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Osteomalacia Content Supplied by NHS Choices
Introduction

Rickets is a condition that affects bone development in children. It causes the bones to become soft and weak, which can lead to bone deformities.

Rickets in adults is known as osteomalacia or soft bones.

Rickets can cause bone pain, poor growth and deformities of the skeleton, such as bowed legs, curvature of the spine, and thickening of the ankles, wrists and knees.

Children with rickets are also more likely to fracture their bones.

Read more about the signs and symptoms of rickets.

What causes rickets

A lack of vitamin D or calcium is the most common cause of rickets. Vitamin D largely comes from exposing the skin to sunlight, but it's also found in some foods, such as oily fish and eggs. Vitamin D is essential for the formation of strong and healthy bones in children.

In rare cases, children can be born with a genetic form of rickets. It can also develop if another condition affects how vitamins and minerals are absorbed by the body.

Read more about the causes of rickets.

Who's affected

Rickets was common in the past, but it mostly disappeared in the western world during the early 20th century after foods like margarine and cereal were fortified with vitamin D.

However, in recent years, there's been an increase in cases of rickets in the UK. The number of rickets cases is still relatively small - less than 700 cases were diagnosed in hospitals in England in 2013-14 - but studies have shown a significant number of people in the UK have low levels of vitamin D in their blood.

Any child whose diet doesn't contain enough vitamin D or calcium can develop rickets, but the condition is more common in children with dark skin, as this means they need more sunlight to get enough vitamin D, as well as children born prematurely or taking medication that interferes with vitamin D.

Treating rickets

For most children, rickets can be successfully treated by ensuring they eat foods that contain calcium and vitamin D, or by taking vitamin supplements.

Some families are eligible for free vitamin supplements from the government's Healthy Start scheme - find out if you qualify for Healthy Start.

If your child has problems absorbing vitamins and minerals, they may need a higher supplement dose or a yearly vitamin D injection.

Read more about treating rickets.

Preventing rickets

Rickets can easily be prevented by eating a diet that includes vitamin D and calcium, spending some time in sunlight, and if necessary, taking vitamin D supplements.

Read more about:

When to seek medical advice

Take your child to see your GP if they have any of the signs and symptoms of rickets.

Your GP will carry out a physical examination to check for any obvious problems. They may also discuss your child's medical history, diet, family history, and any medication they're taking.

A blood test to measure calcium, phosphorous and vitamin D levels can usually confirm a diagnosis of rickets, although your child may also have some X-rays or possibly a bone density scan (DEXA scan). This is a type of X-ray that measures the calcium content in bones.

Causes of rickets

Rickets usually occurs because of a lack of vitamin D or calcium, although it can also be caused by a genetic defect or another health condition.

Lack of vitamin D and calcium

The most common cause of rickets is a lack of vitamin D or calcium in a child's diet. Both are essential for children to develop strong and healthy bones.

Sources of vitamin D are:

  • sunlight - your skin produces vitamin D when it's exposed to the sun, and we get most of our vitamin D this way
  • food - vitamin D is also found in some foods, such as oily fish, eggs and fortified breakfast cereals
  • dietary supplements

Calcium is commonly found in dairy products, such as milk, cheese and yoghurt, and green vegetables, such as broccoli and cabbage.

Over time, a vitamin D or calcium deficiency will cause rickets in children and soft bones (osteomalacia) in adults.

See preventing rickets for more information and advice about ensuring your child gets enough vitamin D and calcium.

Who's at risk

Any child who doesn't get enough vitamin D or calcium can develop rickets, but there are certain groups of children who are more at risk.

For example, rickets is more common in children of Asian, African-Caribbean and Middle Eastern origin because their skin is darker and needs more sunlight to get enough vitamin D.

Babies born prematurely are also at risk of developing rickets because they build up stores of vitamin D while they're in the womb. Babies who are exclusively breastfed, especially for longer than six months, may also be at risk of vitamin D deficiency.

This is why the Department of Health recommends that:

  • pregnant and breastfeeding women should consider taking a daily supplement containing 10 micrograms (mcg) of vitamin D
  • babies from birth to one year of age, whether exclusively or partially breastfed, should be given a daily supplement containing 8.5 to 10mcg of vitamin D, to make sure they get enough
  • babies fed infant formula do not need a vitamin D supplement until they are receiving less than 500ml (about a pint) of infant formula a day, because infant formula is fortified with vitamin D
  • children aged 1 to 4 years old should be given a daily supplement containing 10mcg of vitamin D

For more information, read who should take vitamin D supplements.

Genetic defect

Rare forms of rickets can also occur in some inherited (genetic) disorders. For example, hypophosphatemic rickets is a genetic disorder where the kidneys and bones deal abnormally with phosphate.

Phosphate binds to calcium and is what makes bones and teeth hard. This leaves too little phosphate in the blood and bones, leading to weak and soft bones.

Other types of genetic rickets affect certain proteins in the body that are used by vitamin D.

