Rickets, Vitamin D Deficiency Rickets, Vitamin D Deficiency Important It is possible that the main title of the report Rickets, Vitamin D Deficiency is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report. Synonyms None General Discussion Vitamin-D deficiency rickets, a disorder that becomes apparent during infancy or childhood, is the result of insufficient amounts of vitamin D in the body. The vitamin deficiency may be caused by poor nutrition , a lack of exposure to the sun, or malabsorption syndromes in which the intestines do not adequately absorb nutrients from foods. Vitamin D is needed for the metabolism of calcium and phosphorus in the body, which, in turn affects how calcium is deposited in the bones; thus it is considered essential for proper bone development and growth. Major symptoms of vitamin D deficiency rickets include bone disease, restlessness, and slow growth. This disorder is rare in the United States but is not uncommon in certain areas of the world.

Resources NIH/National Institute of Diabetes , Digestive & Kidney Diseases Office of Communications & Public Liaison Bldg 31, Rm 9A06 31 Center Drive, MSC 2560 Bethesda, MD 20892-2560 Internet: For a Complete Report This is an abstract of a report from the National Organization for Rare Disorders (NORD). A copy of the complete report can be downloaded free from the NORD website for registered users. The complete report contains additional information including symptoms, causes, affected population, related disorders, standard and investigational therapies (if available), and references from medical literature. For a full-text version of this topic, go to and click on Rare Disease Database under "Rare Disease Information". The information provided in this report is not intended for diagnostic purposes. It is provided for informational purposes only. NORD recommends that affected individuals seek the advice or counsel of their own personal physicians. It is possible that the title of this topic is not the name you selected. Please check the Synonyms listing to find the alternate name(s) and Disorder Subdivision(s) covered by this report This disease entry is based upon medical information available through the date at the end of the topic.

Since NORD's resources are limited, it is not possible to keep every entry in the Rare Disease Database completely current and accurate. Please check with the agencies listed in the Resources section for the most current information about this disorder. For additional information and assistance about rare disorders, please contact the National Organization for Rare Disorders at P.O. Box 1968, Danbury, CT 06813-1968; phone (203) 744-0100; web site or email orphan@rarediseases.org Last Updated: 4/25/2008 Rickets Causes, Symptoms,Treatments & Prevention Medical Author: David Perlstein, MD, MBA, FAAP David Perlstein, MD, MBA, FAAP Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx. Medical Editor: William C. Shiel Jr., MD, FACP, FACR William C.

Shiel Jr., MD, FACP, FACR Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology. Share Your Story Rickets is a bone disorder caused by a deficiency of vitamin D, calcium, or phosphate. Rickets leads to softening and weakening of the bones and is seen most commonly in children 6-24 months of age. There are several subtypes of rickets, including hypophosphatemic rickets (vitamin-D-resistant rickets), renal or kidney rickets ( renal osteodystrophy ), and most commonly, nutritional rickets (caused by dietary deficiency of vitamin D, calcium, or phosphate). Classic nutritional rickets is also medically termed osteomalacia. What is the history of rickets?

Roman descriptions of individuals with rickets can be found as early as the second century, and in the 1640s, the condition was well documented as a common bone ailment across England. Unfortunately, the scientifically proven cause of rickets was not identified until the 1920s, and by the 1930s, public-health initiatives recommended fortifying milk with vitamin D and cod-liver oil as a nutritional supplement for young infants and children. This led to a near eradication of rickets in the United States and other industrialized nations. Unfortunately, rickets has made a comeback and is still common in less-developed nations. Moreover, for a variety of reasons, rickets is seen more frequently amongst infants and children living in industrialized nations, often among more affluent populations. Medically Reviewed by a Doctor on 3/7/2016 Rickets: MedlinePlus Medical Encyclopedia Work indoors during the daylight hours You may not get enough vitamin D from your diet if you: Are lactose intolerant (have trouble digesting milk products) Do not drink milk products Follow a vegetarian diet Infants who are breastfed only may develop vitamin D deficiency. Human breast milk does not supply the proper amount of vitamin D.

This can be a particular problem for darker-skinned children in winter months (when there are lower levels of sunlight). Not getting enough calcium and phosphorous in your diet can also lead to rickets. Rickets caused by a lack of these minerals in diet is rare in developed countries, because calcium and phosphorous are found in milk and green vegetables. Your genes may increase your risk of rickets. Hereditary rickets is a form of the disease that is passed down through families. It occurs when the kidneys are unable to hold onto the mineral phosphate. Rickets may also be caused by kidney disorders that involve renal tubular acidosis . Disorders that reduce the digestion or absorption of fats will make it more difficult for vitamin D to be absorbed into the body. Occasionally, rickets may occur in children who have disorders of the liver, or who cannot convert vitamin D to its active form. Rickets is rare in the United States. It is most likely to occur in children during periods of rapid growth, when the body needs high levels of calcium and phosphate. Rickets may be seen in children ages 6 to 24 months. It is uncommon in newborns.

Symptoms Urine calcium Treatment The goals of treatment are to relieve symptoms and correct the cause of the condition. The cause must be treated to prevent the disease from returning. Replacing calcium, phosphorus, or vitamin D that is lacking will eliminate most symptoms of rickets. Dietary sources of vitamin D include fish, liver, and processed milk. Exposure to moderate amounts of sunlight is encouraged. If rickets is caused by a metabolic problem, a prescription for vitamin D supplements may be needed. Positioning or bracing may be used to reduce or prevent deformities. Some skeletal deformities may require corrective surgery. Outlook (Prognosis) The disorder may be corrected by replacing vitamin D and minerals. Laboratory values and x-rays usually improve after about 1 week, although some cases may require large doses of minerals and vitamin D. If rickets is not corrected while the child is still growing, skeletal deformities and short stature may be permanent. If it is corrected while the child is young, skeletal deformities often improve or disappear with time. Possible Complications Skeletal fractures, may occur without cause When to Contact a Medical Professional Call your child's health care provider if you notice symptoms of rickets.

