Rickets- Rickets- brief view brief view with homoeopatic with homoeopatic

approachapproach

Presented By: Dr. SANDEEP ANWANEPresented By: Dr. SANDEEP ANWANEGovt. Homoeo. Medical College, BhopalGovt. Homoeo. Medical College, Bhopal

Alternative NamesAlternative Names::

Osteomalacia in children; Vitamin D Osteomalacia in children; Vitamin D deficiency; Renal ricketsdeficiency; Renal rickets

DefinitionDefinition::

Rickets is a constitutional disease of infancy Rickets is a constitutional disease of infancy and childhood, characterized by impairment of and childhood, characterized by impairment of the general health, arrested growth, abnormal the general health, arrested growth, abnormal proliferation of classification of the developing proliferation of classification of the developing bone.bone.

Rickets is a disorder primarily caused by lack Rickets is a disorder primarily caused by lack of vitamin D, calcium, or phosphate, which of vitamin D, calcium, or phosphate, which leads to softening and weakening of the bones.leads to softening and weakening of the bones.

CausesCauses: :  The most common cause of osteomalacia is a The most common cause of osteomalacia is a

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

Insufficient sunlight exposure - Insufficient sunlight exposure - Sunlight Sunlight makes vitamin D in your skin. Therefore makes vitamin D in your skin. Therefore osteomalacia can develop in people who spend osteomalacia can develop in people who spend little time in the sunlight, wear very strong little time in the sunlight, wear very strong sunscreen, live in areas where sunlight hours sunscreen, live in areas where sunlight hours are short, or where the air is smoggy.are short, or where the air is smoggy.

Insufficient vitamin D intake -Insufficient vitamin D intake -A diet low in A diet low in vitamin D is the most common cause seen vitamin D is the most common cause seen worldwide. Is less common in the U.S. worldwide. Is less common in the U.S. because many foods, such as milk and cereals because many foods, such as milk and cereals are fortified with vitamin D.are fortified with vitamin D.

Certain Surgeries - Certain Surgeries - The removal of part or all of The removal of part or all of your stomach known as gastrectomy, can lead to this your stomach known as gastrectomy, can lead to this disease because the stomach breaks down foods to disease because the stomach breaks down foods to release vitamin D and other materials, which are then release vitamin D and other materials, which are then absorbed by your intestines. Surgery removing or absorbed by your intestines. Surgery removing or bypassing your small intestine can lead to bypassing your small intestine can lead to osteomalacia.osteomalacia.

Chronic pancreatitis - Chronic pancreatitis - Pancreatitis is the long-Pancreatitis is the long-standing inflammation of your pancreas, an organ that standing inflammation of your pancreas, an organ that makes digestive enzymes and hormones. If the makes digestive enzymes and hormones. If the pancreas is inflamed enzymes in charge of breaking pancreas is inflamed enzymes in charge of breaking down food and releasing nutrients do not flow as down food and releasing nutrients do not flow as freely into your intestines.freely into your intestines.

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

Mechanism of Vitamin –D:Mechanism of Vitamin –D:

The National Institutes of Health has stated The National Institutes of Health has stated that the following amounts of total calcium that the following amounts of total calcium intake per day are useful to intake per day are useful to preventprevent rickets: rickets:

400 mg until six months of age400 mg until six months of age

600 mg from six to twelve months600 mg from six to twelve months

800 mg from one year through age five800 mg from one year through age five

800–1,200 mg from age six until age ten800–1,200 mg from age six until age ten

Vitamin D helps the body properly control calcium Vitamin D helps the body properly control calcium and phosphate levels in the body. When the body is and phosphate levels in the body. When the body is deficient in vitamin D, it is unable to properly control deficient in vitamin D, it is unable to properly control calcium and phosphate levels. If the blood levels of calcium and phosphate levels. If the blood levels of these minerals become too low, the body may these minerals become too low, the body may produce other body hormones to stimulate release of produce other body hormones to stimulate release of calcium and phosphate from the bones. This leads to calcium and phosphate from the bones. This leads to weak and soft bones.weak and soft bones.

Vitamin D may be absorbed from food or may be Vitamin D may be absorbed from food or may be produced by the skin when the skin is exposed to produced by the skin when the skin is exposed to sunlight. Lack of vitamin D production by the skin sunlight. Lack of vitamin D production by the skin may occur in people who must stay indoors, work may occur in people who must stay indoors, work indoors during the daylight hours, or live in climates indoors during the daylight hours, or live in climates with little exposure to sunlight.with little exposure to sunlight.

Because vitamin D is a fat-soluble vitamin, Because vitamin D is a fat-soluble vitamin, malabsorption disorders that reduce digestion malabsorption disorders that reduce digestion or absorption of fats will decrease the ability or absorption of fats will decrease the ability of vitamin D to be absorbed into the body.of vitamin D to be absorbed into the body.

