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Rickets

  1. What is rickets?
  2. Symptoms
  3. Causes
  4. Diagnosis
  5. Treatment
  6. Prevention
  7. Outlook
  8. FAQs
  9. Other names

What is rickets?

Rickets is a condition which affects the development of bones. Caused in most, but not all cases, by a deficiency of vitamin D and subsequently also calcium, the condition can lead to the bones becoming soft and weak. This process can ultimately lead to serious bone deformity if left untreated.

Rickets is most common in children, but a similar condition can occur in adults. In adults, the condition is known as osteomalacia or soft bones.

Treating rickets generally involves following a nutritionally-balanced diet and/or taking vitamin supplements. In most cases, the condition can be treated successfully.[1]

Symptoms of rickets

Signs and symptoms of rickets may include:[2][3][4]

  • Growth and development issues. Children with rickets may be shorter than average due to bone development problems.
  • Pain. Bones may become sore or painful, especially when pressure is applied. This may lead to a child being reluctant to walk or get up from a sitting position, and they may appear to walk abnormally.
  • Brittle bones. Bones may become weaker than normal, leading to an increased likelihood of fracturing and breaking.
  • Dental issues. May include weak tooth enamel, slow development of teeth and an increased likelihood of cavities.
  • Deformities. The ankles, wrists and knees may become thicker than normal. Bowed legs, or in some cases knock knees,[5] a softening of the skull and – less commonly – a bending of the spine may also occur.
  • Muscle weakness. There may be a general lack of muscle tone, causing delays in the achievement of developmental milestones in children.[6]
  • Seizures. Low levels of calcium may cause seizures in infants.
  • Proneness to illness. Children with rickets may pick up many infectious diseases.

If any of these symptoms are present, medical attention should be sought without delay.

Many of the same symptoms may also occur in adults experiencing osteomalacia. However, adults tend to report more bone pain and tenderness than children with rickets. If you are concerned about any symptoms, consider using the Ada app for a free health assessment.

Bowed legs and rickets

Though rickets may be the first condition that many people think of when seeing a person with bow legs, i.e. legs that remain apart at the knees and lower sections even when the feet are together, there are a number of other possible causes of this type of bone alignment. These include:[7][8]

  • Blount disease
  • Skeletal dysplasia, or dwarfism

Good to know: Having slightly bowed legs may not be related to any health conditions, and may be unproblematic for the person.

Causes of rickets

Rickets can be caused by a variety of factors, including:

  • Vitamin D and/or calcium deficiency
  • Genetics
  • Underlying conditions

Vitamin D and calcium deficiency

A deficiency of vitamin D and/or calcium is by far the most common cause of rickets in children.

The majority of children will receive sufficient amounts of calcium from a balanced diet. (See the section on diet for more information on foods which contain vitamin D.) However, for some people, diet and sun exposure alone will not provide sufficient quantities of vitamin D. A vitamin D supplement may at times be needed to ensure that they get the required amount.[9][10][11]

Vitamin D and calcium supplements are widely available without a prescription. However, consulting a physician prior to starting any supplement is recommended, in order to ensure that it is safe and appropriate for the particular person and the specific condition they are experiencing.

Risk factors for vitamin D deficiency

Factors that may make children more likely to develop rickets related to vitamin D deficiency include the following:[12]

  • Dark skin. Dark skin contains more melanin than light skin, increasing the amount of UV-B light/sun exposure needed to produce vitamin D.
  • Lack of exposure to sun. Children who spend the majority of their time indoors, or lack exposure to sunlight for any other reason, are less likely to produce a sufficient amount of vitamin D. Additionally, if children live in countries that are far away from the equator and/or in the northern hemisphere, even if they spend plenty of time outdoors, the sunlight may not be strong enough to effectively stimulate vitamin D production.
  • Pre-existing conditions. Certain conditions – such as liver disease, kidney disease and celiac disease – can affect the way the body produces and controls vitamin D.
  • Breastfeeding. Children who are exclusively breastfed and have dark skin and/or a mother who is lacking in vitamin D have a higher chance of developing rickets. However, this is not a reason to avoid breastfeeding, as the practice offers numerous health benefits. A doctor will be able to help a parent devise an optimal breastfeeding plan.

