Treatment of rickets after 2 years. Modern approach to the treatment of rickets in children. Groups of children most susceptible to rickets

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This disease has been known to physicians for several centuries. Many parents, if they have not encountered it, have heard it for sure. So what is called rickets? It turns out that this is not one disease, but a whole group associated with impaired metabolic processes. According to statistics, this pathology affects from 20 to 60% of children, especially those living in northern regions or environmentally unfavorable.

Signs of childhood rickets occur due to rapid age-related changes in bone tissue and imperfection in the regulation of metabolic processes.

The reasons

Vitamins, minerals and salts play an important role in these processes. Calcium is involved in the important process of the formation of bones and teeth, is a valuable component of organs and muscle tissue. The second indispensable component of teeth and bones is phosphorus. With its participation and its derivatives, most of the processes in the body occur. Magnesium is responsible for the transfer and favorable absorption of all the necessary substances. Sodium is actively involved in the work of nervous and muscle tissue, digestion. Manganese is needed to strengthen connective and bone tissue, and iron is needed for the appearance of hemoglobin. The formation of bones and tooth enamel is impossible without fluoride. These and a number of other vitamins take an important part in metabolic processes and their deficiency can lead to rickets.

But the main factor in the appearance of the disease is insufficient production or absorption of vitamin D by the body. Its deficiency occurs for several reasons:

1. Lack of sufficient amount of ultraviolet radiation, especially in the cold season. Children who are little in the sun and even on the street in autumn and winter get sick with rickets.
2. Also, the reasons may be the use of certain drugs, hormones and antibiotics.
3. Insufficient intake of vitamin D from food.
4. Diseases of the kidneys and liver, in which vitamin D in them does not enter its active stage and is not absorbed by the body.

There are a number of factors that predispose to the development of the disease:

• The accelerated growth of the child in the first years of life, when the need for vitamin D increases.
• Early artificial feeding. With natural breastfeeding, 70% of calcium is absorbed from mother's milk, and with artificial breastfeeding from cow's milk and mixtures, only 20%.
• Irrational nutrition: for example, semolina porridge several times a day.
• Deficiency of vitamins A. E. C, K group B and minerals of calcium, phosphorus, silicon, magnesium, iron and manganese.
• Acute and other diseases of the child, in which vitamin D is intensively consumed.
• Lack of adequate physical activity of the baby, gymnastics and massage, tight swaddling, immobility in case of damage to the central nervous system or congenital dislocation of the hip.
• Poor living conditions for the child, lack of adequate care and preventive measures to prevent vitamin D deficiency.
• Vitamin deficiency in the prenatal period of development. If they are not enough in the last trimester of pregnancy, then the bones of the born child will be poorly mineralized. And in the first year of life, the need for them is quite large, and at a time when insufficient bone mineralization is noted, it is problematic to talk about normal development.

Can lead to intrauterine deficiency:

1. pregnancy in autumn and winter, insufficient ultraviolet radiation (it rarely happens in the sun), life in the northern regions;
2. poor and monotonous nutrition of a pregnant woman (a lot of flour and cereals, few vegetables and fruits;
3. complications of pregnancy (toxicoses, threats of miscarriage, hypoxia, illnesses suffered during pregnancy);
4. twins, large fetus, prematurity.

Rickets can affect children in infancy (3-4 weeks), but most often the disease affects children from 1 to 2 years. To date, doctors consider rickets as a systemic disease with a violation of the processes of mineral metabolism, ossification and with a change in the functioning of various organs and systems.

Mineral metabolism is primarily understood as phosphorus-calcium. In addition, changes in the metabolism of proteins, macro- and microelements of iron, fluorine, zinc, copper, manganese and oxidative degradation of lipids are of no small importance. The frequency of the spread of the disease is directly related to the lack of natural sunlight. Children born in winter and autumn suffer from rickets much more often and in more severe forms.

The causes of rickets in children are due to anatomical and physiological features:

• intensive growth, requiring the supply of a large amount of plastic material;
• emphatic (fast) metabolism;
• features of the structure of bone tissue;
• imperfection of the processes of osteogenesis and the exchange of calcium and phosphorus;
• the absence of an acceptable static-dynamic load on the bone tissue.

There are several causes of rickets, the main of which is a lack of vitamin D. As a rule, it is associated with exogenous (insufficient dietary intake) and endogenous (weak production by the body in the absence of sunlight) causes. Under the influence of ultraviolet radiation, vitamin D is formed in the skin from 7-dehydrocholesterol, and with food it enters the form of vitamin D2 (ergocalciferol) and D3 (cholecalciferol). Therefore, two of its active forms are distinguished.

Why is vitamin D needed?

Vitamin D is very important for a child's body. It is both a hormone and a fat-soluble vitamin. It is a protohormone for the formation of active metabolites in the liver and kidneys. In its active form, vitamin D is manifested by the production of metabolites, the action of which is directed to three types of tissues:

• the mucous membrane of the small intestine, where calcium is absorbed into the intestine;
• bone tissue, in which resorption and remodeling occurs under its influence;
• proximal tubules of the kidneys, where vitamin D increases phosphorus reabsorption.

Recent studies have also shown that calciferol produces the production of interferon, affecting the state of the immune system.

Vitamin D Functions:

1. Impact on the skeletal system. The main function of the vitamin is the absorption of calcium and magnesium, which are necessary for the development of bones and teeth. It also promotes the absorption of calcium in the intestines and kidneys, the regulation of the level of phosphorus and calcium in the blood. In the hormonal regulation of phosphorus and calcium, vitamin D occupies a major place.
2. Activation of cell growth. Vitamin D takes an active part in the development and growth of cells. The hormone calcitriol is an effective protection against oncological diseases of the skin, breast and large intestine, as well as a prophylactic agent for cancer of the prostate, ovaries, breast, skin, and brain. Externally, vitamin D3 is used in the treatment of psoriasis.
3. Impact on immune processes. The quantitative composition of vitamin D in the body can affect the area of ​​the brain responsible for the production of immune system cells. By regulating the synthesis of monocytes, it improves immunity.
4. Hormonal system. Vitamin D directly affects blood glucose levels.
5. Regulation of the nervous system: thanks to vitamin D, an optimal level of calcium in the blood is maintained, which is responsible for the transmission of nerve impulses and muscle contraction.

The causes of rickets in children may also be an increased production of parathyroid hormone by the parathyroid glands. This biologically active hormonal substance regulates the level of calcium and phosphorus in the blood. Its main task is to increase the concentration of calcium and lower the concentration of phosphorus in the blood serum. This is due to increased absorption of calcium in the intestine and its active absorption by the cells of the body.

The level of the hormone depends on the level of calcium ions in the blood - the lower it is, the more active the parathyroid glands secrete the hormone. Its main function in the body is:

• prevention of calcium loss in the urine;
• increased excretion of phosphorus in the urine;
• with a deficiency of phosphorus and calcium in the body, extracting it from bone tissue;
• with an excess of calcium in the body - its transportation to the bone tissue.

In violation of the release of parathyroid hormone, phosphorus-calcium metabolism suffers: malabsorption by the intestines, loss of calcium by the kidneys and washing it out of the bones. With excessive release of the hormone, the formation of bone tissue slows down, and the already formed bone beams can actively dissolve, which leads to their softening. The density of bones and their strength decreases, calcium under the level of the hormone is washed into the plasma and its content in the blood will be increased. Due to the increase in phosphorus salts, the kidneys suffer, blood circulation in the vessels is disturbed, and calcification occurs in them.

Antagonist of parathyroid hormone in phosphorus-calcium metabolism is thyrocalcitonin. This hormone is produced by the thymus, thyroid, and parathyroid glands. Its main role is to maintain a balance between osteoblasts and osteoclasts. Thyrocalcitonin lowers the level of calcium and phosphorus in the blood, helps new bone tissue cells (osteoblasts) to actively capture it. Thus, it helps the formation of inert tissue, that is, the activity and reproduction of osteoblasts, and the strengthening of mineralization processes. And at the same time, a sufficient level of the hormone inhibits the action of osteoclasts, which contribute to the destruction of bone tissue. In the intestines and kidneys, thyrocalcitonin enhances the absorption of phosphates and reduces the resorption of calcium.