You may not get enough Vitamin D from your You may not get enough Vitamin D from your diet if you follow a vegetarian diet, do not diet if you follow a vegetarian diet, do not drink milk products, or are lactose intolerant drink milk products, or are lactose intolerant (have trouble digesting milk products). Infants (have trouble digesting milk products). Infants who are exclusively breastfed may develop who are exclusively breastfed may develop vitamin D deficiency. Human breast mil does vitamin D deficiency. Human breast mil does not supply the proper amount of vitamin D. not supply the proper amount of vitamin D. This can be a particular problem for darker-This can be a particular problem for darker-skinned children in winter months (when there skinned children in winter months (when there are lower levels of sunlight).are lower levels of sunlight).

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

Risk Factor:Risk Factor:Those at higher risk for developing rickets Those at higher risk for developing rickets

include:include: Breast-fed infants whose mothers are not Breast-fed infants whose mothers are not

exposed to sunlightexposed to sunlight Breast-fed infants who are not exposed to Breast-fed infants who are not exposed to

sunlightsunlight Individuals not consuming fortified milk, such Individuals not consuming fortified milk, such

as those who are lactose intolerantas those who are lactose intolerant Individuals with red hair have been speculated Individuals with red hair have been speculated

to have a decreased risk for rickets due to their to have a decreased risk for rickets due to their greater production of vitamin D in sunlight.greater production of vitamin D in sunlight.

Your genes may increase your risk of rickets. Your genes may increase your risk of rickets. Hereditary rickets is form of the disease that is Hereditary rickets is form of the disease that is passed down through families. It occurs when passed down through families. It occurs when the kidneys are unable to retain the mineral the kidneys are unable to retain the mineral phosphate. Rickets may also be caused by phosphate. Rickets may also be caused by kidney disorders that involve renal tubular kidney disorders that involve renal tubular acidosis.acidosis.

Occasionally, rickets may also occur in Occasionally, rickets may also occur in children who have disorders of the liver, or children who have disorders of the liver, or cannot convert vitamin D to its active form.cannot convert vitamin D to its active form.

Incidence and Prevalance:Incidence and Prevalance:

In the United States it is estimated that 20 to 25 In the United States it is estimated that 20 to 25 million people suffer from osteomalacia, including 25 million people suffer from osteomalacia, including 25 percent of women beyond menopausepercent of women beyond menopause

Incidence of 1 per 1000 people in the United StatesIncidence of 1 per 1000 people in the United States Rickets: In the U.S., severe nutritional rickets has Rickets: In the U.S., severe nutritional rickets has

become rare, although the mild disorder continues in become rare, although the mild disorder continues in the high-risk population (eg, individuals with dark the high-risk population (eg, individuals with dark skin, persons who live in inner-city areas). Breastfed skin, persons who live in inner-city areas). Breastfed infants who receive no vitamin D supplementation infants who receive no vitamin D supplementation also are at risk.also are at risk.

Rickets: Incidence in Europe is similar to that Rickets: Incidence in Europe is similar to that in the U.S. In sunny areas, such as in the in the U.S. In sunny areas, such as in the Middle East, rickets may occur when infants Middle East, rickets may occur when infants are bundled in clothing and are not exposed to are bundled in clothing and are not exposed to sunlight. In some parts of Africa, deficiency of sunlight. In some parts of Africa, deficiency of calcium and/or phosphorous in the diet may calcium and/or phosphorous in the diet may lead to rickets.lead to rickets.

Rickets is rare in the United States. It is most Rickets is rare in the United States. It is most likely to occur during periods of rapid growth, likely to occur during periods of rapid growth, when the body demands high levels of calcium when the body demands high levels of calcium and phosphate. Rickets may be seen in young and phosphate. Rickets may be seen in young children 6 to 24 months old and is uncommon children 6 to 24 months old and is uncommon in newborns.in newborns.

Signs and SymptomsSigns and Symptoms:: Bone pain or tendernessBone pain or tendernessArms Arms Legs Legs Spine Spine PelvisPelvis Skeletal deformitiesSkeletal deformitiesBowlegs Bowlegs Forward projection of the breastbone (pigeon chest) Forward projection of the breastbone (pigeon chest) Bumps in the rib cage (rachitic rosary) Bumps in the rib cage (rachitic rosary) Asymmetrical or odd-shaped skull Asymmetrical or odd-shaped skull Spine deformities (spine curves abnormally, including Spine deformities (spine curves abnormally, including

scoliosis or kyphosis) scoliosis or kyphosis) Pelvic deformitiesPelvic deformities

Increased tendency toward bone fracturesIncreased tendency toward bone fractures Dental deformitiesDental deformities

Delayed formation of teeth Delayed formation of teeth

Defects in the structure of teeth, holes in the Defects in the structure of teeth, holes in the enamel enamel

Increased incidence of cavities in the teeth Increased incidence of cavities in the teeth (dental caries) (dental caries)

Progressive weakness Progressive weakness

Decreased muscle tone (loss of muscle strength)Decreased muscle tone (loss of muscle strength)

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

Exams and TestsExams and Tests::A physical exam reveals tenderness or pain in the bones, A physical exam reveals tenderness or pain in the bones,

rather than in the joints or muscles.rather than in the joints or muscles. The following tests may help diagnose rickets:The following tests may help diagnose rickets:Blood tests (serum calcium) may show low levels of Blood tests (serum calcium) may show low levels of

calcium.calcium.Tetany (prolonged muscle spasm) may occur if serum Tetany (prolonged muscle spasm) may occur if serum

levels of calcium are low.levels of calcium are low.