Prevention You can prevent rickets by making sure that your child gets enough calcium, phosphorus, and vitamin D in the diet. People who have gastrointestinal or other disorders may need to take supplements. Ask your child's health care provider. Kidney (renal) causes of poor vitamin D absorption should be treated right away. People who have renal disorders should have their calcium and phosphorus levels monitored regularly. Genetic counseling may help people who have a family history of inherited disorders that can cause rickets. Alternative Names Osteomalacia in children; Vitamin D deficiency; Renal rickets; Hepatic rickets Images X-ray References Greenbaum LA. Rickets and hypervitaminosis D. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 48. Read More Rickets: Causes, Symptoms and Treatments - Medical News Today Rickets: Causes, Symptoms and Treatments Written by Stephanie Brunner B.A. 4 16 Rickets is a childhood bone disorder in which bones soften and become prone to fractures and deformity.

Although rare in industrialized nations, it is still fairly common in some developing countries. The main cause of rickets is a lack of vitamin D . Not having enough calcium in one's diet may also be a cause of rickets, as may vomiting and diarrhea . Some childhood kidney and liver diseases can cause rickets, as may a digestive disorder complication that affects calcium and phosphorous absorption. Rickets affects mainly children, although the disorder may also affect adults (osteomalacia). In most cases, the child suffers from severe and long-term malnutrition , usually during early childhood. The term rickets comes from the Old English word "wrickken", meaning to twist or bend. Rickets was common in the UK and USA during the 19th century. For proper absorption of calcium and phosphorous from the gut, we need vitamin D. If vitamin D levels in a child are low, he/she may have inadequate calcium and phosphorous bone levels. A study published in JAMA in 2013 suggested that babies should be given a daily dose of vitamin D of 400 IU (international units) to help them stay healthy . Providing a child with extra vitamin D and some minerals usually resolves the rickets problem.

Symptoms of rickets A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. Symptoms of rickets may include: Baby is floppy Causes of rickets Some of the conditions that can be caused by vitamin D deficiency. Lack of vitamin D - the main cause of rickets. Our bodies need vitamin D in order to absorb calcium from the intestines. Ultraviolet light (from sunlight) helps our skin cells convert vitamin D from an inactive into an active state. If we do not have enough vitamin D, calcium that we get from the food we eat is not absorbed properly, causing hypocalcemia (lower-than-normal blood calcium) to develop. Hypocalcemia results in deformities of bones and teeth, as well as neuromuscular problems. The following foods are known to be rich on vitamin D: eggs, fish oils , margarine, some fortified milks and juices, some oily fishes, and some soymilk products that have vitamin D added. Genetic defect - hypophosphatemic rickets is a rare genetic fault that undermines the way the kidneys process phosphates.

Phosphate blood levels are too low, leading to weak and soft bones. Some diseases - some renal (kidney), hepatic (liver) and intestinal diseases can interfere with the way the body absorbs and metabolizes minerals and vitamins, resulting in rickets. Risk factors for rickets Vitamin D is described as the sunshine vitamin. A study published in the journal Pharmacology and Pharmacotherapeutics in 2012 suggested that 50% of the worldwide population may be deficient in vitamin D ( source ). A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. Risk factors for rickets include: Poverty - rickets is more likely to occur among children who are poor. Sunlight - children who do not get enough sunlight are more dependent on excellent nutrition to make sure they are getting enough vitamin D. Malnutrition - rickets is more common in areas of the world where severe droughts and starvation occur. On the next page we look at the diagnosis of rickets, complications caused by the condition and the available treatments for rickets.

Vitamin D Council | Vitamin D and rickets Rickets Summary Rickets is a condition that affects the development of bones in children. It causes soft weak bones, which can become bowed or curved. It’s a condition that only develops in children. It’s most commonly diagnosed in children between the age of 3 and 18 months. The main signs and symptoms of rickets include a misshaped or deformed skeleton, pain, fragile bones and poor growth and development. The most common cause of rickets is an extreme lack of vitamin D or a lack of calcium, or both together. The link between vitamin D and rickets has been known for many years and is well understood by doctors and scientists. If your child doesn’t get enough of the minerals needed to make healthy strong bones, or enough vitamin D, the bones can’t form hard outer shells. This is why they become soft and weak. The type of rickets that is caused by a lack of vitamin D and other minerals can be totally prevented by making sure your child gets enough vitamin D and calcium. Your baby can get the vitamin D he or she needs from your breast milk (as long as you’re getting good amounts yourself) or from formula milk with vitamin D added.

However, if you don’t get good amounts of vitamin D yourself, your breast milk will not provide much vitamin D at all and require you to give your baby vitamin D supplements. Older children can take vitamin D supplements, or get vitamin D by exposing their skin to the sun. Research now shows that getting enough vitamin D during pregnancy is important for the health of your baby. If you’re pregnant you should consider taking a vitamin D supplement, particularly if you have darker skin or get little sunshine on your skin. Rickets can be effectively treated with vitamin D supplements. As well as giving vitamin D, doctors may also prescribe calcium supplements to treat rickets. What is rickets? Rickets is a condition that affects the development of bones in children. It causes soft weak bones, which can become bowed or curved. Rickets is a condition that affects the development of bones in children. It causes soft weak bones, which can become bowed or curved. As you child grows up, his or her bones are continually growing and developing. How the bones develop, and how strong they are, depends on the amount of minerals such as calcium and phosphorus, that form the hard outer shell of the bones. This process is called mineralization.

Calcium and phosphorus are absorbed from the food and drink your child has and end up in the bones. Your child needs vitamin D too, because it helps the body to use calcium properly, and makes sure it gets to where it’s needed (the bones or teeth). If your child doesn’t get enough of the minerals needed to make healthy strong bones, or enough vitamin D, the bones can’t form hard outer shells. They become soft and weak and as your child grows and gets heavier, the increase in their weight can cause the bones to become bowed, misshaped and deformed. If you child has rickets, then he or she is also more likely to develop infections such as pneumonia and gastroenteritis (infection of the stomach and bowel). 1 These can be very serious in babies and young children. Babies and children with rickets may also be more likely to break (fracture) bones. 2 How common is rickets? The number of children that develop rickets in the US isn’t known. 3 However, research from the UK found that about 1 in every 100 non-Caucasian children has rickets.