Signs of rickets in children

The initial clinical signs of rickets in a child appear at the age of 2-3 months and are associated with damage to the nervous system. The child becomes shy, shudders at sharp sounds or bright lights, is often irritated, cries, sleeps poorly (as a rule, sleep is superficial and short). A characteristic sign of rickets in a one-year-old child is sweating of the back of the head after sleep, which can be seen from the wet pillow around the head. This is due to increased sweating of the body and the acidic reaction of sweat, as a result of which the skin is irritated, the baby is worried, rubs his head against the pillow. Characteristic areas of baldness may appear.

The manifestation of rickets in children during this period is weakness of the muscles and ligamentous apparatus, looseness of the joints. Because of this, the first teeth appear later, children later begin to sit, stand and walk. Symptoms of rickets in children can also be observed in the form of deformation of the spine and chest, and weakness of the muscles of the abdominal cavity leads to a “frog belly” and constipation.

The initial period lasts from 2 weeks to a month, then the peak of the disease is observed, during which changes in the bone tissue progress rapidly. The bones of the skull soften, the edges of the large fontanel become pliable, the back of the head flattens. In the areas of bone growth, osteoid tissue actively grows. Sick children are characterized by late closure of fontanelles, late teething and subsequently caries.

As rickets manifests itself in children, characteristic bone deformities appear:

• when the child begins to walk, due to the softening of the bones, the legs become O-shaped and X-shaped;
• muscular hypotension contributes to the curvature of the spine and there is a "rachitic kyphosis";
• the shape of the head becomes square, the parietal and frontal tubercles stand out clearly, an "Olympic forehead" is formed;
• due to softening of the bones of the chest and muscle weakness, the sternum sinks or protrudes, “chicken breast” or “cobbler's chest” appears;
• on the ribs in the places where the inert tissue passes into the cartilaginous tissue, seals are formed - “rachitic beads”;
• there is a thickening of the epiphyses of the bones of the forearm - "rachitic bracelets", and thickening in the growth zones on the fingers "pearl bracelets";
• the pelvic bones are deformed, it becomes flat, which subsequently makes childbirth difficult for girls;
• there is a delay in the growth of tubular bones in length, which causes "short-legged".

Treatment of rickets

As a rule, the treatment of the disease is long and is carried out in the following areas:

• elimination of hypovitaminosis D;
• normalization of phosphorus and calcium metabolism;
• restoration of the functions of muscle tissue, other organs and systems.

Adequate nutrition, observance of the daily regimen are prescribed. Specific treatment is carried out by a pediatrician, taking into account the time of year, the period of growth and the specifics of the course of the disease, and includes UV irradiation or vitamin D intake against the background of calcium supplements. It is impossible to combine these two types of treatment, because an excess of vitamin D can cause serious complications.

Non-specific treatment includes bathing:

• salty (10 g of sea salt per 10 liters of water);
• coniferous (10-15 g of coniferous extract per 10 liters of water);
• herbal (a glass of decoction of chamomile, calamus root or oak bark, plantain per 10 liters of water).

The temperature of the bath is 32-36 degrees, the duration is 10-15 minutes, after which it is necessary to rinse with fresh clean water. The course of treatment is 10-15 baths.

Prevention of rickets

It is important to take preventive measures already during pregnancy. The expectant mother needs to eat rationally and balanced, adhere to the sleep and rest regimen, and spend enough time in the sun.

Specific prophylaxis is carried out for healthy children under 1 year old and includes:

1. 10-15 sessions of UV irradiation in spring and autumn;
2. Daily intake of vitamin D from October to March at a daily dose of 400-500 IU.

Nonspecific prevention of rickets includes:

• complete childcare;
• strict sleep and rest schedule;
• sufficient daily exposure to the street during daylight hours;
• regular air and air-light baths;
• timely bathing and massage after it;
• daily gymnastics for at least 30 minutes;
• breast-feeding;
• timely and adequate introduction of complementary foods, especially of animal origin.

With adequate and timely treatment during the recovery period, the signs of rickets decrease, and then do not occur at all. However, if time is lost, bone deformities can remain for life.

Useful video about rickets in children

Despite significant advances in medicine, rickets remains a disease that affects almost every second or third child to some extent at the very initial stage of its development, namely in the first year of life. What measures should parents take to protect their baby from this disease?

Rickets (from the Greek rhachis - backbone, spine) is a disease of infants and young children (usually from 2 months to 1 year), caused by vitamin D deficiency in the body and proceeding with metabolic disorders (mainly mineral). It was first described in the middle of the 17th century by the English physician Glisson. One of the main symptoms of the disease was then considered a curvature of the spine, the so-called "rachitic hump", which determined the name of the disease. Rickets develops when a child does not take enough vitamin D with food or when the natural formation of this vitamin in the body, namely in the skin (insufficient ultraviolet radiation), is disturbed. It occurs more easily in the winter season in children who are bottle-fed, premature, often ill.

Rickets transferred at an early age can lead to a violation of posture, persistent deformities of the chest, legs, pelvis, contribute to the formation of malocclusion and flat feet, and cause a delay in psychomotor development.

Manifestations of rickets

The first signs of rickets can appear as early as 2-3 months of a baby's life, and in premature babies even earlier. Often the first symptoms of the disease (the so-called initial period of rickets) that parents notice are sleep disturbances (sleep becomes restless, anxious, with shudders), irritability, tearfulness, frequent shuddering of the child even with a soft sound. The baby appears excessive sweating, especially during sleep or feeding. The face and scalp sweat the most. Due to changes in metabolic processes in the body, sweat becomes "sour", irritates the skin, while the child begins to rub his head on the pillow, which causes baldness at the back of the head. Urine can also have a sour smell and irritate the baby's skin, often causing the appearance. Examining the child, the doctor, as a rule, notes a slight softening of the bones of the skull, which form the edges of the large and sutures. If treatment is not started at this stage and the causes contributing to the development of rickets are not eliminated, then the clinical manifestations of the disease begin to gradually increase, and pronounced bone changes appear in the child.

The peak period of the disease most often occurs at the end of the first half of the baby's life. The softening of the bones of the skull joins the softness and suppleness of the edges of the large fontanel - a flattening of the back of the head appears, and asymmetry of the head occurs. As a result of excessive growth of non-calcified bone tissue (which normally stops growing after calcification), the frontal and parietal tubercles begin to protrude in the child, and the skull acquires a peculiar shape. In addition, seals appear on the ribs in the form of "rachitic beads", and on the wrists in the form of "rachitic bracelets". In the second half of life, when the load on the bones increases, there are curvature of the spine ("rachitic hump"), chest (it can be pressed inward or bulges), pelvis (narrow, irregularly shaped pelvis ("flat rachitic pelvis"). With the onset of independent walking in babies, the legs are often bent, taking on an O-shaped and less often X-shaped shape, it develops.Bone deformities are especially clearly visible on x-rays, however, due to side effects on the body, this study is very rare in young children and only under strict indications.

At the same time, in addition to distinct bone changes, a decrease in muscle tone develops ( muscle). As a result of muscle weakness, a large belly ("frog" belly), increased mobility in the joints, the child begins to linger in the development of motor skills (begins to roll over on his stomach and back, sit, crawl, stand, walk late).

In addition, in children with manifestations of rickets, teething is delayed, often there is a violation of the internal organs: lungs, heart, gastrointestinal tract (tendency to constipation). Because of this, children often get sick with respiratory infections.

However, the symptoms of the disease gradually subside - a period of recovery begins. At the same time, the child’s well-being improves, changes in the nervous system and internal organs disappear, the child begins to sit, stand, walk better, however, muscle tone disorders and bone deformities persist for a long time, some persist for life.

Normalization of calcium and phosphorus levels in the blood indicates the transition of the disease to an inactive phase - a period of residual effects, when there are no signs of active rickets, but deformations from the bones persist - a large head, deformed chest, narrow pelvis, flat feet, malocclusion.

The mechanism of development of rickets

As you know, vitamin D enters the human body with food products of both vegetable (vegetable oil, wheat germ, nuts, etc.) and animal (dairy products, fish oil, butter, egg yolk, etc.) origin, as well as produced in the skin under the influence of ultraviolet rays.

The most significant forms of vitamin D are ergocalciferol (vitamin D 2) and cholecalciferol (vitamin D 3). However, research scientists have found that vitamins D 2 and D 3 have very little biological activity in the human body. The main effect on the organs (intestines, bones, kidneys) is provided by the products of their metabolism, which are formed in the liver and kidneys as a result of certain biological transformations. It is they (i.e. active metabolites) that determine the main function of vitamin D in the body - maintaining the required level of phosphorus-calcium metabolism. This happens through the effect of vitamin D on the absorption of calcium and phosphorus in the intestine, on their reabsorption (reverse absorption) in the kidneys and deposition in the bones.

