Rickets in children – symptoms and treatment
Symptoms of rickets in children
The first symptoms of rickets usually start at the 3th month. Only in premature and twins it may occur early at the 2nd, even at the end of the 1st month. Rachitis could also develop later – at the 2nd half of the first year, even after the first year if factors of rachitis affect the child in older age.
The earliest symptoms of rickets are from the nervous system. They occur before detectable bone manifestations. The child becomes restless, startled by insignificant noise, not only during sleep, but when awake. Muscle tonus is lowered, the child becomes relaxed. But in most cases the general appearance is good. Very important early symptom of rickets is the intensive sweating of the baby. During breastfeeding or when the baby is sleeping the mother finds the pad wet from sweat, sometimes even the entire coat of the child is wet. Rotation of the head due to itching when sweating leads to hair loss in the area. This exposure of the occipital region is not sure symptom of rickets. It can be seen also in children that lie on their back for a long time.
Most articulate, confident and relatively early symptom of rickets is craniotabes - softening of the skull. It is found in the occipital and parietal bones, rarely in the temporal bones. Finger pressure on the skull in the areas of softening causes sinking feeling as pressure on the ball ping - pong or parchment, sometimes accompanied by a slight crunching. Craniotabes is found at the 3rd to 6-8 months and rarely at the end of the 1-th year.
In the investigation for craniotabes child’s head is covered with two hands and consistently exert pressure with different fingers while feeling characteristic sinking. Susceptibility of the skull is also rachitic symptom, but it is not termed as craniotabes. It can be found on the edges of the bones, but also in the middle. The edges of the fontanel, which are normally susceptible to the 45th day after birth, in rickets remain soft and susceptible to pressure even later.
Moreover, in rachitic children fontanel remains with larger sizes and closes later after 14 to 16 month, sometimes up to 2 years. Because of the softening of skull bones when children lie on the same side occurs deformation of the head – it becomes flat on the side at which the child lies. Osteoid accumulation of tissue in the frontal and parietal tuber leads to their protrusion. Thus the head may have a rectangular shape (caput quadratum), witch remains for a lifetime.
Spine and chest undergo several changes in rickets. Even at 4-5 months appear rachitic rosaries - thickening of the ribs where the bridge goes into cartilage. This thickening is felt well with hand fingers, but at thin childs well-defined rachitic rosaries can also be seen. As a result of pulling of the diaphragm occurs permanent sinking of the breast and that is called Harrison groove. Up to 3 months after birth suchpitting occurs in each breath as a physiological phenomenon called groove of Trousseau. In more severe rickets softening of the bones of the rib cage can lead to permanent hollow in the sternum - shoemaker’s chest, or pectus excavatum. Sometimes instead of pitting occurs protrusion of the sternum as in birds, so this breast is called pectus carinatum. In the most severe rickets chest may become bell shaped with a strong extended lower aperture.
Due to the weakness of the dorsal muscles when the infant begins to sit, the backbone is distorted under the weight of the upper body. Occurs rachitic hump in the thoracic and lumbar spine, which is rounded. In some children this hump can be left after toddlerhood. Side distortions can also be seen – scoliosis, which, however, is more characteristic of older children with poor sitting on the desk.
In the most severe forms of untreated rickets pelvic bones can be deformed. This happens after the toddier under the action of gravity on the body. So obtained flat rachitic pelvis with decreasing distance from the symphysis to promontorium. Once obtained the deformation of the pelvis remains stable in girls and later may create difficulties at birth.
The bones of the limbs are affected in varying degrees in rickets. On the one hand, the accumulation of osteoid tissue in the epiphysis leads to their thickening, and the other, softening of the bones causes their distortion. Thickening of the epiphysis of the radial bone in the wrist forms rachitic bracelets. They appear at 5-6 months and represent enlargements of the roughness of the epiphysis to epiphyseal growth line, denoted as rickety cups because resemble wine glasses. Distortion of the bones of the legs occurs after the period of toddlers. Femur is bent in the neck and the angle it forms with the body of the bone is straight from the blunt, even harsh. As a result, in rachitic child can be seen waddle, similar to that of congenital dislocation of the hip. More frequently is observed distortion of the long bones of the feet in or out, giving rise to feet in the form of the letters O, K and X. The distortion is most pronounced in the knee. Occur genu valgum, genu varum, and rarely and genu recurvatum. In most cases, with age and the gradual shift of rickets these deformations reduce or disappear, but may remain for a lifetime. This also applies to rachitic flatfoot – flattening of the arch under the influence of body weight due to softening of the bones and weakness of ligaments. Once received flat feet usually remain for a lifetime.
