Rickets is a disorder identifiable by bowing of the legs, and is something that can be seen throughout the Caribbean. Although it can be inherited, it is mainly seen in growing children as the result of soft weak bones secondary to a vitamin D deficiency and, in some cases, a lack of calcium or phosphate.
Vitamin D is one of the essential vitamins and is vital for the absorption of calcium and phosphorus—which make strong, healthy bones. But it isn’t just our bones that benefit from vitamin D; it helps boost the immune system, improve muscle function, keep the heart and lungs healthy, improve brain function and development and also has anti-cancer effects. The two main sources of vitamin D come from the sun and our diet.
Exposure to sunlight produces vitamin D, which is why it is sometimes referred to as the sunshine vitamin. The fact that living in the Caribbean exposes us to abundant sunshine, compared to those living in places like North America or England, should mean that it is a condition rarely seen on our islands; but this is actually not the case. So why do we see a high incidence of this condition? The answer is simple: the same process that protects people with dark skin from some of the harmful effects of the sun also affects the production of vitamin D. Dark skin has more melanin, pigments that provide extra protection against the harmful effects of the sun. The benefits of exposure to sunlight are also being experienced by people of all skin colours due to the increased use of protective sun cream.
All is not lost if you are unable to get enough sun; food is the next line of defence. Many foods and beverages contain vitamin D such as milk, orange juice, eggs, oily fish and liver; and to make sure we have plenty of sources; some foods have been fortified with vitamin D. Have a look at the cereal boxes next time you go out shopping. When we ingest food and drink containing vitamin D, our bodies convert it into its active form in the kidney and liver. It’s important to remember, however, that if food is your only source of vitamin D, you may need to take a supplement to ensure you meet the minimum daily requirement.
Rickets had almost been eradicated in many countries but over the last few years it has slowly started to reappear. So, exactly how does rickets cause all these problems? It is down to the strength and hardness of bones. Soft bones in young children can impact on how bones grow and can affect the growth plates, areas of new bone growth at the ends of bones, and signs are usually noticed between the ages of six months and two years. This can not only cause bone deformity such as bow legs, knock knees or scoliosis, but also thickening at the wrists and ankles. As well as these common visual sign, rickets can also lead to delayed growth, delayed motor skills, muscle weakness and pain, especially in the back and legs. If left untreated it can also affect the teeth and cause seizures.
As well as lack of vitamin D in our diets and by exposure to the sun, there are other factors that predispose children and adults to this problem. People who have Celiac disease, inflammatory bowel disease, cystic fibrosis and kidney problems are at higher risk of experiencing a deficiency. Other factors include:
• Dark skin
• People who live in places where there is less sunlight
• A mother having vitamin D deficiency during pregnancy
• Premature babies
• Medications such as
anti-seizure and anti-retroviral can affect the body’s use of Vitamin D
• Breastfeeding if the mother is deficient in Vitamin D.
Diagnosis is usually made in childhood. Doctors may notice that the baby is not developing as expected and shows signs of excessive bowing of the legs when starting to walk. Bowing legs in a toddler is not abnormal, but it usually lessens as the child gets older. When bowing appears to worsen as the child gets older, it may be a sign of the presence of rickets. This, along with other signs mentioned above, and other diagnostic tests such as X-rays, and blood and urine tests, can assist your healthcare provider when making a definitive diagnosis of rickets.
In most cases rickets is treated with vitamin D and calcium supplements. If the deformities are severe, your healthcare provider may suggest bracing of the legs and/or spine to assist with positioning as the body grows. In some cases physiotherapy may help where there is muscle weakness and decreased function. If conservative management is not successful in managing the symptoms and progress of the condition, then surgery may be indicated. But do not over worry if your toddler appears to have bow legs; it may be quite normal. It is only a problem if, as they grow older, the problem gets worse.
Prevention is not possible in all cases but certain lifestyle changes can help in many instances. The best source of vitamin D is sunlight but if, as we discussed earlier, you live in countries with limited sunlight (close to the northern latitudes or during long, winter months) or have dark skin, this may not be an option. The next option is to ensure that your diet is rich in foods that are high in vitamin D. However, in some cases the only option is to take a vitamin D or calcium supplement. If you feel that you are not getting enough vitamin D, or you notice excessive deformities or some of the symptoms mentioned earlier, then it is important to contact your physician for guidance and advice.