The need for calcium and phosphorus in young children (in the first three years of life) is several times higher than in older children and especially adults. The rapid growth of the baby during this period requires the intake of a sufficient amount of building material. With a decrease in calcium and phosphorus in the blood (hypocalcemia and hypophosphatemia), as a result of their insufficient intake with food or impaired absorption in the intestine, minerals are “washed out” from the bones. Therefore, it has recently been considered that the development of rickets is largely determined not so much by a deficiency of vitamin D, but by a deficiency in the body of phosphorus and calcium compounds.

Risk factors

Prematurity (the fetus creates the largest reserves of calcium and phosphorus in the last weeks of pregnancy), the birth of children from multiple pregnancies, as well as children with large body weight at birth, can contribute to the occurrence of a deficiency of phosphorus and calcium compounds.

Insufficient intake of minerals from food (early feeding with non-adapted products (whole cow's milk), late introduction of complementary foods (after 6 months), introduction of carbohydrate-rich foods (semolina porridge) as complementary foods, adherence to strict vegetarianism (complete exclusion of meat products from the diet), violation absorption of calcium and phosphorus in the intestine due to disease of the gastrointestinal tract or immaturity of enzymes can also contribute to the development of rickets.In addition, there may be individual characteristics of the child, such as dark skin color (these children have reduced production of vitamin D in the skin), hereditary features of vitamin D metabolism, congenital disorders of the intestines, liver and kidneys, predisposing to disorders of calcium, phosphorus and vitamin D metabolism in the baby's body.

Diagnosis of rickets

The minimum research program includes the collection and analysis of a genealogical and clinical history, examination data and a urine sample according to Sulkovich.

The Sulkovich test is a qualitative reaction for determining the concentration of calcium in the urine. 2-3 days before the test, it is necessary to exclude kefir and other foods rich in calcium from the diet. Collect urine in the morning and strictly on an empty stomach. In healthy children, the calcium content corresponds to 2+. The height of rickets is characterized by a negative test of Sulkovich. The test is also used to monitor the treatment of rickets. With an increase in its values ​​to 3-4, the therapeutic dose of vitamin D is reduced to prophylactic or canceled.

The maximum research program is carried out when severe forms of rickets are detected or when treatment is ineffective. It includes determining the level of calcium and phosphorus in blood plasma, determining the activity of alkaline phosphatase, daily excretion of calcium and phosphorus in the urine, x-ray or ultrasound examination of the tubular bones of the forearm, determining the level of vitamin D metabolites in blood plasma, determining the acid-base state.

Treatment of rickets

Treatment of children with manifestations of rickets should be comprehensive, taking into account the reasons that led to the development of the disease. And it is necessary to start treatment when the first symptoms of the disease appear and to carry it out for a long time, achieving a complete cure for the child. Treatment of rickets is prescribed by a pediatrician. It is accepted to allocate specific and non-specific methods of treatment of rickets.

Among non-specific methods aimed at general strengthening of the body, the following are of great importance:

• a properly organized daily routine with sufficient exposure of the child to the fresh air;
• nutrition aimed at normalizing disturbed metabolic processes in the baby's body;
• regular gymnastics, massage, swimming.

Children should be outdoors for at least 2-3 hours daily. It should be remembered that children's skin, due to its characteristics (reduced ability to produce melanin pigment), is very sensitive to ultraviolet rays. In this regard, in the summer, children of the first year of life are contraindicated in direct sunlight. In order for the baby's skin to produce enough vitamin D, it is enough to walk in the so-called "lace" shade of trees, and not in the open sun.

Breastfeeding is optimal for a child of the first year of life. If the baby is forced to receive artificial feeding, it is necessary to give preference to a milk formula that is as close as possible (adapted) in composition to human milk. Since children with manifestations of rickets have a lack of phosphorus-calcium and vitamin (not only vitamin D, but also vitamins A, C, group B) metabolism, it is important to introduce vegetable and fruit purees, juices, cereals, meat, cottage cheese into the diet in a timely manner. As the first complementary foods for children suffering from rickets, vegetable puree is recommended (from 4-6 months of age), followed by the addition of egg yolk to it at 7-8 months, rich in calcium, phosphorus, vitamins and trace elements. Adding porridge, cottage cheese, meat to the diet will help ensure sufficient intake of high-grade proteins in the child's body. But the excessive consumption of bread, flour products, fat should be avoided, as they impair the absorption of calcium in the intestines.

Mandatory in the treatment of rickets is the appointment of vitamin D preparations, as well as calcium and phosphorus preparations, in other words, specific treatment.

The appointment of vitamin D, the calculation of the therapeutic dose and the duration of the course of treatment is determined only by the pediatrician, taking into account the severity of the course of rickets in a particular child, as well as the presence of concomitant conditions, such as prematurity, anemia (decrease in hemoglobin in the blood), dysbacteriosis, diseases of the skin, liver , kidneys, etc.

It should be noted that medicinal products may contain vitamin D in the form of D 2 (ergocalciferol) or D 3 (cholecalciferol), be in the form of an oily, aqueous or alcoholic solution. Vitamin D content is measured in international units (IU). Before starting to give vitamin D to a child, parents should pay attention to its content in one drop of the solution, which must be noted on the bottle: 1 drop of the oil solution contains approximately 650 IU of vitamin D; in 1 drop of an aqueous solution - 500 IU; in 1 drop of alcohol solution - about 4000 IU.

Recently, doctors have given preference to prescribing vitamin D 3 preparations (Vigantol, Videhol, Aquadetrim) and mainly its water-soluble forms (Aquadetrim). They are better absorbed in the intestines of the baby, have a longer effect in the body compared to oil solutions.

An alcohol solution of vitamin D is practically not used due to the content of large doses of vitamin D in it. In addition, due to the evaporation of alcohol (with a loosely closed vial) and an increase in the concentration of the solution, an overdose of vitamin D is possible. Fish oil preparations are rarely used now, since they have a specific taste and smell, which sometimes causes a negative reaction in a child when taken orally .

An important point in the treatment of rickets is the correct calculation of the therapeutic dose of vitamin D. Recently, doctors have been wary of prescribing both excessively high doses and shock treatments for rickets (a method in which a single child receives very high doses of vitamin equal to doses calculated for the entire course treatment), as this can lead to the development of a serious disease - hypervitaminosis D. With an overdose of vitamin D, weakness, loss of appetite, nausea, vomiting, diarrhea, weight loss, sharp pains in the joints, convulsions, fever, slowing of the pulse, difficulty breathing. In addition, the individual hypersensitivity of the child to vitamin D is possible. Therefore, if after several days of taking vitamin D the baby begins to refuse food, he develops nausea or vomiting, you should immediately consult a doctor, perhaps the listed signs are a consequence of an overdose of the drug.

If, after a few days of taking vitamin D, the baby begins to refuse food, he develops nausea or vomiting, you should immediately consult a doctor.

At the same time, do not worry if mom accidentally dripped two drops instead of one. In this case, the next time the drug should be given not the next day, but every other day. Cases of overdose are more common if the baby is given an alcohol solution instead of an oil or water solution every day - by mistake. Therefore, you need to be extremely careful when buying a drug, strictly follow the doctor's prescription.

At the end of the treatment course of vitamin D, they switch to a long-term prophylactic dose of vitamin D - 400 IU per day, which lasts throughout the year, with the exception of the warm months (from May to September).

Sometimes taking a therapeutic dose of vitamin D may not be as effective, and this is often due to a deficiency of a number of vitamins in the child's body (hypopolyvitaminosis), especially a deficiency of vitamins C and B2, which are directly involved in the formation of active vitamin D metabolites. In this regard, treatment rickets include multivitamin preparations (Polivit baby, Biovital gel, Multi tabs and others), including vitamin D in a moderate dose.

Previously, in the treatment of rickets, artificial ultraviolet irradiation (UVR) of the skin was actively prescribed. However, given the possible carcinogenic effect - the likelihood of developing cancer, this method of treatment in children has not been used recently. Calcium and phosphorus preparations have no independent value in the treatment of rickets. However, in some groups of children (premature, children with severe softening of the bones of the skull, a decrease in calcium in the blood), they still require their appointment within 2-3 weeks. It is useful to conduct massage and therapeutic exercises. Children over 6 months of age are prescribed therapeutic baths - salty, coniferous.

