen in hereditary rickets
- Vitamin D for certain types of genetic rickets that affect vitamin D action
- Treating the underlying condition like liver or kidney disease that affects the vitamin D absorption or metabolism
Surgery might be recommended in some cases where the child has bowed legs or a curved spine.
Some common risk factors associated with rickets are:2
- Age: Rickets is more common in newborns and infants
- Skin colour: Children with darker skin tones have more melanin, which reduces the skin's ability to produce vitamin D from sunlight. They need more sun exposure or vitamin D supplements to prevent rickets
- Diet: Children who follow a vegetarian or vegan diet, or who have lactose intolerance or milk allergy, may not get enough vitamin D or calcium from their food sources. They may need fortified foods or supplements to meet their nutritional needs
- Geographic location: Children living in regions with little sunlight, such as northern latitudes or areas with high pollution, may not get vitamin D from sun exposure. They might have to increase their exposure time to sunlight or take vitamin D supplements to prevent rickets
- Pregnant mothers: Mothers with vitamin D deficiency can give birth to a baby with signs of rickets
If untreated, rickets results in complications such as:
- Failure to grow: Rickets can affect the growth and development of children, resulting in short stature or delayed puberty
- Bone deformities: Rickets causes the bone to soften and weaken, leading to abnormal curvature of the spine, enlarged joints, bowed legs, or thickening of the ends of long bones
- Dental defects: Rickets can affect the formation and health of teeth, causing delayed eruption, increased risk of cavities enamel hypoplasia or malocclusion
- Seizures: Rickets can result in low calcium levels in the blood thereby affecting the functioning of the nervous system and resulting in muscle spasms, cramps, or seizures
- Breathing problems: Rickets can cause chest wall deformities or weakness of the respiratory muscles, which can impair breathing and increase the risk of infections or respiratory failure3
Can rickets be prevented?
You can prevent rickets by ensuring adequate intake and exposure to vitamin D and calcium, such as:
- Eating foods that contain vitamin D and calcium: Foods like fatty fish (such as tuna and salmon), egg yolks, fish oil, fortified foods (such as infant formula, milk, cereal, bread and orange juice), and dairy products (such as cheese and yoghurt)
- Spending some time outside in the sun: Sunlight stimulates the skin to produce vitamin D. Apply SPF 30 sunscreen on babies and young children before exposing them to the sun as they have very sensitive skin that burns easily
- Taking vitamin D supplements if necessary: People with dark skin, people who live in regions with little sunlight, people who follow a vegetarian or vegan diet, or those who have problems absorbing vitamins and minerals, or have a genetic form of rickets may need to take vitamin D supplements to prevent rickets. The recommended daily intake of vitamin D for babies from birth to 1 year is 8.5 to 10 micrograms (mcg) unless they are fed 500ml or more of infant formula a day. For children over the age of 1 year and adults, it is 10mcg
How common is rickets?
Rickets were common in the past, but when vitamin D-fortified foods like margarine and cereal were made available in the early 20th century the number of rickets cases dropped drastically in the Western world. However, in recent times an increase in cases of rickets in the UK has been noticed. Though the number of rickets cases is still relatively small, studies have shown that many people in the UK have low levels of vitamin D in their blood.
Rickets can also occur in other parts of the world like Africa, Asia, and the Middle East where vitamin D or calcium deficiency is prevalent.2
When should I see a doctor?
You should see a doctor if your child shows any of the symptoms of rickets. Your physician might conduct physical examinations, blood tests, X-rays, or bone density scans and based on the results your physician will decide the best treatment plan.
Rickets is a condition that causes the bone to become soft and weak resulting in bone pain, poor growth, and bone deformities. The most common cause of rickets is the deficiency of vitamin D which is essential for the absorption of calcium and phosphate from food.
Rickets can also be caused by the lack of calcium in the diet, certain underlying health conditions or can also be inherited. If your child shows poor growth and development, or if your child experiences bone pain, seizures, cramps, muscle spasms, dental problems etc visit your GP immediately.
Your GP will decide the best treatment plan after conducting physical exams, blood tests and X-rays. The treatment plan usually involves consuming foods rich in vitamin D and calcium or taking vitamin D or calcium or phosphorous supplements, treating the underlying conditions responsible for rickets and in cases where bone deformities are noticed surgery might be required.
- Haffner D, Leifheit-Nestler M, Grund A, Schnabel D. Rickets guidance: part I-diagnostic workup. Pediatr Nephrol [Internet]. 2022 Sep [cited 2023 May 16];37(9):2013–36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9307538/
- Dahash BA, Sankararaman S. Rickets. In: StatPearls [Internet] [Internet]. StatPearls Publishing; 2023 [cited 2023 Nov 21]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562285/
- Fernandes ASC, Lobo S, Sandes AR, Simão C, Lobo L, Bandeira T. Case Report: Vitamin D-dependent rickets: a resurgence of the rachitic lung in the 21st century. BMJ Case Reports [Internet]. 2015 [cited 2023 Nov 21];2015. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636699/