RICKETS

Rickets - a disease of young children, due to lack of vitamin D; metabolic disorder characterized primarily calcium and phosphorus, bone formation disorders, the nervous system and internal organs. The leading role in the development of rickets have the disadvantage ultraviolet irradiation, leading to disruption of the formation of vitamin D in the skin, low levels of vitamin D in food (especially in breast milk). Also plays a significant role deficiency of vitamins B1, B5, B6, C, A, E, involved in the building of bone. Therefore rickets regard as polyhypovitaminosis. It also facilitates the development deficiency in minerals such as magnesium, zinc, iron, copper and cobalt. Contributing factors are the increased need for vitamin D of young children (especially the 1st year of life) due to their enhanced growth and intense formation of the skeleton; pathology pregnancy and various extragenital diseases of the mother; irrational feeding (excess of carbohydrates or proteins child nutrition); artificial feeding (the ratio of phosphorus and calcium in cow's milk does not meet the needs of the child's body); gastrointestinal and infectious diseases, in which is always changing and evolving mineral metabolism acidosis , leading to disruption of bone formation processes; lack of exposure to fresh air; small static load, typical for children of 1st year of life, and others.

In preterm infants compared to full-term incidence of rickets is much higher. This is due to a reduced supply of vitamin D, calcium and phosphorus, inadequate mineralization of the skeleton, a more pronounced tendency to acidosis, hypoproteinemia, low levels of citric acid in the blood serum, the increased need for calcium and phosphorus due to the enhanced growth after birth, violation of intestinal absorption of fat and vitamin D.

The clinical picture of rickets variable and depends on the period of development. Distinguish the initial period, the height of the disease (blooming rickets), convalescence periods and residual effects. The first signs of rickets in term infants are usually found at the age of 2 - 3 months. The initial period usually lasts 2 - 3 weeks and is manifested mainly nervous system disorders. Changes the mood and behavior of the child: he became moody, irritable, restless, difficulty falling asleep and not sleeping. It appears severe sweating (especially the head), increasing during feeding and sleep. Sweat sticky, with unpleasant sour smell, it irritates the skin. The child rubs his head on the pillow, as a result of the hair on the back of his head fall. On his head there is a clear pattern of subcutaneous veins. Chair unstable, urine becomes sharp smell of ammonia. Identify easy malleability of a large fontanelle and the edges of the skull bones along the sagittal and lambdoid sutures.

At the height of the disease observed marked changes in bone, muscular systems as well as internal organs. In the first place there are areas in the softening of the skull bones (craniotabes). In severe cases, softened almost all the bones of the skull, back of the head is flattened. As a result, excessive formation of osteoid appear frontal and parietal hillocks, the head becomes a square shape, forehead overhangs, the bridge seems to be sunken, there exophthalmos . Slows teething and change its order, violated bite. On the border of the bone and cartilaginous parts of chest ribs formed thickening ( "beads"), most expressed on the V-VIII ribs. The bones become soft chest, the chest is deformed: it looks as if flattened laterally, the lower its aperture is set, the top tapering. On the surface of the chest, respectively, of the diaphragm attachment line appears sunken - Harrison's groove. In severe cases, there is protrusion of the anterior wall of the chest, along with the sternum ( "chicken breast"), in the lumbar spine may appear kyphosis - rachitic hump. In children older than 6 - 8 months observed thickening of the epiphyseal bone of the forearm (bracelets) and shins, phalanges ( "string of pearls"), lower limb bones are bent in the shape of the letter O - varus deformity, sometimes in the form of letters of the X - valgus deformity. The bones of the pelvis rarely deformed.

Characterized by weakness of ligament-muscular system, leading to laxity of the joints, the discrepancy recti and its spreading - frog belly. During this period may develop shortness of breath , pulmonary atelectasis caused by deformation of the chest, diaphragm hypotension; frequent prolonged pneumonia. Heart sounds are generally muted, the pulse speeded up, blood pressure is often reduced. Most children identify hypochromic anemia, enlarged liver and spleen, disorders of motor and secretory functions of the gastrointestinal tract, decreased appetite, unstable chair. Possible renal dysfunction and endocrine glands. As a result of violations of immunity increases the incidence of acute respiratory viral infections. There may be convulsions .

convalescence period is characterized by regression of symptoms.

The period of residual effects in children aged 2 - 3 years and older. By this time the rachitic process ends and remain its consequences - deformation of the bones, sometimes stored for a long time increasing the size of the liver and spleen.