Salt baths are recommended for lethargic, inactive children (2 tablespoons of sea salt per 10 liters of water, temperature - 35-36 ° C). The first baths should be taken no more than 3 minutes, the next no more than 5. Baths are carried out every other day, the course is 10 procedures. Coniferous baths (1 teaspoon of liquid or 1 strip of a briquette of coniferous extract per 10 liters of water, temperature - 36 ° C) are indicated for children with increased nervous excitability. They begin to take baths lasting 5 minutes, gradually increasing the time to 10 minutes, for a course of 10-15 baths every other day.

Rickets is not a contraindication to the appointment of preventive vaccinations, however, they can be carried out in babies no earlier than 2-3 weeks after the start of treatment, since after this time the baby's body adapts to the treatment started.

Prevention of rickets should begin from the first days of a child's life (the so-called postnatal prophylaxis). It includes:

• compliance with the correct daily regimen with daily walks in the fresh air;
• rational nutrition of the child in accordance with his age needs. Optimal is the preservation of breastfeeding, the timely introduction of complementary foods (no later than 4-6 months of life). If the baby in the first year of life suffers and is forced to receive a less varied diet, the doctor may recommend courses of taking multivitamin preparations for infants. It should be noted that the vitamin complexes that a nursing mother takes only provide for her needs, and despite the mother taking these drugs, the baby should receive prophylactic doses of vitamin D, and regular gymnastics and massage with a gradual and uniform increase in load are also necessary.

Taking into account the state of health, the area where the baby lives, as well as the time of year, the pediatrician will certainly help resolve the issue of prophylactic administration of vitamin D. Healthy full-term children in the first year of life receive vitamin D in a dose of no more than 400 IU per day to prevent rickets, starting from 4-5 weeks of life during the entire autumn-winter-spring period. As already mentioned, one drop of the aqueous solution contains 500 IU, to give the baby 400 IU, you need to put a drop of the drug on a spoon, give the baby medicine from the spoon - we can assume that the remaining drug contains 100 IU of vitamin D. However, in the summer with an insufficient number of sunny days (cloudy, rainy summer), especially in the northern regions of Russia, as well as when feeding children with whole milk, it is advisable to prescribe vitamin D in a prophylactic dose.

As the first complementary foods for children suffering from rickets, vegetable puree is recommended.

A special place is given to premature babies, in whom the prevention of rickets is carried out already from the 2-3rd week of life during the first 2 years, excluding the summer months. At the same time, the prophylactic dose of the vitamin may be higher than in full-term children, and only a pediatrician can decide this. For full-term infants, prophylactic doses of vitamin D are usually prescribed after a month.

Children with a small large fontanel also need to be prevented from rickets in the first year of life, however, in order to avoid early closure of the fontanel, they are recommended to take vitamin D after 3-4 months of life.

Irina Ferganova, pediatrician

- a disease of a fast-growing organism, characterized by a violation of mineral metabolism and bone formation. Rickets is manifested by multiple changes in the musculoskeletal system (softening of the flat bones of the skull, flattening of the occiput, deformity of the chest, curvature of the tubular bones and spine, muscular hypotension, etc.), nervous system, and internal organs. The diagnosis is established on the basis of the detection of laboratory and radiological markers of rickets. Specific therapy for rickets involves the appointment of vitamin D in combination with therapeutic baths, massage, gymnastics, UVI.

General information

Rickets is a polyetiological metabolic disease, which is based on an imbalance between the child's body's need for minerals (phosphorus, calcium, etc.) and their transportation and metabolism. Since rickets mainly affects children aged 2 months to 3 years, in pediatrics it is often called the "disease of the growing organism." In older children and adults, the terms osteomalacia and osteoporosis are used to refer to this condition.

In Russia, the prevalence of rickets (including its mild forms) is 54-66% among term infants and 80% among premature infants. Most children in 3-4 months have 2-3 mild signs of rickets, and therefore some pediatricians suggest considering this condition as paraphysiological, borderline (similar to diathesis - anomalies of the constitution), which is independently eliminated as the body grows older.

Pathogenesis of rickets

The decisive role in the development of rickets belongs to exogenous or endogenous vitamin D deficiency: insufficient formation of cholecalciferol in the skin, insufficient intake of vitamin D from food and impaired metabolism, which leads to a disorder of phosphorus-calcium metabolism in the liver, kidneys, and intestines. In addition, other metabolic disorders contribute to the development of rickets - a disorder of protein and microelement metabolism (magnesium, iron, zinc, copper, cobalt, etc.), activation of lipid peroxidation, multivitamin deficiency (deficiency of vitamins A, B1, B5, B6, C , E), etc.

The main physiological functions of vitamin D (more precisely, its active metabolites 25-hydroxycholecalciferol and 1,25-dihydroxycholecalciferol) in the body are: increased absorption of calcium (Ca) and phosphorus (P) salts in the intestine; obstruction of the excretion of Ca and P in the urine by increasing their reabsorption in the tubules of the kidneys; bone mineralization; stimulation of the formation of red blood cells, etc. With hypovitaminosis D and rickets, all of the above processes slow down, which leads to hypophosphatemia and hypocalcemia (low levels of P and Ca in the blood).

Due to hypocalcemia, secondary hyperparathyroidism develops according to the feedback principle. An increase in the production of parathyroid hormone causes the release of Ca from the bones and the maintenance of a sufficiently high level in the blood.

A change in the acid-base balance towards acidosis prevents the deposition of P and Ca compounds in the bones, which is accompanied by a violation of the calcification of growing bones, their softening and a tendency to deformation. Instead of full-fledged bone tissue, osteoid non-calcified tissue is formed in the growth zones, which grows in the form of thickenings, tubercles, etc.

In addition to mineral metabolism, with rickets, other types of metabolism (carbohydrate, protein, fat) are also disturbed, disorders of the function of the nervous system and internal organs develop.

Causes of rickets

The development of rickets is largely associated not with an exogenous deficiency of vitamin D, but with its insufficient endogenous synthesis. It is known that more than 90% of vitamin D is formed in the skin due to insolation (UVR) and only 10% comes from outside with food. Just a 10-minute local irradiation of the face or hands can provide the synthesis of the level of vitamin D necessary for the body. Therefore, rickets is more common in children born in autumn and winter, when solar activity is extremely low. In addition, rickets is most common among children living in regions with a cold climate, insufficient natural insolation, frequent fogs and clouds, unfavorable environmental conditions (smog).

Meanwhile, hypovitaminosis D is the leading, but not the only cause of rickets. Deficiency of calcium salts, phosphates and other osteotropic micro and macro elements, vitamins in young children can be caused by multiple rachitogenic factors. Since the most enhanced intake of Ca and P to the fetus is observed in the last months of pregnancy, premature babies are more prone to developing rickets.

The increased physiological need for minerals in conditions of intensive growth predisposes to the occurrence of rickets. A deficiency of vitamins and minerals in a child's body may be the result of an improper diet of a pregnant or lactating woman, or the baby itself. Impaired absorption and transport of Ca and P contributes to the immaturity of enzyme systems or pathology of the gastrointestinal tract, liver, kidneys, thyroid and parathyroid glands (gastritis, dysbacteriosis, malabsorption syndrome, intestinal infections, hepatitis, biliary atresia, CRF, etc.).

The risk group for the development of rickets includes children with an unfavorable perinatal history. Adverse factors on the part of the mother are gestosis of pregnant women; hypodynamia during pregnancy; operational, stimulated or rapid childbirth; mother's age is younger than 18 and older than 36; extragenital pathology.

On the part of the child, a large weight (more than 4 kg) at birth, excessive weight gain or malnutrition can play a certain role in the development of rickets; early transfer to artificial or mixed feeding; restriction of the child's motor mode (too tight swaddling, lack of baby massage and gymnastics, the need for prolonged immobilization in case of hip dysplasia), taking certain medications (phenobarbital, glucocorticoids, heparin, etc.). The role of gender and hereditary factors has been proven: for example, boys, children with swarthy skin, II (A) blood group are more predisposed to the development of rickets; Rickets is less common among children with I (0) blood group.

