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RicketsProf. Dr. Saad S Al AniSenior Pediatric consultantHead Of Pediatric DepartmentKhorfakkan hospitalSharjah ,UAEsaadsa...
Background Rickets is a disease of growing bone that is unique to children and adolescents. It is caused by a failure of o...
Vitamin D deficiency rickets occurs when  the metabolites of vitamin D are deficient.  Less commonly, a dietary deficiency...
Vitamin D-3 (cholecalciferol) is formed in the skin from a derivative of cholesterol under the stimulus of ultraviolet- B ...
Source of vitamin D1. Ultraviolet light2. Cod liver oil3. Ergosterol (vitamin D-2)Dairy milk is fortified with vitamin D(4...
Pathophysiology3/8/2012     Rickets Prof. Dr.Saad S Al ani   6                 Khorfakkan Hospital
Cholecalciferol (i.e., vitamin D-3) is formed in the skin from 5-dihydrotachysterol.3/8/2012         Rickets Prof. Dr.Saad...
This steroid undergoes hydroxylation in 2 steps     . The first hydroxylation Occurs at position 25 in the liver, producin...
The second hydroxylation Occurs in the kidney at the 1 position,where it undergoes hydroxylation tothe active metabolite c...
CalcitriolActs at 3 known sites to tightly regulatecalcium metabolism:(1) it promotes absorption of calcium and phosphorus...
Epidemiology    The frequency increasing internationally  1.Children to wear sunscreen while outdoors  2.Children spend mo...
Clinical Presentation3/8/2012     Rickets Prof. Dr.Saad S Al ani   12                 Khorfakkan Hospital
Knock knee deformity (genu valgum)           Bowleg deformity (genu varum)3/8/2012            Rickets Prof. Dr.Saad S Al a...
Wrist enlargement           Rib beading (rachitic rosary)3/8/2012        Rickets Prof. Dr.Saad S Al ani   14              ...
Frontal bossing                    Tibial bowing3/8/2012         Rickets Prof. Dr.Saad S Al ani   15                     K...
Scoliosis           Harrisons sulcus and pot belly3/8/2012         Rickets Prof. Dr.Saad S Al ani   16                    ...
Differential Diagnoses1. Hypophosphatasia2. Jansen syndrome3. Hypophosphatemic vitamin D–resistant   rickets.4. Severe cal...
Approach Considerations  Serum measurements in the workup  for rickets may include the  following:  1.Calcium.2.Phosphorus...
Serum Chemistry  Calcium (ionized fraction) is low  Calcidiol (25-hydroxy vitamin D) is low  Parathyroid hormone is elevat...
Radiography   1.      Cupping of the metaphysis   2.      Fraying of the edge   3.      Widening of the osteoid tissue   4...
Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of...
Radiograph in a 4-year-old girl with rickets depicts bowing of                 the legs caused by loading.3/8/2012        ...
Radiographs of the knee of a 3.6-year-old girl withhypophosphatemia depict severe fraying of the metaphysis.3/8/2012      ...
Treatment & Management      Treatment for rickets may be      administered gradually over several      months or in a sing...
If the gradual method is chosen, 125-250 mcg(5000-10,000 U) is given daily for 2-3 monthsuntil:1. Healing is well establis...
If the vitamin D dose is administered in a      single day, it is usually divided into 4 or 6      oral doses. An intramus...
Rickets Medications   Vitamin D is a fat-soluble vitamin used to   prevent or treat vitamin D deficiency3/8/2012         R...
Cholecalciferol(Vitamin D3, D drops Kids, Delta-D3)1.single-day dose of 15,000 mcg (600,000U),which is usually divided int...
References  1. McKay CP, Portale A. Emerging topics in ediatric bone and mineral      disorders 2008. Semin Nephrol. Jul 2...