Read more about Vitamin D Deficiency »

Genetics

In rare cases, rickets can run in families.

The most common form of this is hereditary hypophosphatemic rickets, which results from mutations in several genes. This condition renders the kidneys unable to retain phosphate, leading to a deficiency of this important chemical. Phosphate plays a central role in bone formation and growth.[2][13]

Underlying conditions

In rare cases, rickets can develop as a result of underlying conditions of the liver, kidneys or intestines, some of which are hereditary. These conditions typically affect the way the body produces, absorbs and retains minerals and vitamins, and may lead to deficiencies. They include phosphate and calcium deficiencies, which can result in rickets if left untreated.[2]

Examples of these conditions include:[2]

Diagnosing rickets

Diagnosing rickets will usually involve a doctor taking the person’s medical history, as well as asking about their diet and exposure to the sun. This will typically be followed by blood tests to check their phosphate (a key marker), vitamin D, calcium and parathyroid hormone levels. Blood tests are also used to check liver and kidney function, among other investigations. In some cases, a urine sample may also be collected for testing.[4]

X-rays will typically be taken if rickets is suspected, to check for skeletal changes or deformity.[14] A dual energy X-ray absorptiometry (DEXA) bone density scan may also be used to check bone calcium density levels.[2]

Rickets treatment

The necessary treatment route for rickets depends on the underlying cause.

When rickets is caused by a deficiency of vitamin D or calcium, increasing the intake of each is the primary treatment option. Methods of doing this include:[15]

  • Consuming more food rich in vitamin D and calcium, such as oily fish, cereals and eggs for vitamin D, and green leafy vegetables and dairy products for calcium
  • Taking supplements containing vitamin D and calcium
  • Receiving a vitamin D injection, which is usually administered yearly and, in most cases, only if other options are unavailable
  • Increasing one’s exposure to sunlight, safely

Treatment for genetic forms of rickets will depend on the type. Hereditary hypophosphatemic rickets, the most common genetic form, typically requires treatment with phosphate and vitamin D supplements.

Supplement side-effects

It is fairly rare for vitamin D or calcium supplements to cause any side-effects. However, if an incorrect dose of calcium is given, this could result in a condition known as hypercalcemia, where there is too much calcium in the blood.

Hypercalcemia

Signs and symptoms of hypercalcemia may include:[16]

  • Loss of appetite
  • Nausea and/or vomiting
  • Constipation
  • Abdominal pain
  • Thirstiness and an increased need to urinate
  • Fatigue and/or weakness
  • Muscle pain
  • Confusion
  • Headaches

If any of these signs or symptoms appear after starting a new supplement, medical attention should be sought without delay.

Read about the effects of excess vitamin D »

Rickets prevention

To ensure one receives the required amount of vitamin D, several measures can be taken:[17]

  • Eating a nutritionally-balanced diet
  • Spending time in the sun, though care must be taken to prevent sunburn and other complications of excessive sun exposure
  • Taking vitamin supplements, after talking to a doctor about the most suitable type and dose

Diet

Maintaining a diet rich in vitamin D and calcium can be an effective way of helping to prevent the onset of rickets. Examples of foodstuffs containing these include the following:

  • Vitamin D. Oily ocean-going fish, eggs, red meat, beef liver and some cereals.
  • Calcium. Dairy products including cheese, milk and yoghurt, as well as green vegetables such as kale and broccoli, and almonds.

Sunlight

Exposure to natural sunlight can be a good source of vitamin D. Depending on where a person lives, the time of year, the color of their skin and the clothes they wear, the amount of time needed in the sun will differ. For a person to produce vitamin D, sunlight has to reach the areas of skin that are not covered by clothes.