Rickets classification

Etiological classification involves the allocation of the following forms of rickets and rickets-like diseases:

1. Vitamin D-deficientrickets(calcipenic, phosphoropenic variant)
2. Vitamin D dependent(pseudo-deficient) rickets with a genetic defect in the synthesis of 1,25-dihydroxycholecalciferol in the kidneys (type 1) and with genetic resistance of target organ receptors to 1,25-dihydroxycholecalciferol (type 2).
3. Vitamin D-resistant rickets(congenital hypophosphatemic rickets, Debre de Toni-Fanconi disease, hypophosphatasia, renal tubular acidosis).
4. Secondary rickets with diseases of the gastrointestinal tract, kidneys, metabolism or drug-induced.

The clinical course of rickets can be acute, subacute and recurrent; severity - mild (I), moderate (II) and severe (III). In the development of the disease, periods are distinguished: initial, peak of the disease, convalescence, residual effects.

Symptoms of rickets

The initial period of rickets falls on the 2-3rd month of life, and in premature babies in the middle - the end of the 1st month of life. Early signs of rickets are changes in the nervous system: tearfulness, fearfulness, anxiety, hyperexcitability, superficial, disturbing sleep, frequent shuddering in a dream. The child has increased sweating, especially in the scalp and neck. Sticky, sour-smelling sweat irritates the skin, causing persistent diaper rash. Rubbing the head against the pillow leads to the formation of foci of baldness on the back of the head. On the part of the musculoskeletal system, the appearance of muscle hypotension (instead of physiological muscle hypertonicity), compliance of the cranial sutures and the edges of the fontanel, thickenings on the ribs ("rachitic beads") is characteristic. The duration of the initial period of rickets is 1-3 months.

During the height of rickets, which usually falls on the 5-6th month of life, progression of the process of osteomalacia is noted. The consequence of the acute course of rickets can be softening of the cranial bones (craniotabes) and unilateral flattening of the occiput; deformity of the chest with depression ("cobbler's chest") or bulging of the sternum (keeled chest); the formation of kyphosis ("rachitic hump"), possibly lordosis, scoliosis; O-shaped curvature of tubular bones, flat feet; formation of a flat rachitic narrow pelvis. In addition to bone deformities, rickets is accompanied by an increase in the liver and spleen, severe anemia, muscle hypotension ("frog" belly), looseness of the joints.

In the subacute course of rickets, hypertrophy of the frontal and parietal tubercles occurs, thickening of the interphalangeal joints of the fingers (“strings of pearls”) and wrists (“bracelets”), costal-cartilaginous joints (“rachitic beads”).

Changes in the internal organs in rickets are caused by acidosis, hypophosphatemia, microcirculation disorders and may include shortness of breath, tachycardia, loss of appetite, unstable stools (diarrhea and constipation), pseudoascites.

During the period of convalescence, sleep normalizes, sweating decreases, static functions, laboratory and radiological data improve. The period of residual effects of rickets (2-3 years) is characterized by residual deformation of the skeleton, muscle hypotension.

In many children, rickets is mild and not diagnosed in childhood. Children suffering from rickets often suffer from SARS, pneumonia, bronchitis, urinary tract infections, atopic dermatitis. There is a close relationship between rickets and spasmophilia (children's tetany). In the future, in children who have had rickets, there is often a violation of the timing and sequence of teething, malocclusion, enamel hypoplasia.

Diagnosis of rickets

The diagnosis of rickets is established on the basis of clinical signs, confirmed by laboratory and radiological data. To clarify the degree of violation of mineral metabolism, a biochemical study of blood and urine is carried out. The most important laboratory signs that allow you to think about rickets are hypocalcemia and hypophosphatemia; increased activity of alkaline phosphatase; decreased levels of citric acid, calcidiol and calcitriol. At research of KOS of a blood acidosis comes to light. Changes in urine tests are characterized by hyperaminoaciduria, hyperphosphaturia, hypocalciuria. Sulkovich's test for rickets is negative.

When radiography of tubular bones, changes characteristic of rickets are revealed: goblet expansion of the metaphyses, blurring of the boundaries between the metaphysis and epiphysis, thinning of the cortical layer of the diaphysis, indistinct visualization of the ossification nuclei, osteoporosis. Therapeutic mud can also be used to assess the state of bone tissue.

Forecast and prevention

The initial stages of rickets respond well to treatment; after adequate therapy, long-term effects do not develop. Severe forms of rickets can cause pronounced skeletal deformities, slowing down the physical and neuropsychic development of the child. Observation of children who have had rickets is carried out quarterly, for at least 3 years. Rickets is not a contraindication for prophylactic vaccination of children: vaccination is possible as early as 2-3 weeks after the start of specific therapy.

Prevention of rickets is divided into antenatal and postnatal. Prenatal prophylaxis includes the intake of special micronutrient complexes by a pregnant woman, sufficient exposure to fresh air, good nutrition. After childbirth, it is necessary to continue taking vitamins and minerals, breastfeeding, adhere to a clear daily routine, and conduct preventive massage for the child. During daily walks, the child's face should be left open for access to the skin of the sun's rays. Specific prevention of rickets in breastfed newborns is carried out in the autumn-winter-spring period with the help of vitamin D and UV radiation.

Usually such a diagnosis is voiced by a pediatrician, at the next appointment, or drugs are prescribed to prevent rickets, especially in the conditions of the northern territories. Although modern medicine has stepped far forward in terms of diagnosis and treatment of diseases, rickets still remains a topical issue today. Sometimes it is difficult to understand the clinical picture even for a doctor, and ordinary parents cannot do it at all.

The disease is unpleasant because it can disguise itself as others, and manifestations may already be in advanced cases. As a result, either untreated rickets, or self-medication where there is no rickets, which leads to an overdose of drugs.

What is called rickets?

Rickets is considered to be one disease, although in fact it is a whole group of metabolic diseases or disorders that combine one common feature, characterized as a decrease in the level of calcium in the bone tissue - osteopenia. Such a condition can be caused not only by vitamin D deficiency, it can be the influence of external or internal factors, therefore, at the first signs of rickets, you should not immediately treat it with vitamin D, it is necessary to clarify the reasons. Sometimes vitamin D may even be contraindicated.

There are actually a lot of rickets, but in order to make it easier to understand, classic rickets stands out as the most common and rickets-like diseases. Their manifestations are quite similar, but the causes and methods of treatment differ. Rickets-like diseases include several metabolic diseases, but they are not visible to parents, and even a doctor is not always easy to identify them. However, there are fundamental differences in treatment. Therefore, with the first signs of rickets, you must consult a doctor.

A bit of history

Rickets is also called a disease of active growth, since it occurs exclusively in babies at an early age, when there is an active growth of the skeleton and there is a temporary discrepancy between the amount of incoming calcium and vitamin D, and the intake of these substances by the body. Rickets was the lot of kids in antiquity, it was known in Greece, and its name comes from the Greek word "rachis", meaning a ridge or spinal column, since in its severe form deformations in the form of a hump appear.

In the 17th century, rickets began to be called " English disease"due to the fact that it became extremely common among the children of workers who lived near factories, in a zone of constant smog, and who, because of this, did not receive the sun and ultraviolet radiation. The scientist who studied the disease described the full clinic of rickets based on the results of examination and autopsy, even then guessed the reasons, but could not accurately establish them. But he gave a name to several symptoms. In the twentieth century, the cause was identified, first of all it was found that the use of fish oil saves from rickets, and then it was established which of the components of fish oil helps to treat rickets. Thus, vitamin D was discovered and then the era of rickets treatment began, and now there are almost no severe episodes of rickets.

But the first years of treatment of rickets with vitamin D were no less serious, since the first doses that were used were very large, severe complications appeared - hypervitaminosis D, until it was found out what the role of the vitamin is and what are its properties, what doses are therapeutic And what for prevention. However, until now, work on rickets remains relevant and much is still being studied.

Who gets rickets?

Rickets can occur in any country and on any continent, even in Africa, but still the frequency of its occurrence in areas with a small amount of sun is naturally higher. Usually rickets occurs in children who are born from October to March-April, but summer children can also be susceptible to rickets. We have rickets most of all in Siberia and in the Arctic region, although the middle zone also has about 15% of children with manifestations of rickets.
Urban children suffer from rickets more often, as they are less exposed to the sun, especially in cities with smoke, poor environmental conditions, with an abundance of transport. Usually rickets occurs in children with malnutrition and unfavorable conditions for growth and development.