Underlying conditions

Occasionally, rickets develops in children with rare forms of kidney, liver and intestinal conditions. These can affect the absorption of vitamins and minerals.

Treating rickets

As most cases of rickets are caused by a vitamin D and calcium deficiency, it's usually treated by increasing a child's intake of vitamin D and calcium.

Vitamin D and calcium levels can be increased by:

  • eating more foods that are rich in calcium and vitamin D
  • taking daily calcium and vitamin D supplements
  • having a vitamin D injection each year - this is only necessary if the child can't take the supplements by mouth or has intestinal or liver disease

Sunlight also contains vitamin D, so you may be advised to increase the amount of time your child spends outside.

Your GP will advise you about how much vitamin D and calcium your child will need to take. This will depend on their age and the cause of rickets. If your child has problems absorbing vitamins, they may need a higher dose.

See preventing rickets for more information about dietary sources of vitamin D and calcium, as well as advice about getting vitamin D from sunlight.

Treating complications and related conditions

When rickets occurs as a complication of another medical condition, treating the underlying condition will often cure the rickets.

If your child has a bone deformity caused by rickets, such as bowed legs or curvature of the spine, your GP may suggest treatment to correct it. This may include surgery.

Genetic rickets

A combination of phosphate supplements and a special form of vitamin D is required for the treatment of hypophosphatemic rickets, where a genetic defect causes abnormalities in the way the kidneys and bones deal with phosphate.

Children with other types of genetic rickets need very large amounts of a special type of vitamin D treatment.

Supplement side effects

It's very unusual to get side effects from vitamin D, calcium or phosphate supplements if they're given in the correct dose. Your doctor will advise you about how much supplement is needed, for how long, and the monitoring of treatment.

If the vitamin D or calcium dose is too high or the treatment is continued for too long or isn't carefully monitored, it can raise calcium levels in the blood. This can result in a condition called hypercalcaemia.

Symptoms of hypercalcaemia include:

See your GP immediately if you or your child have any of these symptoms.

Preventing rickets

There are several steps you can take to help prevent rickets.

These include ensuring your child:

Babies from birth to one year, including those who are exclusively or partially breastfed, need 8.5 to 10 micrograms (mcg) of vitamin D a day.

Children from the age of one year and adults need 10mcg of vitamin D a day.

Supplements

The Department of Health recommends that:

  • pregnant and breastfeeding women should consider taking a daily supplement containing 10mcg of vitamin D
  • babies from birth to one year of age, whether exclusively or partially breastfed, should be given a daily supplement containing 8.5 to 10mcg of vitamin D, to make sure they get enough
  • babies fed infant formula do not need a vitamin D supplement until they are receiving less than 500ml (about a pint) of infant formula a day, because infant formula is fortified with vitamin D
  • children aged 1 to 4 years old should be given a daily supplement containing 10mcg of vitamin D

For more information, read about who should take vitamin D supplements.

Sunlight

Sunlight is a good source of vitamin D and it's where we get most of our vitamin D from. The vitamin forms under the skin after sun exposure.

In the UK, about 10 to 15 minutes of exposure on the hands and face when the sun is at its strongest (between 11am and 3pm) a few times a week from late March/April to the end of September is enough for most people.

You won't get vitamin D from the sun if you wear sunscreen, but you should apply sunscreen with a sun protection factor (SPF) of at least 15 if you're outside for longer than 10 to 15 minutes. This will help protect your skin from sun damage.

Babies and young children have very sensitive skin that burns easily, so they need to use stronger sunscreen and be covered up when out in the sun.

In the UK, your skin isn't able to make vitamin D from the sun from October to early March because the sunlight isn't strong enough. However, you can get vitamin D from your body's stores and from food sources during this period.

Read more about vitamin D and sunlight and staying safe in the sun.

Signs and symptoms of rickets

Rickets causes a child's bones to become soft and weak, which can lead to bone deformities.

The signs and symptoms of rickets can include:

  • pain - the bones affected by rickets can be sore and painful, so the child may be reluctant to walk or may tire easily; the child's walk may look different (waddling)
  • skeletal deformities - thickening of the ankles, wrists and knees, bowed legs, soft skull bones and, rarely, bending of the spine
  • dental problems - including weak tooth enamel, delay in teeth coming through and increased risk of cavities
  • poor growth and development - if the skeleton doesn't grow and develop properly, the child will be shorter than average
  • fragile bones - in severe cases, the bones become weaker and more prone to fractures

These symptoms can also affect adults who have soft bones (osteomalacia).

Some children with rickets may also have low levels of calcium in their blood (hypocalcaemia). This can make the symptoms of rickets worse and can also cause muscle cramps, twitching, tingling in the hands and feet, and fits.

When to seek medical advice

If your child has any signs or symptoms of rickets, such as bone pain, delayed growth, muscle weakness or skeletal problems, take them to your GP for a check-up.


 
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