4 Rickets is more common in children who have darker skin and in children who are breast fed rather than bottle fed. 5 Rickets is a condition that only develops in children. It’s most commonly diagnosed in children between the age of 3 and 18 months. 6 Adults can also develop soft bones. This condition is called osteomalacia. What are the symptoms of rickets? Rickets causes your child’s bones to become soft, weak and malformed, which can lead to bone deformities. The main signs and symptoms of rickets include: 7 A misshaped skeleton. This can include thickening of the ankles, wrists or knees (‘knock-knees’), legs that curve outwards (‘bow legs’) or a breastbone that sticks out (‘pigeon chest’) Pain. The bones affected by rickets are often sore and painful, so your child may be reluctant to walk or may get tired easily. Fragile bones. The bones become weaker and are more likely to break. Poor growth and development. Your child’s skeleton doesn’t grow and develop properly, so he or she may be short for their age Problems with teeth, including weak tooth enamel and a delay in teeth coming through.

Soft skull bones and a delay in the closing of the soft spot at the top of your baby’s head (the anterior fontanelle) What causes rickets? A severe lack of vitamin D or calcium or both can cause nutritional rickets. The most common cause of rickets is an extreme lack of vitamin D or a lack of calcium, or both together. 8 Vitamin D is produced naturally in your child’s body when bare skin is exposed to sunlight. Your child can also get vitamin D from most infant milk formulas, supplements and a small number of foods. Calcium comes from the food and drink your child has. Milk and dairy foods are a good source of calcium as well as some green vegetables, tofu, sardines and canned salmon. Some foods such as soya and other non dairy milks, bread and breakfast cereals, have calcium added to them. Both calcium and vitamin D are essential for strong, healthy bones. If you breast feed your baby, and you don’t give a vitamin D supplement, then he or she is more likely to be lacking in vitamin D.

When breastfeeding mothers don’t have high levels of vitamin D, their breast milk doesn’t contain much vitamin D and many breastfeeding women don’t get enough vitamin D themselves to pass on to their baby. Therefore children that are breastfed are more likely to develop rickets than children that are bottle fed (infant formula has vitamin D added to it). If your child eats a vegetarian or vegan diet, he or she may also be more likely to develop rickets, because they may not be getting enough calcium. 9 Rickets is more common in children with darker skins. 10 Children with African–American, Hispanic and Asian origins need to spend longer in the sun than children with fair skin to get the same amount of vitamin D. However, children with fair skin can also develop rickets if they don’t go outside in the sunlight very often, are frequently covered up or have sunscreen on all the time. There are other types of rickets that are not caused by a lack of vitamin D or calcium, though these types of rickets are rare. Rickets can develop in children that have other health conditions such as liver disease, kidney disease or kidney failure. 11 There is also a type of rickets that is inherited (genetic).

12 These types of rickets are not treated with just vitamin D or calcium or both and need care from a doctor. What is the link between rickets and vitamin D? The link between vitamin D and rickets has been known for many years and is well understood by doctors and scientists. In the late 19th and early 20th centuries, doctors realized that taking cod liver oil, which contains vitamin D, helped to prevent and treat rickets in children. In the 1930’s vitamin D was added to infant formula milk for the first time. Since then the number of children developing rickets has fallen dramatically and rickets has become a rare disease in the United States. However, rickets does still develop in some children and the numbers of children affected has started to rise. 13 The reasons why the number of children with rickets is rising aren’t clear. It may be because doctors are better at diagnosing it, or because immigrants are moving away from the equator where there is more sun exposure or just more undetected rickets in general. 14 Vitamin D helps your body to control calcium and phosphate levels.

If the blood levels of these minerals become too low, your body produces hormones that cause calcium and phosphate to be released from the bones, so it can have the right amount in the blood. This is what leads to soft and weak bones. When you get very little vitamin D (severe vitamin D deficiency), your body may not absorb enough calcium. Hormones may start taking too much calcium from your bones; hormones that vitamin D usually keeps under control. This makes your bones soft and weak and rickets develops. What does the research say about vitamin D and rickets? The links between vitamin D and rickets are very clear and have been known for a long time, so there has been quite a lot of research in this area, compared to some other conditions. There are also national guidelines for doctors on preventing rickets, produced by the Endocrine Society 15 and the American Academy of Pediatrics. 16 The Endocrine Society also produces guidelines on the treatment of rickets. Preventing rickets Research has shown that the type of rickets that is caused by a lack of vitamin D and other minerals can be totally prevented by making sure your child gets enough vitamin D and calcium.

17 Vitamin D for babies and children To develop their guidelines on preventing rickets, The American Academy of Pediatrics searched for all of the research carried out in the US, and the rest of the world, about rickets and vitamin D. Having looked at all the research and analysed it, the Academy has said that to prevent rickets, infants, children and adolescents need to have at least 400 IU of vitamin D a day. They recommend that: Babies that are being breastfed or partly breastfed should have a vitamin D supplement of 400 IU a day. Babies should keep having a supplement until they are drinking at least one litre of whole milk or formula milk a day (children shouldn’t drink whole milk until they are over one year old). All babies and children drinking less than one litre of infant formula or whole milk a day should also take a supplement of 400 IU of vitamin D each day. Adolescents who don’t get enough vitamin D from fortified milk or foods should take a vitamin D supplement of 400 IU a day. Giving babies and children vitamin D supplements has been preventing rickets for many years.

However, there isn’t much research that has looked at whether the amount that babies and children are given is actually the right amount. For example, doctors used to recommend that babies and children should have 200 IU vitamin D a day to prevent rickets, and this worked. 18 Guidelines in Canada recommend that babies should be given 400 IU a day, but that this should with increase to 800 IU a day in the winter months for babies living in the north of the country. 19 The Endocrine Society in the US recommends that infants and children should have 400IU or 600 IU of vitamin D a day, and that to get the best effect from vitamin D, they may need as much as 1,000 IU a day. 20 What the Vitamin D Council says The Vitamin D Council recommends that infants have 1,000 IU per day and children have 1,000 IU a day per 25lbs of their body weight. Breast milk can provide most or all of this for infants, if the mother is getting enough vitamin D herself.