There are certain risk groups that are more likely to suffer from rickets. You can divide all categories into subgroups. Usually rickets occurs in children whose mothers had problems with pregnancy, are very young, or vice versa, their age exceeds 35-40 years, if they have not been in the sun much, have a chronic pathology, and are malnourished.

One of the risk factors for the development of rickets is a subsequent pregnancy, especially with a small time interval between them, since the mother's reserves of vitamins and minerals are depleted if it is a multiple pregnancy or a premature baby.

One of the significant factors in the development of rickets is the nutrition of the baby, and previously there was an opinion that rickets is more common in infants who receive less vitamin D, because it is not enough in breast milk. But this is actually not true, today it has been proven that breast milk has a characteristic feature - the front portions of milk contain calcium, and the back portions have a sufficient amount of vitamin D, which actively helps in the utilization of calcium. With proper nutrition of a woman and full breastfeeding, without regimes and restrictions, rickets is practically excluded from him.

Most often, rickets occurs in babies receiving mixed or artificial nutrition, especially if these are unadapted mixtures (cow's or goat's milk), or cheap mixtures. Children with malnutrition, malnutrition, obesity, and malnutrition suffer from rickets.

One of the risk factors for rickets is diseases of children that lead to metabolic disorders, including calcium and vitamin D, these are allergies, dermatosis, and malabsorption of food in the intestines. Boys are usually more susceptible to rickets, dark-skinned and with a second blood group, but much still depends on living conditions and care.

What role do minerals play?

For the active growth and development of a child, a strong and healthy bone base is necessary, so that the bones of the skeleton are strong, minerals are needed - magnesium, phosphorus, calcium and vitamin D for their assimilation and deposition in bone tissue. The bones contain up to 90% of all these minerals, and their concentration in the blood regulates the additional intake of these substances with food or water by the feedback principle.

Calcium is a mineral necessary for the growth of the child, because of it the bones become strong, but must be continuously supplied to the body with breast milk or food. In the small intestine, it is absorbed and enters the bloodstream, where, under the influence of hormones, it is sent to the bones or organs that need it. Bones form chalk-type compounds from calcium, they are strong, give the bones the ability to withstand loads.

Calcium is also involved in clotting processes, helps the nervous system, and regulates blood pressure. A sharp decrease in calcium levels in children leads to convulsions, in order to prevent this, the body begins to actively remove calcium from bone tissue under the influence of thyroid and parathyroid hormones. The role of magnesium and phosphorus is to give the bones elasticity and strength, without them the bones will be brittle.

For a stable and full-fledged work of the body, it is necessary to maintain a stable level of minerals in the blood and bones. Especially important is the level of calcium, and in its two forms - total and active or ionized. The level of calcium usually varies within strict limits from 2.2 to 2.7 mmol / l, while the active form in it should be at least 1.22 to 1.37 mmol / l, that is, about half of this amount. Calcium is constantly lost in the urine and therefore a regular supply is necessary. The excretion of calcium in the urine is one of the diagnostic tests for rickets and in determining an overdose of vitamin D. The level of calcium in the urine is the diagnostic basis of the Sulkovich test - it determines the loss of calcium in the urine.

A stable amount of blood phosphorus is also important, but its fluctuations are not so dramatic for the body - its norm is from 1.25 to 2.2 mmol / l, and after three years the level changes to 0.95-1.95 mmol / l.

Why does vitamin deficiency occur?

In fact, the reasons for the change in the level of calcium and phosphorus are enough. In the first place is prematurity of varying degrees, since calcium accumulates in the last weeks of pregnancy, especially actively in the ninth month. Therefore, with prematurity, calcium will naturally be less, and the body will suffer.

Another reason is the lack of calcium in the diet of the expectant mother, especially if she is on a diet, is a vegetarian or fasts. The influence of various diets of the child himself is also important, for example, when feeding him with kefir, cow's milk or semolina.

The problem of mineral metabolism will also be acute in case of violation of intestinal absorption or transport of minerals to the bones. This phenomenon is possible when there is a violation of the work of enzymes in the intestine, immaturity of digestion, kidney disease, or a violation of hormone metabolism. And an important influence is exerted by the ingestion of such substances as chromium, zinc or lead into the body due to poor ecology, which replace calcium and disrupt its deposition in bone tissue.

Rickets is closely related to endocrine diseases - the work of the thyroid or parathyroid glands affects rickets, as they are responsible for the exchange of phosphorus and calcium. Calcium is strongly lost in kidney diseases, then vitamin D deficiency will complement the clinic.

The role of vitamin D

The main function of vitamin D is to maintain a constant concentration of calcium in the blood, enhance its absorption in the intestines, return it from the kidneys and primary urine, deposit calcium in bone tissue, and improve the functioning of the immune system. with nutrition, the child receives up to 20% of the vitamin, while most of it is formed in the skin under the influence of ultraviolet radiation.

In the skin, under the influence of ultraviolet waves of a special length, the precursors of vitamin D are converted into its active form. In summer, there is more than enough sun, so basically rickets becomes relevant from October to April, when it is still cold and children spend some time outdoors and in the sun. Clouds, fog or the presence of smoke and smog also interfere with the absorption of ultraviolet waves, the rays of the sun on the balcony through glass or reflected waves do not help.

In the first year of life, breast milk will be the most complete source of minerals and vitamins, since in it all the substances are in their optimal form for absorption, so they are almost not lost and everything goes to building the body. The most expensive and most adapted mixtures will still not come close to breast milk in terms of absorption, and animal milk is even further from the composition of breast milk in terms of calcium and phosphorus, at best, up to 40% of calcium from it can be absorbed.

The most valuable food products for calcium and vitamin D are animal products - milk and dairy dishes, cottage cheese, fish meat, eggs, but there is very little calcium in plants. Plus, most vitamin D comes from the skin.

Vitamin D is a fat-soluble substance, there are several forms in the body - D2 from food and D3 from the skin, and in the liver they go through an episode of transformation, turning into a soluble form, and getting into the kidneys, they go into active forms of vitamin D, which work in body.

The most active metabolite is calcitriol, it is enhanced by a decrease in the level of calcium in the blood. If calcium levels are normal or even elevated, another vitamin D metabolite begins to work, sending calcium, magnesium, and phosphorus salts to bone tissue. And the level of vitamin D affects the functioning of the parathyroid glands, activates the intestinal wall to absorb calcium from food and supports the immune system.

Diagnosis of rickets

How is it classified

Typically, pediatricians divide rickets into three degrees of severity, and basically today there is mild rickets, in which the symptoms are not pronounced, usually these are mild neurological disorders or a violation of the musculoskeletal system.

With moderate severity of disorders, the violations are already quite pronounced, bright, and there are violations in the functioning of the nervous system, problems with the bones, and they are joined by problems of muscles, blood, and respiratory disorders. Digestion, blood vessels and heart suffer. In severe form, persistent and severe disorders occur, leading to disability.

In addition to the severity, rickets is divided into acute, which manifests itself sharply and quickly, passing with adequate therapy, subacute - the manifestations gradually appear and it proceeds sluggishly and recurrently, episodes of exacerbations come with episodes of remission.

In addition, the cards often mark the stage of rickets - the initial manifestations, the height of the disease, convalescence or recovery, and residual effects.

Reasons for suspicion

The manifestations of rickets are even more diverse than the causes leading to it, and most of these manifestations are not specific to rickets, such manifestations may well be in most childhood diseases. That is why the detected symptoms of rickets themselves will not allow a diagnosis to be made and active treatment to begin. A whole range of examinations and confidence in the legitimacy of the diagnosis are needed.

Rickets never occurs in the first three months of a child's life, mostly rickets occurs in the period from six months to a year, after a year rickets occurs rather as an exception to the rule. The main manifestations of rickets occur due to a lack of calcium and phosphorus in the blood, which is washed out of the bones as a result of the activation of hormones, these same hormones affect the kidneys, preventing calcium from being lost in the urine.

One of the manifestations of rickets is the signs of the baby's anxiety, his fearfulness is more than usual, he shudders from bright lights or sharp sounds. There is an increase in sweating, especially in the head area, sweat of a specific sour smell, with severe itching. The head sweats especially strongly, he rubs the head against the pillow, because of which the hair on the back of the head comes out - a bald spot is obtained.