In a very sunny location in summer, a person may not need much outdoor time daily to produce a healthy amount of vitamin D. The body can produce between 10 000 and 25 000 IU of vitamin D in little less than the time it takes for the skin to start burning. Vitamin D production is maximized when a large area of the skin, such as the back, is exposed.[18]

In many countries in the northern hemisphere, including Germany, the UK, Canada and northern parts of the US, the sun is too weak to produce sufficient amounts of vitamin D between roughly September and March. This means that, even if people spend a lot of time outdoors, it will be necessary to rely on other sources of this vitamin during the winter months.[19]

Although exposure to sunlight is important, it is crucial to keep in mind the potential damage sunlight can cause to the skin, especially when sunburn occurs. If spending an extended amount of time exposed to the sun, sunscreen should always be worn. Foregoing adequate sun protection in order to increase one’s vitamin D intake is never recommended.

Supplements

It is generally advised that the following groups of people take vitamin D supplements:

  • Breastfed babies from birth to one year of age.
  • Children who consume less than 1 liter of milk that has been fortified with vitamin D on a daily basis, unless they have regular exposure to direct sunlight.[20]

In the autumn, winter and early spring, children and adults may benefit from taking vitamin D supplements, especially those living in regions far from the equator.

Vitamin D supplements are typically available over-the-counter from pharmacies, but may also be prescribed by a doctor, who will be able to recommend the safest, most suitable supplement for a specific person. It is important to see a doctor before starting any supplement or medication.

Outlook

With appropriate treatment, the outlook for rickets is generally good. However, recovery may take a long time.[21][22]

Most bone deformities caused by rickets, including bowed legs, can get better on their own, with growth. However, orthopedic correction may be necessary after severe deformities have healed and in very severe cases, surgery may be recommended.[21][22]

Rickets FAQs

Q: How common is rickets?
A: Today, rickets is a rare condition in developed countries, in large part due to many common foodstuffs (such as cereals and bread) being fortified with vitamin D. However, children with darker skin, those who are not outside much and/or those without access to adequate nutrition are at risk of developing rickets, even in developed countries. Rickets is starting to occur more frequently, with one possible reason being that children spend increasing amounts of time indoors.[23]

Q: Can rickets occur in adults?
A: While f rickets is a condition that affects children, adults can develop a condition known as osteomalacia or soft bones. The two conditions share similar causes, symptoms and treatment options.[4]

Q: Are osteomalacia and osteoporosis the same condition?
A: No, they are not the same condition. Osteomalacia is the name given to what may colloquially be referred to as the adult equivalent of rickets, while osteoporosis is a different bone disorder that involves the loss of bone density.[4]

Q: What are the signs of rickets in babies?
A: Signs of rickets in infants may include:[24][6][25]

  • Bone deformities, such as bowed legs or in some cases knock knees, wrist, chest and rib abnormalities, curving of the spine and wide ankles
  • Thinning and softening of the skull bones, with a large forehead
  • Large, protruding belly
  • Seizures
  • Delayed growth

Q: What is the cure for rickets?
A: As detailed above, treatment for rickets depends on the underlying cause. However, it will often involve increasing one’s intake of vitamin D and calcium.

Q: Is there a link between rickets and scurvy?
A: Rickets is caused, in most cases, by a deficiency of vitamin D and calcium. Scurvy is caused by a deficiency of vitamin C, usually due to a poor diet. It is possible for a person to have both rickets and scurvy at the same time, though this co-occurrence is not common.[26][27]

Q: Is rickets contagious?
A: No, rickets is not contagious. It cannot be spread from one person to another. It is caused by deficiencies of essential nutrients like vitamin D and calcium, not germs.