If she isn’t, then breast milk cannot provide much of the 1,000 IU a day requirement. See our breastfeeding page for more information. More research is needed to say exactly how much vitamin D is needed to prevent rickets. However, that research may never come. Something else that researchers and doctors also have to take into account is whether the amount of vitamin D children get is enough to meet other health needs, as well as to prevent rickets. The amount of vitamin D children need for other health reasons may be higher than what is needed to prevent rickets, though again, more research is needed. Vitamin D in pregnancy Some researchers have explored whether the amount of vitamin D a mother gets when she is pregnant may help to prevent rickets in her child. How much vitamin D a woman has in her body decides how much vitamin D her baby will have when he or she is born. If you’re very deficient (lacking) in vitamin D when you’re pregnant, then your child is more likely to develop rickets. 21 Women who have darker skin and women who don’t expose their skin much to the sun are more likely to be deficient in vitamin D.

22 Research now shows that getting enough vitamin D during pregnancy is important for the health of your baby. 23 Therefore, the American Academy of Paediatrics recommends that doctors and midwives should consider giving vitamin D supplements to pregnant women who might be deficient. 24 The Endocrine Society and the Vitamin D Council suggest that all pregnant women need to take vitamin D supplements. Vitamin D and calcium Researchers have also explored the role of calcium and vitamin D in preventing rickets. Vitamin D helps calcium to work properly in your body and your body needs both to develop strong healthy bones. Research shows that babies and children who don’t get enough calcium from the food and milk they have, are more likely to develop rickets. 25 Treating rickets If your child has rickets, your doctor may choose to treat your child’s rickets with a one-time vitamin D supplement or a daily supplement. Rickets has been treated successfully with vitamin D since at least the 1930s, when doctors gave children one very large amount of vitamin D to treat the condition. 26 Now, there is agreement among doctors that rickets should be treated with vitamin D supplements.

This can either be given as one large amount, as weekly amounts or as small amounts given every day for two to three months. 27 More recent research has also looked at whether giving children a large amount of vitamin D just once is effective at treating rickets. Researchers have given children large amounts such as 200,000 or 600,000IU vitamin D in one day and found that it was a safe and effective treatment. 28 , 29 This type of treatment is called Stoss Therapy. Some scientists suggest that rickets should be treated with 5,000 to 15,000 IU of vitamin D a day for three to four weeks and then a smaller dose thereafter. 30 Talk to your doctor about which type of treatment is best for your child; one large supplement, weekly or daily supplements. As well as giving vitamin D, doctors may also prescribe calcium supplements to treat rickets. 31 Key points from research The links between vitamin D and rickets are very clear and have been known for a long time. There are many national guidelines, including a number in the US, which tell doctors how to prevent rickets.

These guidelines have been developed by reading and analyzing all of the research on vitamin D and rickets. Rickets can be prevented by making sure your child gets enough vitamin D and calcium. Babies that are breastfed or partly breastfed should be given a vitamin D supplement, unless the breastfeeding mother gets good amounts of vitamin D herself. Doctors and researchers haven’t come to a definite answer about how much vitamin D supplement is enough to prevent rickets and ensure good bone health. However, it is likely at least 400 IU a day. It’s important for the health of a baby for the mother to get enough vitamin D while she is pregnant. Research suggests that women who are more likely to be deficient in vitamin D during their pregnancy should take a vitamin D supplement to prevent rickets in their child. Babies and children who don’t get enough calcium from the food and milk they have, are more likely to develop rickets Rickets can be treated successfully with vitamin D, calcium or sometimes both. What does this mean for me? Good vitamin D and calcium nutrition can prevent nutritional rickets and help your child grow strong and healthy.

If you’re pregnant you should consider taking a vitamin D supplement, particularly if you have darker skin or get little sunshine on your skin. The Vitamin D Council recommends taking 4,000 IU to 6,000 IU of vitamin D every day if you’re pregnant. Other organizations in the United States have set different recommended daily amounts, usually much lower. For example, the Food and Nutrition Board recommend 600 IU of vitamin D every day because they feel there is not enough research at this time to recommend higher amounts. You can find out more about vitamin D when you’re pregnant by going to our Vitamin D during pregnancy and breastfeeding page . If you’re breastfeeding your baby, either fully or in part, you may need to give your baby a vitamin D supplement every day. If you’re getting enough vitamin D, your baby should be getting enough vitamin D from your milk. However, many women don’t get enough vitamin D and if that is the case, you will need to give your baby a supplement. Not all organizations recommend the same amount of supplement for babies each day.

Here is a list of the current recommendations from organizations in the United States: Vitamin D Council 1,000 IU/day* Endocrine Society 400-1,000 IU/day Food and Nutrition Board 400 IU/day You can find out more about vitamin D when you’re breastfeeding by going to our Vitamin D during pregnancy and breastfeeding page . If you’re giving your baby only infant formula, which contains vitamin D, you may not need to give a supplement. Older children and adolescents also need enough vitamin D to keep their bones healthy and prevent rickets. If your child isn’t able to get vitamin D from being out in the sun, you should give him or her vitamin D supplements. You can find out more by going to our Vitamin D during pregnancy and breastfeeding page . References Y Cesur, M Dogan, S Ariyuca etc al. Evaluation of children with nutritional rickets. J Pediatr Endocr Met 2011;24(1-2):35-43 Winzenberg T, Jones G. Vitamin D and bone health in childhood and adolescence.

Calcif Tissue Int (2013) 92:140-150 Thatcher T, Fischer P, Tebben P et al. Increasing Incidence of Nutritional Rickets: A population-based study in Olmsted County Minnesota. Mayo Clinic Proc 2013; 88(2):176-183 Ashraf S, Mughal MZ ; The prevalence of rickets among non-Caucasian children. Arch Dis Child. 2002 Sep;87(3):263-4. Rickets. eMedicine. Shah BR, Finberg L. Single-day therapy for nutritional vitamin D-deficiency rickets: a preferred method. J Pediatr. Sep 1994;125(3):487-90. Billoo AG, Murtaza G, Memon MA et al. Comparison of oral versus injectable vitamin-D for the treatment of nutritional vitamin-D deficiency rickets, J Coll Physicians Surg Pak. 2009: 19: 428-431. Pettifor JM. Vitamin D Deficiency and Nutritional Rickets in Children.