Rachitic bones seem to be painful, since children with rickets are reluctant to step and stand on their feet. They usually are late in walking, sometimes up to 1-2 years. It should be noted however, that other diseases may be a reason for late walking. On the other hand, early walking does not exclude rickets.
Eruption of teeth in rachitic children is often delayed until 10-12 months. By itself however it does not mean rickets and early eruption of teeth does not exclude the presence of rickets. A characteristic of rickets is a violation of the usual order of cutting teeth, such as penetration of premolar teeth before going up of the incisors is completed. In older rachitic children teeth are with bad enamel, ridden by caries. Characteristic symptom of rickets is muscular hypotonia. Hypotension of abdominal muscle causes enlarged belly, which is diffuse like frogs. Hypotension of respiratory muscles leads to incomplete unfolding of the lungs, which favors more frequent development of pneumonia in rachitic children. Muscular hypotonia contributes to the bones and flat feet in some cases, hypotension is so pronounced that even children over 1 year may not sit well and rest on the hands and resemble a cat squatting, lying on its front paws. Often are found enlarged liver, spleen and lymph nodes. So almost all of the body systems are affected.
Treatment of rickets in children
Treatment of rickets is complex and basic parts are irradiation with ultraviolet light and the vitamin therapy.
Of the rachitic child shoud be provided freedom of movement, walking in fresh air and outdoors. Fresh cool air exacerbates respiratory excursions, which provides more oxygen and improve metabolism. Going outdoors is useful not only in sunny days, but in cloudy weather, because diffused sunlight also contains small amount of ultraviolet rays.
Sunlight is the remedy against rickets. It is performed outdoors during the summer and in winter – in a warm room at an open window. For small infants it is necessary only partial exposure of the limbs and face and those of the second half can make and complete exposure, as the requirement for gradually increasing radiation dose. With the appearance of agitation, insomnia, loss of appetite, skin redness and increased temperature exposures are interrupted temporarily, then start again more carefully.
Ultraviolet lamps replace the sun in winter, irradiation with UV light provides secure and fast effect. This affects not only rickets, improves muscle tone and emotional, and general appearance of the child. Irradiation is conducted in medication instructions specific to each child individually. The effect occurs after the first series of exposures, but permanent cure requires 2-3 sets, alternating with rest.
For small children with rickets the most appropriate is natural nutrition and it should be conducted properly. The quantity of fruit juices should be increased two or more times of the normal amount -fruit acids retain for longer acid reaction in the small intestine and thereby contribute tooth absorption of calcium. Feeding of rachitic infants begins about two weeks earlier, always with vegetable puree. For older infants are limited flour foods - porridge and sour, as well as cow’s milk, giving more fruits and vegetables. in the diet include butter, egg yolk and possibly liver, which are rich in vitamin D.
Oral route of administration of the vitamin D in the form of drops in rickets is preferable as a more physiological. Thus, the vitamin is absorbed more evenly and its effect is more secure. Vitamin D drops are given before eating, preferably in the morning, in spoon with milk or water.
The vitamin prophylaxis in the form of drops is an indispensable component in the complex of preventive measures against rickets. For full-term children the vitamin prophylaxis starts at the 25th day after birth, and for premature - even at 7-8 days. Daily given right dose of vitamin drops is reffered in the morning before feeding in spoon with milk.
Here, as in treatment the dases of of vitamin can be given for 1-2-3 weeks at once. This should be done in the doctor’s appointment. The vitamin prophylaxis continues without interruption until the end of the first year of the child. Exceptionally, if the mother is an executive and provides sunlight of the child during the summer months, vitamin prophylaxis can be discontinued from June to late of September. During the second winter of children over one year vitamin prophylaxis continues at the same doses.
By systematic prevention of rickets, which is based on the exposure to sun or ultraviolet radiation and vitamin prophylaxis, most children can be protected from rickets.