Depending on the severity of the clinical manifestations there are three degrees of severity of the disease. Rickets I degree (mild) characterized by slightly pronounced disorders of the nervous, skeletal and muscular systems (anxiety, sweating, alopecia neck, pliability edges of a large fontanelle, moderate flattening of the occipital bone), which disappear during convalescence. When rickets II severity (average) general condition of the child is considerably violated: there are moderately pronounced changes in the nervous, skeletal and muscular systems, there are functional disorders of the respiratory system, cardiovascular system and gastrointestinal tract. For rickets III degree (severe) characterized by significant changes in bone, muscle and other organs and systems: a sharp retardation, retarded motor development, severe bone deformation, a sharp increase in the size of the liver and spleen, significant functional disorders of the cardiovascular system, respiratory system, gastrointestinal -kishechnogo tract, severe anemia.

By the nature of the clinical course of rickets may be acute, subacute, and recurrent, which determines the difference in the carrying out of remedial measures. Acute rickets occurs more often in the first six months of life, especially for large children. It is characterized by progressive course with nervous, skeletal and other systems. Subacute rickets is characterized by slow, sluggish development of the disease, the prevalence of muscular hypotonia, anemia. Recurrent rickets seen repeated exacerbations has hushed the process, which may be due to changes in environmental conditions, repeated infectious diseases and lack of exposure to fresh air, the sun, poor diet. If not properly treated, the absence of anti-prevention can be observed continuously sluggish progression of rickets.

Treatment involves proper organization dietogigienicheskogo baby mode, the use of vitamin D2 (ergocalciferol) and vitamin D3 compounds with cholesterol (videhola) ultraviolet irradiation, medical massage and gymnastics. Treatment should be individualized and depend on the severity and nature of the disease, age of the child, season, climate and material conditions.

Recommend balanced content of protein, fat, carbohydrates, vitamins and minerals (especially calcium, phosphorus and iron) diet, wherein the need for vitamin D is minimized. Limit your child's intake of cereal and flour products, thereby reducing the tendency to acidosis and poor intake of digestible phosphorus. When artificial feeding must be adapted to use, vitamin enriched formula milk ( "Vitalakt", "biolact" and others.), Acidophilus liquid mixture. The diet should be combined with the observance of hygienic rules of child care and the regime of the day, corresponding to its age, the long stay in the fresh air using tempering procedures: air baths, rubdowns and others.

Specific therapy is started after setting the reaction Sulkovicha (urine calcium content) and is carried out only in the absence of hypercalcemia. Assign 2000 - 10 000 ME of vitamin D a day intervals between feedings for 4 - 6 weeks (1 every 2 weeks exploring the urine via Sulkovicha reaction). Within 1 year is permissible carrying only one course of treatment with a subsequent transition to support preventive doses. Along with vitamin D can not be assigned ultraviolet irradiation, calcium supplements. Ultraviolet irradiation for prevention of recurrence can be used only after 2 months after treatment vitamin D, mainly in autumn and winter. In the complex treatment it is recommended to include ascorbic acid, vitamins A, B group of auxiliary methods of treatment of rickets are sodium chloride (salt) and coniferous baths (at the rate of 15 - 20 baths), designated for children older than 4 - 5 months. When expressed deformations of the skeleton and muscular hypotonia shows application of heated sand, wax, peat and mud (up to 2 years only on the lower limbs).

Forecast with timely and adequate treatment favorable. For children who recover from rickets, it is advisable to conduct medical check-up for at least 3 years.

Prevention should start in the antenatal period through the creation of optimal conditions for pregnant (full, varied, enriched with vitamins and trace elements nutrition, regular alternation of work and rest, hygienic rules, prolonged exposure to the outdoors, and so on. D.). If the last 2 months of pregnancy occur in autumn and winter, it shows the ultraviolet irradiation mercury-quartz lamp (10 - 15 sessions) in the antenatal clinic. If it is impossible for such a course from 30 -32 weeks of pregnancy prescribe vitamin D drugs daily 400-500 ME per day. In the postnatal period, together with the common set of preventive measures carried out specific prevention of vitamin D rickets, which in term infants is carried out from the end of the 1st month of life and premature - 1 - 2 weeks of age. In the autumn and winter should be 1-2 courses of ultraviolet radiation, vitamin D in this period is terminated. When a child is breastfed adapted mixtures, which include heat-stable vitamin the D2, the additional administration of vitamin is required.