In Vitamin D: Third Edition by Feldman D, Pike JW and Adams JS. Elsevier Academic Press, 2011. Rickets. American Academy of Orthopaedic Surgeons. This page in PDF format Are you a health care provider? Print and share this PDF file to your patients: This page was last updated August 2014. We need your help! Vitamin D Deficiency and Rickets - HealthyChildren.org Vitamin D Deficiency and Rickets Page Content ​ ​What is rickets? Rickets is a condition of softening of the bones that occurs in growing children. It happens when the bones can not take up enough calcium and phosphorus to make hard, healthy bone. Although there are genetic and metabolic causes of rickets, the most common cause is a lack of vitamin D . This is also called nutritional rickets. What is vitamin D? Vitamin D is a substance that the body needs to help absorb calcium from the gut and regulate how much calcium and phosphorus gets stored in the bone and how much gets let out of the body in urine by the kidneys.

Vitamin D can be obtained by eating certain types of fatty fish and fish oils, but it is also made in the skin in response to ultraviolet rays of sunlight. However, one must be exposed to the right wavelength of sunlight for a substantial period of time to make enough vitamin D for bone health. The use of sunscreen (which is, of course, important in preventing sunburn and skin cancer ) does not allow the body to make much vitamin D in the skin. For this reason, in the United States and many industrialized nations, cow milk (and infant formula ) is fortified with extra vitamin D. Human milk is often very low in vitamin D. What are the symptoms of rickets? The most classic symptom of rickets is bending or " bowing " of the bones of the legs. This happens because of the stress of walking on "soft" bones that do not have enough minerals. Infants who are crawling but not walking yet can get widening of the area just above the wrists for the same reason. In more severe cases, one can see swelling of the ends of the ribs as well. Sometimes the blood level of calcium can become so low that seizures can develop. How is rickets diagnosed?

A physician can diagnose rickets from a combination of physical exam findings, x-rays (which show widening and "fraying" of the ends of certain long bones), and blood tests that can show low levels of phosphorus and normal or low calcium with an elevated level of an enzyme called alkaline phosphatase. Your doctor may also check the level of "25 hydroxy" vitamin D. On occasion, further blood testing is necessary to diagnose other forms of rickets. Who is at risk for nutritional rickets? Infants who are breastfed and who are not given extra vitamin D are at highest risk. The risk is even greater if the baby's mother is also vitamin D deficient. Vitamin D deficiency among women of childbearing age is quite common. It occurs even more often in dark-skinned people and people who do not expose themselves to much sunlight. How can rickets be prevented? All breastfed infants should receive 400 international units of vitamin D daily. This can be obtained in a standard dose of infant vitamin drops (which usually contain vitamins A, D, and C). Nursing women should make sure that they take in at least 600 units of vitamin D daily.

Many sources recommend 1500 to 2000 units daily. How is nutritional rickets treated? Treatment requires high doses of either ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) to build up the body stores of the vitamin. The standard regimen is about 2000 to 4000 units daily for several months. It can vary based on the size and age of the child being treated. Some physicians use other regimens. It is helpful to note that some forms of vitamin D (especially the liquid) can be expensive when obtained through a pharmacy and not covered by insurance. These preparations are available on the Internet at a cheaper cost. However, please check with your physician before ordering on the Internet by yourself. Supplemental calcium is also needed to keep the blood calcium level normal and heal the bones if the dietary intake of calcium is not sufficient. If the treatment is adequate, the x-ray changes start to resolve and the blood alkaline phosphatase normalizes in about 6 to 8 weeks. If bowing of the legs has developed, it can take many months to straighten out, but it usually does improve.

Rickets and osteomalacia - Causes - NHS Choices Rickets and osteomalacia - Causes Rickets Prevention 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. Page last reviewed: 21/12/2015 Vitamin D Deficiency including Osteomalacia and Rickets | Health | Patient Vitamin D Deficiency including Osteomalacia and Rickets Vitamin D Deficiency including Osteomalacia and Rickets 604 Vitamin D is important for good health, growth and strong bones. A lack of vitamin D is very common. Vitamin D is mostly made in the skin by exposure to sunlight. Most foods contain very little vitamin D naturally, though some are fortified (enriched) with added vitamin D. A mild lack of vitamin D may not cause symptoms but can cause tiredness and general aches and pains. A more severe lack can cause serious problems such as rickets (in children) and osteomalacia (in adults), described below. Treatment is with vitamin D supplements. Some people are more at risk of vitamin D deficiency, and so are recommended to take vitamin D supplements routinely.

These include all pregnant and breast-feeding women, all babies and young children aged 6 months to 5 years, people aged 65 and over, and people who are not exposed to much sun. A doctor may also recommend routine supplements for certain people with darker skin, and for people with certain gut, liver or kidney diseases. What is vitamin D? Vitamin D is a vitamin that is needed for good health. Unlike other vitamins, we do not need to get vitamin D from food. A main source of vitamin D is made by our own bodies. It is made in the skin by the action of sunlight. This is a good thing because most foods contain no or very little vitamin D naturally. Foods that contain vitamin D include: Oily fish (such as sardines, pilchards, herring, trout, tuna, salmon and mackerel). Fortified foods (this means they have vitamin D added to them) such as margarine, some cereals, infant formula milk. The best dietary source of vitamin D is oily fish and cod liver oil. There is little or no vitamin D in UK milk and dairy products. Only infant formula milk and margarine have statutory vitamin D supplementation in the UK.

Egg yolk, liver, and wild mushrooms contain only small quantities of vitamin D. Vitamin D and sunlight Ultraviolet B (UVB) rays in sunlight convert cholesterol in the skin into vitamin D. For a fair-skinned person, it is estimated that around 20-30 minutes of sunlight on the face and forearms around the middle of the day 2-3 times a week is sufficient to make enough vitamin D in the summer months in the UK. However, for people with darker skin and the elderly, the amount of time needed exposed to sunlight to make enough vitamin D can be much more than this. Note: it is not the same as sunbathing; the skin simply needs to be exposed to sunlight. But, the sunlight has to fall directly on to bare skin (through a window is not enough). For six months of the year (October to April), much of western Europe (including 90% of the UK) lies too far north to have enough UVB rays in sunlight necessary to make vitamin D in the skin. So, many people in the UK are at risk of not getting enough vitamin D unless they get it in their diet. Note: too much exposure to the sun's rays can be damaging.