Chvostek's sign may be positive (a spasm of facial Chvostek's sign may be positive (a spasm of facial muscles occurs when the facial nerve is tapped) muscles occurs when the facial nerve is tapped) indicating low serum levels of calcium.indicating low serum levels of calcium.

Serum phosphorus may be low.Serum phosphorus may be low.

Serum alkaline phosphatase may be high.Serum alkaline phosphatase may be high.

Arterial blood gases may reveal metabolic Arterial blood gases may reveal metabolic acidosis.acidosis.

Bone x-rays may show loss of calcium from Bone x-rays may show loss of calcium from bones or changes in the shape or structure of bones or changes in the shape or structure of the bones.the bones.

A bone biopsy is rarely performed but will A bone biopsy is rarely performed but will confirm rickets.confirm rickets.

Other tests and procedures include Other tests and procedures include the following: the following:

PTHPTH Urine calciumUrine calcium Calcium (ionized)Calcium (ionized) ALP (alkaline phosphatase) isoenzymeALP (alkaline phosphatase) isoenzyme

Treatment:Treatment:        The treatment goals are to relieve symptoms and The treatment goals are to relieve symptoms and

correct the cause of the condition. The underlying correct the cause of the condition. The underlying cause must be treated to prevent recurrence.cause must be treated to prevent recurrence.

The symptoms disappear with the replacement of The symptoms disappear with the replacement of deficient calcium, phosphorous, and/or vitamin D.deficient calcium, phosphorous, and/or vitamin D.

Biologically active form of vitamin D could be used Biologically active form of vitamin D could be used in people who have difficulty in converting vitamin D in people who have difficulty in converting vitamin D to its active form. Including fish, liver and processed to its active form. Including fish, liver and processed milk, which are rich sources of vitamin D in the diet. milk, which are rich sources of vitamin D in the diet.

Exposure to moderate amounts of sunlight.Exposure to moderate amounts of sunlight. Skeletal deformities could be corrected by Skeletal deformities could be corrected by

maintaining a good posture and bracing could help in maintaining a good posture and bracing could help in reducing the deformities.reducing the deformities.

Outlook (Prognosis)Outlook (Prognosis):   :   The disorder may be corrected with The disorder may be corrected with

replacement of deficient minerals and vitamin replacement of deficient minerals and vitamin D. Laboratory values and x-rays usually D. Laboratory values and x-rays usually improve after about 1 week, although some improve after about 1 week, although some cases may be resistant and require large doses cases may be resistant and require large doses of minerals and vitamin D.of minerals and vitamin D.

If rickets is not corrected while children are If rickets is not corrected while children are still growing, skeletal deformities and short still growing, skeletal deformities and short stature may be permanent. If it is corrected stature may be permanent. If it is corrected while the child is young, skeletal deformities while the child is young, skeletal deformities often diminish or disappear with time.often diminish or disappear with time.

Possible ComplicationsPossible Complications:   :  

Chronic skeletal painChronic skeletal pain Skeletal deformitiesSkeletal deformities Skeletal fractures, may occur without causeSkeletal fractures, may occur without cause

PreventionPrevention:: Osteomalacia caused by inadequate sun exposure and Osteomalacia caused by inadequate sun exposure and

a diet low in vitamin D can be prevented.a diet low in vitamin D can be prevented. Spend a few minutes in the sun Direct exposure in the Spend a few minutes in the sun Direct exposure in the

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

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

Take supplements If a person doesn’t get enough Take supplements If a person doesn’t get enough vitamins and minerals in their diet or if they have a vitamins and minerals in their diet or if they have a medical condition affecting the ability of their medical condition affecting the ability of their digestive system to absorbing nutrients, they are digestive system to absorbing nutrients, they are recommended to ask a doctor about taking vitamin D recommended to ask a doctor about taking vitamin D and calcium supplements.and calcium supplements.

Exercise Exercise such as walking helps Exercise Exercise such as walking helps strengthen bones, but if a patient has slight strengthen bones, but if a patient has slight fractures due to osteomalacia, they should fractures due to osteomalacia, they should avoid strenuous activity until their bones heal.avoid strenuous activity until their bones heal.

Renal (kidney) causes of vitamin D Renal (kidney) causes of vitamin D malabsorption should be treated promptly. malabsorption should be treated promptly. Levels of calcium and phosphorus should be Levels of calcium and phosphorus should be monitored regularly in people who have renal monitored regularly in people who have renal disorders.disorders.

Genetic counseling may help people with a Genetic counseling may help people with a family history of inherited disorders that can family history of inherited disorders that can cause rickets.cause rickets.

Homoeopathic Treatment:Homoeopathic Treatment: Calcarea phosCalcarea phos

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

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

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

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

Thanks Thanks For patience For patience EarEar