3/8/2012   Rickets Prof. Dr.Saad S Al ani   30               Khorfakkan Hospital
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Rickets

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Definition of Rickets ,causes ,presentation ,differential diagnosis ,management ,prevention

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Rickets

  1. 1. RicketsProf. Dr. Saad S Al AniSenior Pediatric consultantHead Of Pediatric DepartmentKhorfakkan hospitalSharjah ,UAEsaadsalani@yahoo.com
  2. 2. Background Rickets is a disease of growing bone that is unique to children and adolescents. It is caused by a failure of osteoid to calcify in a growing person. Failure of osteoid to calcify in adults is called Osteomalacia.3/8/2012 Rickets Prof. Dr.Saad S Al ani 2 Khorfakkan Hospital
  3. 3. Vitamin D deficiency rickets occurs when the metabolites of vitamin D are deficient. Less commonly, a dietary deficiency of calcium or phosphorus may also produce rickets3/8/2012 Rickets Prof. Dr.Saad S Al ani 3 Khorfakkan Hospital
  4. 4. Vitamin D-3 (cholecalciferol) is formed in the skin from a derivative of cholesterol under the stimulus of ultraviolet- B light. Natural nutritional sources of vitamin D are limited primarily to fatty, ocean-going fish.3/8/2012 Rickets Prof. Dr.Saad S Al ani 4 Khorfakkan Hospital
  5. 5. Source of vitamin D1. Ultraviolet light2. Cod liver oil3. Ergosterol (vitamin D-2)Dairy milk is fortified with vitamin D(400 IU/L)Human milk contains littlevitamin D(less than 20-40 IU/L)3/8/2012 Rickets Prof. Dr.Saad S Al ani 5 Khorfakkan Hospital
  6. 6. Pathophysiology3/8/2012 Rickets Prof. Dr.Saad S Al ani 6 Khorfakkan Hospital
  7. 7. Cholecalciferol (i.e., vitamin D-3) is formed in the skin from 5-dihydrotachysterol.3/8/2012 Rickets Prof. Dr.Saad S Al ani 7 Khorfakkan Hospital
  8. 8. This steroid undergoes hydroxylation in 2 steps . The first hydroxylation Occurs at position 25 in the liver, producing calcidiol (25-hydroxycholecalciferol)3/8/2012 Rickets Prof. Dr.Saad S Al ani 8 Khorfakkan Hospital
  9. 9. The second hydroxylation Occurs in the kidney at the 1 position,where it undergoes hydroxylation tothe active metabolite calcitriol(1,25-dihydroxycholecalciferol )3/8/2012 Rickets Prof. Dr.Saad S Al ani 9 Khorfakkan Hospital
  10. 10. CalcitriolActs at 3 known sites to tightly regulatecalcium metabolism:(1) it promotes absorption of calcium and phosphorus from the intestine(2) it increases reabsorption of phosphate in the kidney(3) it acts on bone to releasecalcium and phosphate.3/8/2012 Rickets Prof. Dr.Saad S Al ani 10 Khorfakkan Hospital
  11. 11. Epidemiology The frequency increasing internationally 1.Children to wear sunscreen while outdoors 2.Children spend more time indoors watching television or playing electronic games, instead of playing outdoors •Lowdon J. Rickets: concerns over the worldwide increase. J Fam Health Care. Mar-Apr 2011;21(2):25-9.[Medline].3/8/2012 Rickets Prof. Dr.Saad S Al ani 11 Khorfakkan Hospital
  12. 12. Clinical Presentation3/8/2012 Rickets Prof. Dr.Saad S Al ani 12 Khorfakkan Hospital
  13. 13. Knock knee deformity (genu valgum) Bowleg deformity (genu varum)3/8/2012 Rickets Prof. Dr.Saad S Al ani 13 Khorfakkan Hospital
  14. 14. Wrist enlargement Rib beading (rachitic rosary)3/8/2012 Rickets Prof. Dr.Saad S Al ani 14 Khorfakkan Hospital
  15. 15. Frontal bossing Tibial bowing3/8/2012 Rickets Prof. Dr.Saad S Al ani 15 Khorfakkan Hospital
  16. 16. Scoliosis Harrisons sulcus and pot belly3/8/2012 Rickets Prof. Dr.Saad S Al ani 16 Khorfakkan Hospital
  17. 17. Differential Diagnoses1. Hypophosphatasia2. Jansen syndrome3. Hypophosphatemic vitamin D–resistant rickets.4. Severe calcium deficiency5. Severe phosphorus deficiency3/8/2012 Rickets Prof. Dr.Saad S Al ani 17 Khorfakkan Hospital