The muscles are usually of reduced tone, as a result of which the babies later begin to crawl, sit, get up and then walk, and from the muscles of the anterior abdominal wall, hypotension is manifested by symptoms of a flattened abdomen, a frog belly. In this case, an umbilical hernia, deformation of the ribs can form.

There is a softening of the edges of the fontanel, this occurs due to the washing out of calcium and the edges become soft and pliable, you can clearly feel the seams on the skull, and if the changes are pronounced, the seams can diverge. Due to the softness of the bones, at the beginning of active movement with the legs, they become crooked - the letter O or X. Due to pressure on the back of the head when lying down, it can flatten, the chest is deformed, it sinks or protrudes like a keel or chicken breast.

Naturally, in the child's body, all these changes do not go unnoticed, the body tries to carry out compensatory work, to correct the situation. Thus, the mechanism of strengthening the bone tissue due to its growth is launched. However, calcium in rickets is still not enough, and as a result, frontal and parietal tubercles are formed on the head - Socratic forehead with bald patches. Growths in the areas of bone tissue will also be visible on radiographs in the form of typical zones - rachitic nodules on the wrists, bracelets, rachitic rosaries on the ribs, strings of pearls on the bones of the fingers. In addition, an additional symptom of rickets is the late timing of fontanel closure, although this may be a family or constitutional feature, and timing can vary greatly.

With rickets, one of the symptoms may be late teething, but the teeth can have individual eruption terms, along with the fontanel, and many factors, both external and internal, affect eruption.

The functioning of the nervous system may also suffer, convulsive readiness develops with convulsions as a result of minor influences, the digestive system does not work very actively, children gain weight poorly, gains are minimal or at the lower limits of weight. Often there is regurgitation, stool disorders with constipation or diarrhea, iron deficiency develops with anemia. Children with rickets often get colds with complications that turn into pneumonia, otitis or bronchitis, as there are defects in immunity.

The doctor finds in the blood tests a shift in biochemistry indicators - the level of calcium changes especially strongly - total and ionized, they decrease or are at the lower limit of normal. The level of phosphorus in the blood is low, but the level of alkaline phosphatase, a special enzyme in the body, begins to rise, and quite sharply.

The initial stage of rickets lasts from one to three months, and if it is not treated, rickets goes into the stage of peak, then all the symptoms will appear much sharper. With a correct and timely diagnosis, recovery can be achieved in about three to four weeks of illness. Then they switch to maintenance therapy for rickets. As the treatment progresses, the state of health begins to improve, nervous disorders and digestive disorders disappear. Children quickly catch up with their peers in development and skills, then muscle tone and changes in bones take longer.

Rickets diagnosis

The main thing in establishing a diagnosis is the examination and examination of a doctor, and not consultations and treatment in absentia, by phone or on the Internet. A thorough and phased examination of the doctor is necessary, a story about all the disturbing symptoms, especially those related to stool disorders, excitability and bone changes. But, without laboratory tests and other tests, rickets cannot be diagnosed, since several diseases look like rickets.
One of the simplest, but not accurate diagnostic methods is urinalysis, the Sulkovich test. This test allows you to assess the loss of calcium in the urine, as well as control treatment. The method does not give exact numbers, it is semi-quantitative, it is determined by the degree of turbidity of urine on a special scale, if mixed with a special reagent.

Normally, the test is positive by one or two pluses, or is given in units from 0 to 4. If the reaction is negative or doubtful, in combination with the examination data, a diagnosis of rickets can almost certainly be made. The same test is applicable to monitor vitamin D treatment - if it is strongly positive by 3-4 plus or units, vitamin D should be withdrawn.

It is also important to donate blood and urine for biochemical parameters - to determine the level of calcium, phosphorus and alkaline phosphatase. They will confirm the diagnosis definitively. Previously, X-rays of the bones were also used to reveal typical bone changes, but today it is not used.

How is rickets treated?

Treatment of rickets- this is the main task of the doctor, because it affects the entire metabolism, the growth of the body and immunity. However, for the treatment of rickets, not only drops of vitamin D are used, but also a whole range of measures - a regimen, walks, massages, and, last but not least, medications.

It is important to start by organizing the correct daily routine so that it is sure to be in the air, you need to walk for at least 2-3 hours, you can shorten walks in winter and increase them in summer. In the nursery, it is necessary to regularly ventilate, clean and open the curtains.

It is important to properly feed the child with the enrichment of nutrition with vitamins and minerals, timely complementary foods, but without haste. You can not overload the intestines of the crumbs, as allergies and digestive disorders disrupt the absorption of calcium and vitamin D. Hygiene, hardening procedures, gymnastics for muscle tone and massages are needed daily. These measures maintain muscle tone, strengthen the body.

Drug treatment, as well as doses of drugs, is chosen only by a doctor. It is impossible to give vitamin D on your own, even as a preventive measure, an overdose and negative consequences for the body may occur.

Vitamin D is prescribed based on the severity of the condition, the stage of the disease and the identified abnormalities in the state of health. The dose is selected individually for each child, it depends on age, heredity and genetics, the nature of nutrition, and other characteristics. In addition, doses at different times of the year will vary greatly. Vitamin D is usually dosed in international units contained in a drop of solution. It is important to read the label and dose carefully. Previously practiced recommendations on loading doses of vitamin D in the treatment of rickets did not justify themselves, they often led to signs of an overdose.

Today, small doses and a long course of treatment are prescribed, with a gradual transition to maintenance therapy. Many doctors generally prescribe a whole complex of multivitamins, since with rickets the entire metabolism as a whole suffers to one degree or another.

Today, the main drugs for the treatment of rickets are the oil or water forms of vitamin D, these are the preparations vigantol and aquadetrim. They are well absorbed and absorbed in the digestive system, even in the presence of digestive problems and allergies. The drug Akvadetrim is especially indicated for such children. They are accurately dosed, in one drop of the drug there are approximately 500 IU of the substance, and it is convenient to calculate the dose in drops.

On average, 4 to 10 drops of the solution are prescribed per day, starting with the minimum doses and gradually increasing them to therapeutic ones until the effect is achieved. On average, high doses are needed only for severe bone changes. On average, the course lasts from 30 to 45 days, after which the dose is left prophylactic at 500-1000 IU, that is, one or two drops. This dose is taken from October to April during the first two years of life.
The effectiveness of treatment is assessed by the Sulkovich test, monitoring every 2-4 weeks.

In addition, calcium supplements are prescribed in parallel with the vitamin D preparation, since one dose of vitamin D can reduce the level of calcium in the blood. To prevent such disorders, calcium gluconate or lactate is used in the first two weeks of vitamin D intake, but not all children, especially infants, are prescribed calcium, since their level of calcium in milk is quite sufficient. Calcium is especially indicated for small, premature babies and sick people.

Prevention of rickets

Measures to prevent rickets begin during pregnancy - in the form of walks and a balanced diet of the mother. In addition, it is important to breastfeed your baby, then he will get enough calcium and vitamin D. It is useful to take multivitamins and calcium.

After birth, from about 2-3 months, it is necessary in the cold season to prevent rickets to use vitamin D drop by drop daily, under the supervision of a pediatrician.

It is important to introduce complementary foods on time, often go outside, especially in sunny weather. For muscle tone and absorption of calcium, massages and gymnastics, hardening and healing activities are necessary. And of course, constant medical supervision is necessary.

Of course, the problem of rickets is still relevant today, but today there are many ways to deal with this problem, and it is only important to start prevention in time, then the baby will be healthy.

Deficiency-related diseases are quite common in children. Not only babies, but also older kids can get sick with them. Today we will talk about rickets in babies older than one year.

What it is?

Rickets is a childhood pathology associated with a pronounced violation of calcium-phosphorus metabolism. There are various reasons for this pathological condition. lack of vitamin D or calciferol in the body. Normally, this biologically active substance is involved in the internal exchange of calcium and phosphorus, which ensures normal concentrations of these substances.

Usually, early adverse signs of rickets appear in a child in the first months and within 1 year after birth. However, the disease is also recorded in children and at an older age.

According to statistics, children living in northern countries are more susceptible to this disease.

Boys get rickets just as often as girls. Severe deficiency of vitamin D in the child's body leads to a violation of the exchange between calcium and phosphorus. Both of these substances provide bone strength. With a disturbed calcium-phosphorus metabolism, a child develops various adverse symptoms associated with a pronounced deficiency of biologically active substances.

