Rickets: Types, Causes, Risk Factors, Symptoms, Diagnosis and Treatment

It is a medical condition that affects the bones.

It usually occurs during childhood and makes bones brittle. This bone disease affects babies and young children.

A child’s growing bones do not develop properly due to a lack of vitamin D.

This can cause soft and weakened bones, fractures, muscle pain, and bone deformities.

You can help in the effects of rickets by understanding your risk factors for vitamin D deficiency and taking steps to prevent it.

Although rickets can occur due to genetic abnormalities, it is always caused due to deficiency of vitamin D, calcium, or phosphorus.

Vitamin D is essential to promote the absorption of calcium and phosphorus from the gastrointestinal tract, which are needed to build strong bones.

A vitamin D deficiency makes it difficult to maintain adequate levels of calcium and phosphorus in the bones.

Your body detects an imbalance of calcium and phosphorus in your bloodstream and reacts by taking calcium and phosphorus from your bones to raise blood levels to where they need to be.

This softens or weakens the structure of the bone, most commonly resulting in skeletal deformities, such as bowed legs or improper curvature of the spine.

Osteomalacia is the adult version of rickets.

Children with naturally dark skin or inadequate exposure to sunlight are among the most affected.

Having a mother with vitamin D deficiency also increases the risk of a child.

Other causes can be nutritional deficiencies and disorders of the liver, kidney, or small intestine.

A similar condition can occur in adults, but this is called osteomalacia.

The earliest description of rickets dates back to the 2nd century and well-documented descriptions of the conditions were found in the mid-17th century in England as a common bone condition throughout England.

Types of rickets

Basically, rickets is of three types:

Nutritional rickets – Caused by inadequate dietary intake of vitamin D, phosphorus, or calcium, or insufficient exposure to sunlight. Vitamin D deficiency is not as common in developed countries, but it can happen to a baby, who depends solely on breast milk, or has limited or no exposure to sunlight.

Children with dark skin require more exposure to sunlight to produce the same amount of vitamin D. This is due to melanin, which acts as a neutral filter. Nutritional rickets only occurs in the first years of life.

Vitamin D dependent: This can be divided into two types:

  • Vitamin D-dependent rickets Type 1: it is a secondary defect of the defect in the gene that encodes the production of renal 25 (OH) D3-1-α-hydroxylase.
  • Vitamin D-dependent rickets Type 2: This is a rare autosomal disorder, caused by mutation in vitamin D receptors. It does not respond to vitamin D treatments.

The two types can be differentiated by the levels of circulating calcitriol. Type 1 vitamin D-dependent rickets has higher levels of circulating calcitriol, a hormone and metabolite of vitamin D.

Vitamin D-resistant rickets : Also known as familial hypophosphatemic rickets, it is an inherited condition. It occurs when the phosphate regulator gene on the X chromosome mutates. Calcitriol levels remain within allowable limits in this type of rickets.

Causes of rickets

Rickets can be caused by deficiency of vitamin D, or less commonly, calcium and phosphorus.

  • Vitamin D deficiency: You need to have vitamin D from two sources, namely sunlight and food.
  • Sunlight: The sun is the natural source of vitamin D. The skin produces vitamin D when it is exposed to the sun. Limited sun exposure can lead to vitamin D deficiency, which can cause rickets.
  • Diet: fatty fish, fatty oil and egg yolk are rich in vitamin D. A low amount of vitamin D in the diet can cause rickets.
  • Exclusive breastfeeding (without vitamin D supplements) in babies whose mothers are vitamin D deficient.
  • Problem with absorption: In some cases, the body cannot process and absorb vitamin D.
  • Some of the diseases that give rise to this condition are:
  1. Celiac diseases
  2. Inflammatory bowel disease
  3. Cystic fibrosis.
  4. Kidney problems
  • Hereditary rickets (X-linked hypophosphatemia) – an inherited form of rickets caused by the inability of the kidneys to retain phosphorus or a complication of renal tubular acidosis, a condition in which the kidneys are unable to excrete acids in the urine .

