Rickets : Articles

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

Rickets was once considered an extremely common disorder of childhood. The term itself is derived from the old English word for "twist," or "wrick," and throughout history children with rickets could be identified by their bowed legs and knock knees, which gave them a twisted appearance. Rickets is caused by a deficiency in vitamin D . During growth, human bone is made and maintained by the interaction of calcium , phosphorus , and vitamin D. Calcium is deposited in immature bone (osteoid) in a process called calcification, which transforms immature bone into its mature and familiar form. However, in order to absorb and use the calcium available in food, the body needs vitamin D. In rickets, the lack of this important vitamin leads to low calcium, poor calcification, and deformed bones. Vitamin D is the only vitamin that can be both acquired through food and made by the body itself. Although vitamin D can be absorbed through foods rich in animal fat , such as milk, cheese, fish, and meat, this absorption constitutes only about 10 percent of what the body needs in a single day. The remaining 90 percent is created by the body. Ultraviolet radiation from the sun converts 7-dihydrocholesterol in the skin to vitamin D 3 . This is then converted to the hormone calcitriol (the active form of vitamin D) in the kidney. Calcitriol allows absorption of calcium and phosphorus in the gut, primarily in the small intestine, and maintains the body's balance of calcium and phosphate through the kidney and bone. Without adequate vitamin D, the body can only absorb 10 to 15 percent of the calcium available in food. This balance of vitamin D, calcium, and phosphate is essential to the growth and maintenance of bones, especially in children. Deficiencies can also occur in elderly adults, a condition called osteomalacia . Historically, rickets plagued the populations of European countries in the northern latitudes—at one time it was called "the English disease." During the Industrial Revolution and into the early 1900s, smog filled the developing cities of Europe, diminishing the amount of sunlight to which children were exposed and causing an epidemic of rickets. Some researchers estimate that prior to 1915, almost 85 percent of children in these industrialized areas of Europe and North America suffered from rickets. With research into the sources and function of vitamin D in the 1920s, however, the use of cod-liver oil, fortified cow's milk, and fortified formula virtually eliminated rickets in Europe and North America. This child's bowed legs are a symptom of rickets, a disease resulting from vitamin-D deficiency. Because their skin absorbs less sunlight, dark-skinned people need more sun exposure to synthesize the recommended daily amount of vitamin-D. [photograph by Marion Post Wolcott. Corbis. Reproduced by permission.] As vitamin D can either be consumed in small quantities through the diet or made in the skin, there are two main groups of risk factors for developing rickets. Dietary risk factors include diets low in vitamin D–rich foods, such as eggs, cow's milk, meat, and fish. Breast milk, a primary source of childhood nutrition , contains very little vitamin D, and infants who are exclusively breastfed are more likely to develop the disease. While human milk does contain sufficient amounts of calcium and phosphorus for an infant, its vitamin D content is only 4-60 IU/L (international units per liter), while the full-term infant requires approximately 400 IU daily. Infants and children who are not exposed to sunlight, like those in smog-filled cities or those who remain indoors or covered for cultural or religious reasons, are also at increased risk of developing rickets. In children with darkly pigmented skin, melanin acts in a similar way to block sunlight's ability to help the skin make vitamin D. Dark-skinned people require almost six times as much sunlight exposure to make the same amount of vitamin D as those with lighte