Sunburn should be avoided at all costs (mainly because it can increase your risk of skin cancer). Why do we need vitamin D? A main action of vitamin D is to help calcium and phosphorus in our diet to be absorbed from the gut. Calcium and phosphorus are needed to keep bones healthy and strong. So, vitamin D is really important for strong and healthy bones. In addition, vitamin D seems to be important for muscles and general health. There is also some evidence that vitamin D may also help to prevent other diseases such as cancer, diabetes and heart disease. Who gets vitamin D deficiency? Vitamin D deficiency means that there is not enough vitamin D in your body. Broadly speaking, this can occur in three situations: The body has an increased need for vitamin D. The body is unable to make enough vitamin D. Not enough vitamin D is being taken in the diet. Increased need for vitamin D Growing children, pregnant women, and breast-feeding women need extra vitamin D because it is required for growth. So, vitamin D deficiency is more likely to develop in the following groups of people: Pregnant or breast-feeding women. Vitamin D deficiency is even more likely to develop in women who have had several babies with short gaps between pregnancies.

This is because the body's stores of vitamin D get used up, and there is little time for them to be built up before another pregnancy. Breast-fed babies whose mothers are lacking in vitamin D, or with prolonged breast-feeding, as there is little vitamin D in breast milk. (Note: there are significant advantages to breast-feeding. You should not stop breast-feeding due to concern about vitamin D levels - your baby can simply have vitamin D supplements as drops by mouth.) Where the body is unable to make enough vitamin D This can occur for various reasons: People who get very little sunlight on their skin are at risk of vitamin D deficiency. This is more of a problem in the more northerly parts of the world (including the UK) where there is less sun. In particular: People who stay inside a lot. For example, those in hospital for a long time, or housebound people. People who cover up a lot of their body when outside. Strict sunscreen use can potentially lead to vitamin D deficiency, particularly if high sun protection factor (SPF) creams (factor 15 or above) are used.

Nevertheless, children especially should always be protected from the harmful effect of the sun's rays and should never be allowed to burn or be exposed to the strongest midday sun. Elderly people have thinner skin than younger people and so are unable to produce as much vitamin D. This leaves older people more at risk of vitamin D deficiency. People who have darker skin. For example, people of African, African-Caribbean and South Asian origin, because their bodies are not able to make as much vitamin D. Some medical conditions can affect the way the body handles vitamin D. People with Crohn's disease , coeliac disease , and some types of liver and kidney disease, are all at risk of vitamin D deficiency. Rarely, some people without any other risk factors or diseases become deficient in vitamin D. It is not clear why this occurs. It may be due to a subtle metabolic problem in the way vitamin D is made or absorbed. So, even some otherwise healthy, fair-skinned people who get enough sun exposure can become deficient in vitamin D. Vitamin D deficiency can also occur in people taking certain medicines. Examples include: carbamazepine , phenytoin , primidone , barbiturates and some anti-HIV medicines .

Not enough dietary vitamin D Vitamin D deficiency is more likely to occur in people who follow a strict vegetarian or vegan diet, or a non-fish-eating diet. How common is vitamin D deficiency? It is very common. A recent survey in the UK showed that more than half of adults in the UK did not have enough vitamin D. In the winter and spring about 1 in 6 people have a severe deficiency. It is estimated that about 9 in 10 adults in the UK of South Asian origin may be vitamin D-deficient. Most affected people either don't have any symptoms, or have tiredness or vague aches and pains, and are unaware of the problem. What are the symptoms of vitamin D deficiency? Many people have no symptoms, or may complain of only vague ones such as tiredness or general aches. Because symptoms of vitamin D deficiency are often very nonspecific or vague, the problem is often missed. The diagnosis is more easily reached in severe deficiencies with some of the classical (typical) symptoms and bone deformities. Symptoms in babies and children Babies with severe vitamin D deficiency can get muscle spasms (cramps), seizures and breathing difficulties. These problems are related to consequent low levels of calcium.

Children with severe deficiency may have soft skull or leg bones. Their legs may look curved (bow-legged). They may also complain of bone pains, often in the legs, and muscle pains or muscle weakness. This condition is known as rickets. Poor growth. Height is usually affected more than weight. Affected children might be reluctant to start walking. Tooth delay. Children with vitamin D deficiency may be late teething as the development of the milk teeth has been affected. Irritability in children can be due to vitamin D deficiency. Children with vitamin D deficiency are more prone to infections. Breathing (respiratory) symptoms can occur In severe cases. Breathing can be affected because of weak chest muscles and a soft ribcage. When rickets if very severe, it can cause low levels of calcium in the blood. This can lead to muscle cramps (spasms), fits (seizures) and breathing difficulties. These need urgent hospital treatment. Rarely, an extremely low vitamin D level can cause weakness of the heart muscle (cardiomyopathy). Symptoms in adults Some people complain of a general tiredness, vague aches and pains and a general sense of not being well.

In more severe deficiency (known as osteomalacia), there may be more severe pain and also weakness. Muscle weakness may cause difficulty in climbing stairs or getting up from the floor or a low chair, or can lead to the person walking with a waddling pattern. Bones can feel painful to moderate pressure (often more noticeable in the ribs or shin bones). Not uncommonly, people have a hairline fracture in the bone which is causing tenderness and pain. Bone pain often also occurs in the lower back, hips, pelvis, thighs and feet. Read more blog posts How is vitamin D deficiency diagnosed? It may be suspected from your medical history, symptoms, or lifestyle. A simple blood test for vitamin D level can make the diagnosis. Blood tests for calcium and phosphate levels and liver function may also show changes linked to a low level of vitamin D. Sometimes, a wrist X-ray is done for a child. This can assess how severe the problem is by looking for changes in the wrist bones. What is the treatment for vitamin D deficiency? The treatment is to take vitamin D supplements. This is a form of vitamin D called ergocalciferol or calciferol .

