approach to child with rickets dr.sandeep c agrawal agrasen hospital gondia india

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com

Dr.Sandeep Agrawal

Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital

Gondia

Maharashtra

India

[email protected]

!www.agrasenortho.com

!09960122234

Practical approach to Rickets

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Practical approach to child with Rickets.

Level 1. Is it true Rickets or rickets like states ? !

Do preliminary investigations – Serum calcium, phosphate, Serum Alk P04ase(SAP)

! Have a close look at the x rays

!Consider the following conditions !

! Hypophosphatasia

Metaphyseal dysplasia !



Level 1 – is it True Rickets or rickets like states ?

Features ! !

Radiological signs similar to rickets. But growth plate are not wide with differential involvement of

bones in a joint.! Eg. Femur shows changes but tibia is normal.!

!Levels of serum Ca, P and SAP normal.!

!Diagnosis!

Metaphysial dysplasia



Features .---- !

Clinical signs or rickets are present but x rays show tongue like radiolucency

projecting from growth plate into metaphysis. !

In rickets growth plate is uniformly wide. !

SAP levels are low but S. ca, P Levels are normal. !!

Diagnosis Hypophasphatasia



Level 2 – is it nutritional or non nutritional ?!

!

Look for clues in history or examination:!!

Prematurity Neonatal cholestasis

Anticonvulsant therapy Chronic renal disease



Level 2: Is it nutritional or non nutritional? Useful clues

1.Jaundice - Hepatobiliary disease Metabolic disorders

!2.Cataract - Galactosemia, Wilson’s

!!

3.Positive family history - Metabolic disease, RTA

!!

4.Mental retardation, seizures - Galactosemia !!

5. Drug induced rickets in primary CNS problem !!

6.Alopecia - VDDR type 2.



Level 2.. Is it nutritional or non nutritional?

In the absence of clues –! Presume and treat it as vit D deficiency rickets.!Give vitamin D2 (inj. arachitol) 600000 units 2 doses at two to three weeks interval . Improvement occurs

in nutritional rickets.!!!

Healing is indicated by the presence of provisional zone of calcification.!

! Non healing favours a non nutritional cause.



Level 2.. Is it nutritional or non nutritional?

Features of non nutritional causes:!!

Presentation before six months or after two years of age!

Associated failure to thrive!Positive family history!

Obvious clues mentioned earlier!Failure of vitamin D therapy



Level 3. if it is non nutritional and lack any obvious clues it could be either due to GI or Renal cause:

Features ….!!

Recurrent diarrhea, oily stools. Recurrent abdominal pain and distension.

!Anemia, hypoproteinemia.

!Multiple vitamin and mineral deficiencies.

!Diagonosis !

Malabsorption with rickets.



If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause

Features …!!

Hepatobiliary findings:!!

Raised serum billirubin low serum albumin

prolonged prothrombin time. !

Diagnosis !Hepatic rickets



Level 3.. If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause

Features…!Failure to thrive

Recurrent vomiting lethargy

Acidotic breathing. Hypertension, anemia with or without edema.

!!

Positive findings in urine analysis. Abnormalities in electrolytes,

Blood urea and creatinine. Renal abnormalities in ultrasound abdomen.

!Diagnosis!!

Renal rickets



Level 4.. If it is rickets due to Renal causes what is the underlying renal problem that led to rickets.?

Depends on the clinical features of chronic renal failure and on laboratory investigations.!

!Do urine analysis!

Blood for electrolytes, urea and creatinine.! Blood gas analysis.!

Ultrasonography abdomen.



Level 3.. If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause

Features…!!

Vomiting , lethargy, growth retardation!Hypertension, anemia, with or without edema.!

Features of obstructive uropathy.!Raised blood urea, creatinine.. S. potassium may be

high.!Abnormalities in USG, MCU and DMSA scan.!

!Diagnosis !

Chronic renal failure - renal osteodystrophy.



Features…!!

Recurrent vomiting, diarrhoea with acidotic breathing.!

Positive family history.!Metabolic acidosis with normal anion gap,

hypokalemia, and raised serum chloride!Normal blood urea and serum creatinine.!

No proteinuria or glycosuria.!!

Diagnosis !Renal tubular acidosis



Features….!Severe form of rickets with stunting and

deformity.!Features mentioned in RTA.!

Proteinura, glycosuria present.!Normal or slightly increased B.urea and

S.creatinine.!Features of underlying causes such as

cystinosis.!!

Diagnosis!Fanconi syndrome



Features…!!

Lower limb deformity, stunted growth.!Often with family history.!

Frequent dental abscess and early decay.!Low serum phosphate and low TRP.!

!Diagnosis !

Familial hypophosphataemic rickets(FHR)



Level 5.. Child with rickets, no clues so far, what else?

Features…!Often presenting in early infancy!

Hypocalcemic tetany!!

Improvement with vitamin D therapy and recurrence of symptoms on

discontinuation.!!

Diagnosis !Vitamin D dependent rickets type1



Features…!!

Alopecia with or without any response to any form of vitamin D!

High serum levels of 1,25 dihydroxy vitamin D!!

Diagnosis !Vitamin D dependent rickets type2

!1,25(OH)2 vit D level is high in contrast to

VDDR type 1 where it is low.



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approach to child with rickets dr.sandeep c agrawal agrasen hospital gondia india

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