Rickets

Rickets . Etiology. One of the main factors is hypovitaminosis D, vitamin D deficiency of exogenous or endogenous origin. In addition to improper feeding and vitamin D deficiency, it can also be caused by disruption of the formation of its active forms in the body with a lack of ultraviolet rays (in winter and autumn, in cities), liver and kidney diseases (they form active forms of vitamin).

A certain role is played by prematurity (immaturity of enzyme systems), rapid growth of the child, diseases accompanied by acidosis, insufficient intake of calcium and phosphorus salts.

Pathogenesis. Vitamin D is a steroid compound and is known in the form of vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol), which are very similar in structure, physicochemical properties and effects on the human body. Food vitamin D is transformed in the liver and kidneys, resulting in the formation of 1,25-dihydroxy vitamin D, which has a hormone-like effect. This compound affects the genetic apparatus of the intestinal cells, thereby increasing the synthesis of protein, specifically binding calcium and providing its transport in the body. With a lack of vitamin D, absorption and calcium metabolism is impaired, its concentration in the blood drops, which causes the reaction of parathyroid glands and an increase in the secretion of parathyroid hormone regulating the exchange of calcium and phosphorus. Excessive secretion of parathyroid hormone leads to mobilization of calcium from bone tissue, suppression of reabsorption of phosphates in the renal tubules, and therefore the content of inorganic phosphates in the blood drops. At the same time, the activity of alkaline phosphatase increases sharply. Violations of phosphate-calcium metabolism lead to the development of acidosis, which is accompanied by a disturbance of the excitability of the nervous system.

Clinical picture. By severity, the following degrees of rickets are distinguished: 1 degree (mild) - slight changes in the nervous and muscular systems; There are no residual effects; II degree (moderate severity) - marked changes in bone, muscle, nervous and hematopoietic systems, moderate disruption of internal organs, small increase in liver and spleen, anemia; III degree (severe) - pronounced changes from the central nervous, bone and muscle systems, internal organs. Complications are frequent.

The initial period is more often observed on the 2nd-3rd month, but it can appear throughout the first year of life. Sweating, baldness of the nape, anxiety, muscular dystonia; Unsharp softening of the edges of the large fontanel. Duration 2-3 weeks. Biochemical studies: a reduced amount of phosphorus, an increase in phosphatase activity. X-ray changes are not present.

In the period of the height of the disease, along with the phenomena of inhibition of the nervous system, there are changes in the bones; Craniotabes, changes in the bones of the skull, thorax, limbs. Bony changes, barely noticeable in rickets), and distinct at grade II, become deformed in rickets of grade III. Disturbances of static functions, functions of internal organs, hypotonia of muscles are detected, anemia joins. With rickets of II and III degree, the spleen and liver are enlarged. On radiographs contours of bones are greased. Epiphyses of tubular bones are goblet, the margins of metaphyses are fringed. In the 2-3rd year of life, there are only consequences in the form of deformities of the bones, sometimes anemia.

In acute course there is a rapid development of symptoms of rickets. In the initial period - marked anxiety, sharp sweating, biochemical shifts in the blood, in the midst of a disease, a significant softening of the bones, pronounced muscle hypotension. Acute flow is observed more often in the first months of life, especially in premature and rapidly growing children. Subacute flow is characterized by a slower development of the process. It is observed more often in children older than 6-9 months, as well as in children with hypotrophy. The phenomenon of softening of the bones is much less pronounced. Osteoid hyperplasia predominates over osteomalacia, frontal and parietal tubercles, rosary beads on the ribs, thickening of the epiphyses of tubular bones. Recurrent flow is accompanied by intermittent conditions: usually improvement in summer and worsening in winter. X-ray patterns show bands that correspond to calcification zones in metaphysis during the repair period.

Late rickets include rare cases of the disease, when active manifestations of it are noted at the age of more than 4 years. Late rickets, observed in the military and the first post-war years, was characterized by the presence of common symptoms of the disease (anorexia, sweating, pain in the legs, fatigue). Bony deformities are noted only in some cases. Signs such as hypophosphataemia, and osteoporosis, and changes in calcification zones become especially important.