Usually, the first signs of rickets are detected by a pediatrician during regular examinations of the baby. Diagnosis of the disease does not cause significant difficulties for medical specialists.

The reasons

Various causes lead to the development of the disease in babies, which contribute to a decrease in the level of calciferol. In some cases, the impact of causes may be combined. Understanding exactly what causative factors caused the baby to get sick is very important. Only the elimination of the cause of the disease will lead to the complete recovery of the child.

The peak incidence of rickets occurs in infancy. Usually the first manifestation of rickets occurs within the first three months after the birth of a child. In some cases, with a mild course of the disease, clinical signs are not visible, which greatly complicates the diagnosis. In such a situation, the diagnosis is usually established only by the age of 2-3 years.

The most common causes leading to a deficiency in the children's body of calciferol include:

• Insufficient intake of vitamin D from food. In babies up to a year, this leads to the rapid abolition of breastfeeding. In older children, the cause of an exogenous deficiency in the intake of calciferol is an unbalanced and inadequate diet. Lack of animal products and a vegetarian diet can cause rickets in the baby.
• Accommodation in the northern regions. The lack of solar insolation leads to the fact that an insufficient amount of endogenous (internal) vitamin D is synthesized in the child's body. Exposure to the skin of ultraviolet spectrum rays in the baby causes a cascade of biological reactions that trigger the synthesis of calciferol.

Babies who live in countries with long winters and short daylight hours, according to statistics, have a higher chance of getting rickets than their peers living in the south.

• Chronic diseases of the digestive system. The leading role is given to intestinal pathologies. Chronic enteritis, accompanied by a strong malabsorption of various substances from food, often leads to the formation of various deficient conditions in babies. Without treatment of the underlying disease in this case, the adverse symptoms of rickets cannot be coped with.
• Prematurity and congenital pathologies. The birth of a baby earlier than planned is often the trigger for the development of rickets. This can be explained by the fact that a premature baby has not completed the formation of many internal organs. Violations of intrauterine development often cause various health problems in the future.

Symptoms

The development of the disease undergoes several successive stages. The initial period of the disease is accompanied mainly by the appearance of vegetative disorders. This is manifested by violations in the behavior and mood of the baby. The child becomes nervous, easily irritated by trifles. Kids lose interest in their favorite games, try to limit active movements. Usually the initial stage lasts about a month.

This period of the disease is also characterized by the appearance of a characteristic symptom - the child's sweating increases. The smell also changes. Sweat becomes acrid, sour. Its abundant excretion on the skin contributes to the development of irritation and prickly heat. Toddlers often comb the affected areas of the skin. The change in the smell of sweat is explained by a change in its chemical composition and its constituent electrolytes due to impaired metabolism.

After the initial stage, the disease goes into a period of peak. This is a more unpleasant time, characterized by the appearance of numerous symptoms. The baby has the first deformations of the bone tissue. Basically, all tubular and flat bones that are actively growing are involved in the process. Diagnosis of the disease at this time is not difficult and does not present a problem for the doctor.

The severity of clinical symptoms may vary.

Severe disease in children older than a year is quite rare.

The child has a characteristic curvature of the spine - scoliosis. Changes in the density and thickness of the clavicles. They come forward a little. The architecture of the structure of the chest is also disturbed.

The ribs are somewhat flattened, the intercostal spaces change. Some children develop characteristic signs of rickets: depression or bulging of the lower third of the sternum. Since ancient times, characteristic names for these states have been used - "cobbler's chest" and "chicken breast". The appearance of the child changes greatly. Usually these signs appear in babies who are diagnosed too late.

The shape of the lower extremities changes in the child. They become O- or X-shaped. Usually this sign appears in babies with a pronounced course of rickets by the age of five. In order to identify this symptom, you should look at the baby from different angles. Usually, the curvature of the lower extremities is clearly visible from the side.

Also during the height of the disease muscle hypotonia appears and various neuromuscular pathological conditions join. In a horizontal position in sick babies, it is well traced "frog belly". On examination, the child's tummy becomes flattened and hangs somewhat to the side surfaces of the body. This symptom is due to the presence of pronounced hypotonicity of the muscles that make up the anterior abdominal wall.

Bone deformities of the skeleton also lead to disturbances in the functioning of internal organs. Pathologies of the chest contribute to a decrease in the ventilation capacity of the lungs, which leads to the development of emphysema and other pathological conditions. Respiratory failure affects hemodynamics and vascular tone. Such combined conditions lead to the fact that the baby has problems in the work of the heart muscle and blood vessels.

Hypotonicity of the muscles of the abdominal wall and a pronounced curvature of the spine contribute to the compression of the internal organs. In some cases, this leads to disturbances in the functioning of the liver and spleen. Pathologies of bone tissue contribute to the development of numerous orthopedic diseases in the baby, which require the appointment of appropriate treatment. On average, the peak period lasts several months.

Timely prescribed treatment helps to normalize the child's condition and improve his appearance.

The period of convalescence or recovery can be from 2 to 4 months. In some cases, it lasts up to six months. If a child has had severe rickets, then the residual symptoms of the disease may persist for a couple of years from the moment of convalescence. Usually they completely disappear after a course of rehabilitation measures.

Diagnostics

To identify signs of rickets in babies should be as early as possible. Timely diagnosis will help to avoid the development of long-term complications in the child and help return the baby to an active life. The doctor can identify the very first signs of the disease and suspect rickets during regular examinations. After a clinical examination of the child, the doctor prescribes additional tests to clarify the severity of the violations and confirm the diagnosis.

The following studies are used to detect the disease:

• Measurement of calcium and phosphorus in the blood. Normally, the level of calcium should be - 2.5-2.7 mmol / l, and phosphorus - 1.3-2.3 mmol / l. A decrease in these indicators in a child below the age norm indicates the presence of signs of impaired calcium-phosphorus metabolism.
• Determination of alkaline phosphatase. This enzyme is actively involved in the exchange between calcium and phosphorus. Normally, it is up to 200 IU / l. An increase in this indicator indicates the presence of metabolic disorders in calcium-phosphorus metabolism.
• Radiography. Allows you to clarify the presence of bone deformities and a violation of the architecture of the skeleton caused by the disease. With the help of bone radiography, it is possible to identify specific signs characteristic of rickets: “rachitic bracelets”, pathological curvature of the spinal column, “rachitic rosary”, chest pathologies, bone seals in the tubular bones. This method can be used only under strict indications.
• CT scan. It is carried out according to the same indications as radiography of bone tissue. This method has a higher resolution and allows you to get the most accurate result. The use of computed tomography allows doctors to assess the level of damage and the degree of functional impairment.

Effects

The prognosis of the disease in children is greatly influenced by timely diagnosis and treatment. If rickets in a child was detected at the earliest stages, then negative complications of the disease, as a rule, do not occur. With a belated diagnosis, the baby may experience various long-term consequences of the disease, which require mandatory rehabilitation measures. Common consequences of rickets suffered in childhood include: a moderate decrease in muscle tone, slight curvature of the lower extremities, malocclusion, and others.

Treatment

To eliminate the adverse symptoms of the disease, several therapeutic methods are prescribed. Monitoring the effectiveness of the prescribed therapy is carried out with the obligatory determination of the calcium content in the blood. During the treatment, the clinical condition of the child is also assessed. When prescribing therapy, the baby should feel better and become more active.

For the treatment of rickets in babies, the following principles of treatment apply:

• Regular walks in the fresh air. Insolation with sunlight is necessary for a baby suffering from rickets. Ultraviolet rays have a pronounced therapeutic effect on the children's body, increasing the internal synthesis of calciferol. The baby should take walks in the fresh air every day. Only regularity and consistency will achieve a good and lasting result.
• prescribing medications, containing vitamin D in its composition. Many doctors prefer water-soluble forms. The dosage of the drug should be carried out by the attending physician individually for each baby.

Self-selection of the therapeutic dose is unacceptable! Such self-medication can contribute to the appearance of a very dangerous condition in the baby - an overdose of vitamin D.

• Complete nutrition. In the daily diet of the baby, foods rich in calciferol must be present. These include: meat, chicken, fish, eggs, milk and dairy products, cottage cheese, cheese. The baby must definitely eat a variety of dishes that contain vitamin D. If the child receives medications with calciferol, then the diet must be discussed with the attending physician in order to avoid an overdose of this vitamin entering the child's body.
In infants
• In children from 1 year