Vitamin D can be given as an injection or as a medicine (liquid or tablets). Your doctor will discuss the dose, and best treatment schedule, depending on your situation, age, severity of the deficiency, etc. Briefly, one of the following may be advised. Injection A single small injection of vitamin D will last for about six months. This is a very effective and convenient treatment. It is useful for people who do not like taking medicines by mouth, or who are likely to forget to take their tablets. High-dose tablets or liquids There are different strengths available and a dose may be taken either daily, weekly or monthly. This will depend on your situation and on which particular treatment guideline your doctor is using. Always check with your doctor that you understand the instructions - with high doses of vitamin D it is important to take the medicine correctly. The advantage of the higher-dose treatment is that the deficiency improves quickly - important in growing children. Standard-dose tablets, powders or liquids These are taken every day for about 12 months so that the body can catch up on the missing vitamin D. This is a rather slow method of replacing vitamin D, but is suitable if the deficiency is mild, or for prevention.

Maintenance therapy after deficiency has been treated Once vitamin D deficiency has been treated, the body's stores of vitamin D have been replenished. After this, maintenance treatment is often needed long-term, to prevent further deficiency in the future. This is because it is unlikely that any risk factor for vitamin D deficiency in the first place will have completely resolved. The dose needed for maintenance may be lower than that needed to treat the deficiency. More related content Preventing vitamin D deficiency Various groups of people (detailed earlier) are prone to develop vitamin D deficiency. Therefore, certain people are advised to take vitamin D supplements routinely. In February 2012 the Chief Medical Officers for the United Kingdom issued the following recommendations: All pregnant and breast-feeding women should take a daily supplement containing 10 micrograms of vitamin D. All babies and young children aged 6 months to 5 years should take a daily supplement containing vitamin D in the form of vitamin drops. However, those babies who are fed infant formula will not need vitamin drops until they are receiving less than 500ml of infant formula a day, as these products are fortified with vitamin D.

Breast-fed babies may need to receive drops containing vitamin D from one month of age if their mother has not taken vitamin D supplements throughout pregnancy. People aged 65 years and over and people who are not exposed to much sun should also take a daily supplement containing 10 micrograms of vitamin D. In addition a doctor may advise routine vitamin D supplements for people with certain gut, kidney or liver diseases, people prescribed certain medicines, and to certain people with darker skin. You can buy vitamin D supplements at pharmacies. They are also available on prescription to certain groups of people. Women and children from families who are eligible for the Government’s Healthy Start scheme (see below) can also get free vitamin supplements which include vitamin D. If you are unsure as to whether you should be taking a regular supplement of vitamin D, or what the appropriate dose is, then your doctor, pharmacist, health visitor or midwife can advise. Cautions when taking vitamin D supplements Care is needed with vitamin D supplements in certain situations: If you are taking certain other medicines: digoxin (for an irregular heartbeat - atrial fibrillation) or thiazide diuretics such as bendroflumethiazide (commonly used to treat high blood pressure).

In this situation, avoid high doses of vitamin D, and digoxin will need monitoring more closely. If you have other medical conditions: kidney stones, some types of kidney disease, liver disease or hormonal disease. Specialist advice may be needed. Vitamin D should not be taken by people who have high calcium levels or certain types of cancer. You may need more than the usual dose if taking certain medicines which interfere with vitamin D. These include: carbamazepine, phenytoin, primidone, barbiturates and some medicines for the treatment of HIV infection. Multivitamins are not suitable for long-term high-dose treatment because the vitamin A they also contain can be harmful in large amounts. Are there any side-effects from vitamin D supplements? It is very unusual to get side-effects from vitamin D if taken in the prescribed dose. However, very high doses can raise calcium levels in the blood. This would cause symptoms such as thirst, passing a lot of urine, nausea or vomiting, dizziness and headaches. If you have these symptoms, you should see your GP promptly, so that your calcium level can be checked with a blood test.

Some guidelines advise that people taking high vitamin D doses should have their calcium levels checked during the first few weeks. In practice, this is not usually done unless you develop symptoms of a high blood calcium level. What is the outlook (prognosis)? The outlook is usually excellent. Both the vitamin levels and the symptoms generally respond well to treatment. However, it can take time (months) for bones to recover and symptoms such as pain to get better or improve. The complications of severe deficiency have been mentioned. Rickets can occur in children, and osteomalacia in adults. These diseases affect the strength and appearance of bones, and can lead to permanent bone deformities if untreated or if treatment is delayed. Vitamin D has been linked to other diseases. In recent years there have been associations with conditions such as cancer, heart disease, infectious disorders, autoimmune disease and diabetes. This does not mean that all people with vitamin D deficiency will get these problems. Nor does it mean that if you have one of these illnesses, a vitamin D deficiency is the cause. In these cases, vitamin D is thought to be just one factor.

Follow-up Most people who are treated for vitamin D deficiency will need to be reviewed a few weeks or months after starting treatment, depending on how severe their symptoms are. A further review after one year is advised. Further help & information Symptoms and causes - Rickets - Mayo Clinic Symptoms and causes Signs and symptoms of rickets can include: Delayed growth Pain in the spine, pelvis and legs Muscle weakness Because rickets softens the growth plates at the ends of a child's bones, it can cause skeletal deformities such as: Bowed legs or knock knees Thickened wrists and ankles Breastbone projection When to see a doctor Talk to your doctor if your child develops bone pain, muscle weakness or obvious skeletal deformities. Causes Your body needs vitamin D to absorb calcium and phosphorus from food. Rickets can occur if your child's body doesn't get enough vitamin D or if his or her body has problems using vitamin D properly. Occasionally, not getting enough calcium or lack of calcium and vitamin D can cause rickets. Lack of vitamin D Children who don't get enough vitamin D from these two sources can develop a deficiency: Sunlight. Your skin produces vitamin D when it's exposed to sunlight.