Q: Is rickets fatal?
A: Rickets is not a fatal condition. With appropriate treatment, a person can recover from rickets over time. However, if left untreated, in severe cases, rickets may increase the risk of serious complications that could in some cases lead to death. If rickets is suspected, it is important to see a doctor without delay and to adhere to the treatment plan recommended.[28][29]

Associated terms used for rickets

  • Osteomalacia (in adults)
  • Rickets disease
  • Nutritional rickets
  • Soft bones

  1. NHS Choices. “Rickets and Osteomalacia.” December 21, 2015. Accessed November 23, 2017.

  2. You and Your Hormones. “Rickets.” December, 2014. Accessed November 23, 2017.

  3. NHS Choices. “Rickets and Osteomalacia: Symptoms.” December 21, 2015. Accessed November 23, 2017.

  4. UpToDate. “Overview of rickets in children.” May 25, 2018. Accessed February 27, 2019.

  5. NHS. “Knock knees.” November 19, 2018. Accessed January 29, 2019.

  6. Medscape. “Rickets Clinical Presentation.” March 29, 2017. Accessed January 29, 2019.

  7. UpToDate. “Approach to the child with bow-legs.” April 10, 2018. Accessed January 27, 2019.

  8. OrthoInfo. “Bowed Legs (Blount's Disease).” February, 2015. Accessed January 27, 2019.

  9. National Institutes of Health. “Vitamin D.” November 9, 2018. Accessed January 27, 2019.

  10. Food Safety Authority of Ireland. “Vitamin D.” July 24, 2018. Accessed January 27, 2019.

  11. Jornal de Pediatria. “The importance for growth of dietary intake of calcium and vitamin D.” 2008. Accessed January 27, 2019.

  12. The Royal Children’s Hospital Melbourne. “Rickets.” January, 2014. Accessed November 23, 2017.

  13. Genetics Home Reference. “Hereditary hypophosphatemic rickets.” November 21, 2017. Accessed November 23, 2017.

  14. Medscape. “Rickets Workup.” March 29, 2017. Accessed February 27, 2019.

  15. NHS Choices. “Rickets and Osteomalacia: Treatment.” December 21, 2015. Accessed November 23, 2017.

  16. Cancer. “Hypercalcemia.” January, 2017. Accessed November 23, 2017.

  17. NHS Choices. “Rickets and Osteomalacia: Prevention.” December 21, 2015. Accessed November 23, 2017.

  18. Vitamin Council. “How do I get the vitamin D my body needs?” Accessed November 24, 2017.

  19. Nutrition Bulletin. “Vitamin D: An overview of vitamin D status and intake in Europe.” December, 2014. Accessed February 12, 2018.

  20. UpToDate. “Etiology and treatment of calcipenic rickets in children.” April 17, 2018. Accessed February 27, 2019.

  21. OrthoInfo. “Rickets.” September, 2010. Accessed January 28, 2019.

  22. Medscape. “Rickets Treatment & Management.” March 29, 2017. Accessed January 28, 2019.

  23. Medscape. “Rickets.” March 29, 2017. Accessed February 27, 2019.

  24. Paediatrics & Child Health. “Congenital rickets caused by maternal vitamin D deficiency.” September, 2002. Accessed January 29, 2019.

  25. American Family Physician. “Rickets: What It Is and How It’s Treated.” August 15, 2006. Accessed January 29, 2019.

  26. International Journal of Paleopathology. “Approaches to co-occurrence: Scurvy and rickets in infants and young children of 16–18th century Douai, France.” March, 2016. Accessed January 28, 2019.

  27. BBC News: Health. “Is scurvy making a comeback?” January 22, 2016. Accessed January 28, 2019.

  28. Maternal & Child Nutrition. “The impact of rickets on growth and morbidity during recovery among children with complicated severe acute malnutrition in Kenya: A cohort study.” April, 2018. Accessed January 28, 2019.

  29. Archives de Pédiatrie - Official journal of the French Society of Pediatrics. “Severe nutritional rickets in young children: Resurgence of an old disease.” August, 2017. Accessed January 28, 2019.