  18. 18. Approach Considerations Serum measurements in the workup for rickets may include the following: 1.Calcium.2.Phosphorus.3.Alkaline phosphatase4.Parathyroidhormone 5.25-hydroxy vitamin D 6.1,25-dihydroxyvitamin D Radiography is indicated in patients with rickets3/8/2012 Rickets Prof. Dr.Saad S Al ani 18 Khorfakkan Hospital
  19. 19. Serum Chemistry Calcium (ionized fraction) is low Calcidiol (25-hydroxy vitamin D) is low Parathyroid hormone is elevated Phosphorus level is invariably low for age Alkaline phosphatase levels are uniformly elevated .3/8/2012 Rickets Prof. Dr.Saad S Al ani 19 Khorfakkan Hospital
  20. 20. Radiography 1. Cupping of the metaphysis 2. Fraying of the edge 3. Widening of the osteoid tissue 4. Hypominiralization of bones3/8/2012 Rickets Prof. Dr.Saad S Al ani 20 Khorfakkan Hospital
  21. 21. Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.3/8/2012 Rickets Prof. Dr.Saad S Al ani 21 Khorfakkan Hospital
  22. 22. Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.3/8/2012 Rickets Prof. Dr.Saad S Al ani 22 Khorfakkan Hospital
  23. 23. Radiographs of the knee of a 3.6-year-old girl withhypophosphatemia depict severe fraying of the metaphysis.3/8/2012 Rickets Prof. Dr.Saad S Al ani 23 Khorfakkan Hospital
  24. 24. Treatment & Management Treatment for rickets may be administered gradually over several months or in a single-day dose of 15,000 mcg (600,000 U) of vitamin D3/8/2012 Rickets Prof. Dr.Saad S Al ani 24 Khorfakkan Hospital
  25. 25. If the gradual method is chosen, 125-250 mcg(5000-10,000 U) is given daily for 2-3 monthsuntil:1. Healing is well established2. Alkaline phosphatase concentration is approaching the reference range3/8/2012 Rickets Prof. Dr.Saad S Al ani 25 Khorfakkan Hospital
  26. 26. If the vitamin D dose is administered in a single day, it is usually divided into 4 or 6 oral doses. An intramuscular injection is also available In nutritional rickets: 1.Phosphorus level rises in 96 hrs 2. Radiographic healing is visible in 6-7 days3/8/2012 Rickets Prof. Dr.Saad S Al ani 26 Khorfakkan Hospital
  27. 27. Rickets Medications Vitamin D is a fat-soluble vitamin used to prevent or treat vitamin D deficiency3/8/2012 Rickets Prof. Dr.Saad S Al ani 27 Khorfakkan Hospital
  28. 28. Cholecalciferol(Vitamin D3, D drops Kids, Delta-D3)1.single-day dose of 15,000 mcg (600,000U),which is usually divided into 4 or 6 oral dosesAn intramuscular injection is also available.2.An alternative regimen is to give 125-250mcg (5000-10,000 U) daily for 2-3 months3/8/2012 Rickets Prof. Dr.Saad S Al ani 28 Khorfakkan Hospital
  29. 29. References 1. McKay CP, Portale A. Emerging topics in ediatric bone and mineral disorders 2008. Semin Nephrol. Jul 2009;29(4):370-8. 2. Lowdon J. Rickets: concerns over the worldwide increase. J Fam Health Care. Mar-Apr 2011;21(2):25-9.[Medline]. 3. Chapman T, Sugar N, Done S, Marasigan J, Wambold N, Feldman K. Fractures in infants and toddlers with rickets. Pediatr Radiol. Dec 9 2009;[Medline]. 4. Casey CF, Slawson DC, Neal LR. VItamin D supplementation in infants, children, and adolescents. Am Fam Physician. Mar 15 2010;81(6):745-8. [Medline]. 5. Greer FR. Issues in establishing vitamin D recommendations for infants and children. Am J Clin Nutr. Dec 2004;80(6 Suppl):1759S- 62S. [Medline]. 6. [Guideline] Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. Nov 2008;122(5):1142-52. [Medline].3/8/2012 Rickets Prof. Dr.Saad S Al ani 29 Khorfakkan Hospital
  30. 30. 3/8/2012 Rickets Prof. Dr.Saad S Al ani 30 Khorfakkan Hospital

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