Risk factors for rickets

Some common risk factors associated with rickets are:

  • Poverty: Poor economic conditions increase the risk of rickets, as access to adequate diet and nutrition may be limited.
  • Inadequate sunlight: Children who do not have adequate exposure to sunlight are at higher risk for rickets.
  • Malnutrition : Malnutrition is the main cause of rickets. Diets low in vitamin D lead to rickets.
  • Dark skin: Children with the dark skin type are at higher risk of rickets since dark skin does not react as quickly to sunlight to form vitamin D as light skin does. Children with dark skin need more exposure to the sun to produce the same amount of vitamin D produced by children with lighter skin.
  • Mother’s vitamin D deficiency during pregnancy: If the mother is vitamin D deficient at the time of pregnancy, the chances of rickets in the baby increase.
  • Northern latitudes: Children in northern areas, where there is limited sun, are more likely to get this condition.
  • Premature birth: Babies who are born prematurely are at a higher risk of developing rickets.
  • Medications: Certain medications used to treat HIV can interfere with how well the body makes vitamin D.
  • Exclusive breastfeeding: breast milk is deficient in vitamin D, so that children, who depend exclusively on breast milk, are at greater risk of developing rickets.
  • Clothing: when for religious or cultural reasons most of the body is covered.
  • Diseases: when you have certain medical conditions, such as certain intestinal diseases.
  • Diets: when vegetarian, dairy-free or lactose-free diets are followed.

The role of vitamin D

The body needs vitamin D to absorb calcium and phosphorus.

These minerals are essential for the growth and development of strong and healthy bones.

Lack of vitamin D reduces the body’s ability to control the levels of these vital minerals and increases a child’s risk of developing rickets.

About 80 percent of vitamin D comes from sun exposure.

When direct sunlight hits the skin, ultraviolet radiation converts a substance in the skin called 7-dehydrocholesterol into vitamin D.

There are also very small amounts of vitamin D in some foods.

However, food sources alone are generally not enough to maintain the levels of vitamin D that our bodies need.

Once vitamin D is made in the skin or absorbed from food through the intestine, the liver and kidneys change it to its active form, a hormone.

It is then available to help our bodies develop strong bones and teeth, through the process of ‘mineralization’.


UV radiation levels vary based on location, time of year, time of day, cloud cover, and environment.

Babies and young children need extra protection due to their sensitive skin.

High levels of ultraviolet radiation mean that most children get more than enough vitamin D, even when they are outdoors for very short periods with small amounts of exposed skin.

People with very dark skin may need three to four times more time in the sun than people with fair skin.

This is because the pigments in dark skin slow down the chemical reaction that leads to the production of vitamin D.

Children who are outdoors for long periods, have very fair skin, or have a family history of skin cancer may need to use sunscreen outside the recommended hours.

Symptoms of rickets

Vitamin D deficiency begins months before physical signs and symptoms of rickets appear.

When symptoms of rickets develop, they can include:

  • Pain: Children with rickets usually experience pain in the affected bone. The child may be reluctant to walk, tire easily, or walk differently (with movements similar to a duck walking).
  • Skeleton deformation : Various deformations such as thickening of the knees, wrists and ankles, softening of the skull bones, bowed legs, bent spine are common symptoms of rickets.
  • Dental problems – These can include increased cavities and weak tooth enamel.
  • Poor growth and development: Growth retardation can occur in children with rickets.
  • Brittle bones : Bones are more prone to fracture as they become weak and brittle.
  • Muscle weakness: decreased muscle tone can make movement uncomfortable.

Other prominent symptoms:

  • Loss of muscle tone in a baby’s limbs.
  • Costochondral swelling.
  • Harrison’s groove, in which a horizontal line appears on the chest.
  • Reduced level of calcium in the blood.