Diagnosis in addition to clinical symptoms, confirmed by the study of the content of calcium, phosphorus, alkaline phosphatase in the blood, important data X-ray study.

Differential diagnosis. Rickets is differentiated from a number of rachitis-like diseases of hereditary nature-phosphate-diabetes, kidney tubular acidosis, Debre-de-Tony-Fanconi syndrome (see), and also from congenital dislocation of the thigh, chondrodystrophy, osteopathy in chronic kidney failure, congenital bone fragility.

Treatment. An important role is played by rational nutrition, normalization of the regime with sufficient stay in the fresh air, massage, gymnastics. With initial manifestations, full-term children are prescribed vitamin D2 preparations at 300-800 IU / day, for a course of 400,000-600,000 ME; In the midst of a mid-heavy and severe rickets, 10,000-16,000 IU / day are prescribed in 2-3 sessions, for a course of 600,000-800,000 ME.

The method of shock doses, used in severe complicated forms of rickets, is not currently used. Preparations of vitamin D should be given during meals. Sometimes the purpose of vitamin D2 is combined with 25% citric acid solution, 20% sodium citrate solution (in the intestine is formed easily soluble and well sucked calcium citrate complex) inside of 20 ml per day.

During treatment, it is necessary to carry out the simplest control over the sensitivity of the child's organism to vitamin D with the help of Sulkovich's test for the prevention of hypervitaminosis.

Ultraviolet therapy has a beneficial effect in the initial period and in subacute rickets in young children. The method and dosage of irradiation depends on the child's age, physical condition, environmental conditions, phase and severity of rickets. It is recommended to conduct ultraviolet irradiation with a course that includes 15-20 sessions, administered every other day, with a gradual increase in exposure. The first session for children up to 3 months begins with 1/8 of the biodoza, children older than 3 months - with 1/4 of the biodos. With subsequent treatment, every 2 sessions, the exposure is increased by 1/8, or 1/4 of the biodosome. With insufficient stay in the open air, artificial feeding, recurrent course of rickets, the course of treatment is extended to 25 sessions and repeated after 2 months. At the initial phase of rickets, irradiation is often limited to one course consisting of 15-20 sessions, in the high-rise phase, the course after 2-3 months is increased. In the intervals between irradiation courses, specific prevention with vitamin D2 or fish oil is carried out.

Massage and gymnastics are used in any period, but not with acute flow.

The prognosis with the timely begun treatment and the elimination of the cause is favorable. In severe course, a delay in psychomotor development, deformation of the skeleton and posture disorder are possible.

Prevention. Rational nutrition, sufficient insolation, sanitary-hygienic regime, hardening, correct upbringing.

It is priceless antenatal prophylaxis in pregnant women in the last 2-3 months of pregnancy with vitamin D, 500-1000 IU / day. For antenatal prophylaxis, you can use ultraviolet irradiation of pregnant women. You need a long stay in the open air, rational nutrition.

In the diet of the child should be timely to introduce vegetables and fruits. Lure should contain enough vitamins, salts. Important products are those containing natural vitamin D3 (egg yolk, fish oil).

The addition of citric acid to the diet (25% solution 1 teaspoonful 3 times a day) promotes the formation of easily absorbed calcium citrate and, consequently, the absorption of phosphorus. Flour dishes, porridges contain phosphorus in a form poorly absorbed by the child and can promote the development of rickets, so it is desirable that their number in the daily diet of a child of 1 year of life does not exceed 180-200 g.

In the autumn-winter period, ultraviolet irradiation of children with a preventive goal should start from 1-1.5 months of life. It is necessary to conduct two courses with an interval of 2 months.

The physiological need for vitamin D of a healthy full-term baby at the first year of life varies between 400-500 IU / day. In cases where the child for any reason does not receive with preventive UV radiation, an artificial preparation of vitamin D2 or D3 should be prescribed. In order to prevent antenatal prophylaxis, in the last 3-4 months of pregnancy, gendevit is recommended for 1-2 tablets per day (250- 500 ME vitamin D2), and under unfavorable conditions - 4 tablets per day. Contraindications - the mother's age is more than 30 years, mother's disease. Postnatal prophylaxis is performed from 2-3 years of age to 500 IU per day (1 drop of vihole), for a course of 150 000-200 000 ME.