But children in developed countries tend to spend less time outdoors. They're also more likely to use sunscreen, which blocks the rays that trigger the skin's production of vitamin D. Food. Fish oils, fatty fish and egg yolks contain vitamin D. Vitamin D also has been added to some foods, such as milk, cereal and some fruit juices. Problems with absorption Some children are born with or develop medical conditions that affect the way their bodies absorb vitamin D. Some examples include: Celiac disease Risk factors Factors that can increase a child's risk of rickets include: Dark skin. Dark skin doesn't react as strongly to sunshine as does lighter skin, so it produces less vitamin D. Mother's vitamin D deficiency during pregnancy. A baby born to a mother with severe vitamin D deficiency can be born with signs of rickets or develop them within a few months after birth. Northern latitudes. Children who live in geographical locations where there is less sunshine are at higher risk of rickets. Premature birth. Babies born before their due dates are more likely to develop rickets. Medications.

Certain types of anti-seizure medications and antiretroviral medications, used to treat HIV infections, appear to interfere with the body's ability to use vitamin D. Exclusive breast-feeding. Breast milk doesn't contain enough vitamin D to prevent rickets. Babies who are exclusively breast-fed should receive vitamin D drops. Complications Left untreated, rickets can lead to: Failure to grow Kids Health Info : Rickets Kids Health Info Contact us Rickets Rickets is a preventable bone disease that causes soft bones. Rickets only occurs when children are growing - if a child has softer bones, the bones can bend and become an abnormal shape. Signs and symptoms Children with rickets may have: Legs that are an abnormal shape - 'bow legs' or 'knock knees' or legs that are not straight. It is normal to have some bowing before two years old and some knock-knees around the age of four. Swelling at the wrists, knees and ankles because the ends of the bones are larger than normal. Late teeth and problems with tooth enamel. Late closure of the anterior (front) fontanelle (the soft part on top of a baby's head). Poor growth. Late crawling and walking.

Bone fractures after minor falls or traumas. Infants and children with rickets are often grumpy and irritable because their bones are sore. Sometimes babies with rickets can have symptoms of very low calcium levels, such as muscle cramps or seizures. Seizures from low calcium mostly happen in babies who are less than one year old. Who is at risk? Rickets is not common. Nearly all cases of rickets in Australia occur in infants and children who have migrated to Australia, or whose parents migrated to Australia. Rickets is more common when children are growing quickly. It mostly occurs in infants and young children, but it can also occur in teenagers. The risk factors for rickets are the same as the risk factors for low vitamin D. Rickets is a disease of childhood (the term 'children' is used to refer to infants, children and adolescents). Who is at risk of low vitamin D (and rickets)? Children with very dark skin - the colour in skin (melanin) acts as a natural sunscreen and increases the time people need to make vitamin D. Children who do not expose their skin to sun - people who stay inside or who wear clothing that covers most of their body.

Children with conditions affecting how the body controls vitamin D levels - for example, liver disease, kidney disease, and problems with absorbing food (cystic fibrosis, coeliac disease, inflammatory bowel disease). Some medicines, such as anticonvulsants or isoniazid, can affect vitamin D levels. Breastfed babies who also have other risk factors - breastmilk is the best type of food for babies, but it does not contain much vitamin D. Newborn babies get their store of Vitamin D from their mothers, so they are at risk of low vitamin D if their mother has low vitamin D and/or if they have dark skin. Not all children with low vitamin D get rickets. Rickets is more likely in babies and children who also have low dairy intake, and in babies that breastfeed for a long time without starting solid foods at the normal age (around four to six months). Causes Rickets is usually caused by low vitamin D, especially if children also have low calcium or low phosphate levels. Calcium and phosphate are minerals that are mostly found in milk and dairy foods. Sometimes kidney problems cause rickets by affecting how the body handles vitamin D, calcium and phosphate.

Prevention Rickets can be prevented by: Making sure women have good vitamin D levels during pregnancy. Identifying babies who are at risk of low vitamin D (fully breastfed babies with at least one other risk factor such as dark skin) and starting vitamin D (400 IU daily) from birth and continuing until they are at least one year old. Introducing solid foods for babies when they are four to six months old. Including enough calcium and phosphate in children's and adolescents' diets - they need two to three serves of dairy each day (one serve of dairy is: one glass of milk or one tub of yoghurt or one slice of cheese). Identifying and treating low vitamin D. Spending time outside to prevent low vitamin D (see the Kids Health Info factsheet: Vitamin D ). Children with dark skin who live in the southern parts of Australia may need extra vitamin D supplements during winter. Spending some time in the sunshine every day and including foods with vitamin D and calcium in your child's diet helps prevent rickets. However, foods only provide a small amount (10-25 per cent) of daily vitamin D needs for most people in Australia.

If your child has fair skin, about 20 minutes of sunshine either early in the morning or late in the afternoon is enough for them to get plenty of vitamin D. If your child has darker skin, they will need more time in the sun as their skin does not absorb the sunlight as quickly. It is still important for people with fair to olive skin to use sunscreen and follow skin cancer prevention advice. Treatment Children with rickets (and those with low calcium) need to see a specialist urgently. They will need blood tests (to check vitamin D, calcium balance, phosphate, kidney function, and bone turnover), urine tests, photos and X-rays. Children with very low calcium (including children with seizures) will need admission to hospital to have extra calcium and heart monitoring (low calcium levels can affect the heart rhythm). Rickets caused by low vitamin D is treated by vitamin D supplements. Often children will need extra calcium and phosphate as well, by increasing dairy foods or by taking supplements. Vitamin D tablets or mixtures can be low dose (taken daily) or high dose (taken monthly or less often). It is important to check calcium balance first - sometimes children will need extra calcium and/or phosphate before they have high doses of vitamin D.

Rickets caused by kidney problems is managed by the renal (kidney) doctors. Follow-up Regular follow up with a paediatrician is needed to ensure healthly levels of vitamin D, calcuim and phosphate are maintained. Blood tests to measure vitamin D levels will be done periodically. X-rays to look at bone growth will be done at regular intervals. A review by a dietitian will help to ensure that your child's diet contains all the right food groups. Key points to remember Rickets is a disease where bones are weak and soft. It is caused by not having enough vitamin D. It can be prevented and treated by having daily sun exposure without sunscreen and by eating foods that contain vitamin D. More information Contact your family doctor (GP) or paediatrician Contact your Maternal and Child Health Nurse

Question: A deficiency of which vitamin cause rickets?
Answer: D