Rickets diagnosis and testing

In the initial stage, rickets is diagnosed clinically.

In this, the complete medical and nutritional history of the patient is analyzed, and a medical examination is performed by a healthcare professional.

In the absence of any acute symptoms, such as tetany or seizures, x-rays of long bones such as the ulna, femur, and radial bone are taken.

X-rays and bone scans are evaluated for signs of rickets such as:

  • Enlargement of the metaphysis.
  • Arched femurs.
  • Osteopenia.
  • Rickety rosary (dazzling ribs).
  • Multiple fractures.

If any of the above mentioned signs are found during the evaluation, the following steps will be taken through a blood test to detect the specific reason for the rickets:

  • Vitamin D level.
  • Alkaline phosphatase.
  • Parathyroid hormone.
  • Electrolytes.

In rare cases, a bone biopsy may be done.


The goal of treatment for rickets is to resolve the underlying disorder.

If deficiencies in vitamin D, calcium, or phosphorus are the cause, replacing vitamin D and those minerals generally eliminates the signs and symptoms of rickets, such as bone tenderness and muscle weakness.

Improvement can occur in several weeks.

Rickets treatment may include:

  • Greater exposure to sunlight.
  • Increase your intake of vitamin D and calcium through injections.
  • Increased intake of vitamin D and calcium through foods rich in these nutrients.
  • Take vitamin D and calcium supplements. Some of the medications that can be taken are oral ergocalciferol, oral calcitriol, among others.

When a child suffers from rickets, it must be ensured that they get adequate amounts of vitamin D, phosphorus and calcium through their daily diets.

In the case of a baby, the dose recommended by the doctor should be strictly followed.

For children and adolescents, moderate exposure to sunlight and an adequate amount of vitamin D and calcium should be provided through food and supplements.

In some cases if other complications such as bow legs or spinal deformities are found, the doctor may suggest a special brace to position the child’s body properly as the bones grow.

More serious skeletal deformities may require surgery to treat the underlying complication.

If rickets is caused by genetic conditions, as in the case of hypophosphatemic rickets, then phosphate supplements and specific forms of vitamin D are required.

If the child suffers from rickets due to genetic conditions, he may require a very high dose of specific vitamin D supplements.

Self-management methods for rickets

Several measures to self-manage the condition are as follows:

Increase your intake of vitamin D, calcium, and phosphorus by eating foods rich in these nutrients.

The following natural remedies can be used to prevent and manage rickets:

  • Sun Exposure: The sun is a natural source of vitamin D. The body synthesizes vitamin D when it is exposed to the sun’s rays. Increase exposure to sunlight as the skin synthesizes vitamin D when it comes in contact with sunlight. Although exposure to the sun does not cure rickets, it promotes the body’s absorption of calcium and phosphorus and helps strengthen bones.
  • Cod Liver Oil : Cod liver oil is a well known home remedy for treating rickets in breastfeeding mothers. It is a rich source of vitamin D and improves muscle formation. It is also known to prevent hypertension, type 1 diabetes, and some cancers.
  • Fatty fish : oily fish is one of the few foods rich in natural vitamin D. Although one can have blue fish at any time of the year, it should be eaten in winters when daylight is limited. However, if your child’s exposure to sunlight is limited even in summers, consider feeding him oily fish. Some of the fatty fish that are a good source of vitamin D include sardines, salmon, tuna, mackerel, and catfish.

The consumption of calcium and phosphorus is also important for the formation of bones in childhood.

Breast milk is the best source of calcium during the first year of a child’s life.

Most commercially available formulas also meet calcium requirements.

Unfortunately as children grow into adolescents and adults, many do not absorb enough calcium, an essential component of skeletal formation.

This lack of calcium can lead to osteomalacia, a form of rickets in adults.

The recommended daily intake for calcium is as follows (serving sizes vary with age):

  • Ages 1 to 3: 500 milligrams (mg) (two servings of dairy products per day).
  • Ages 4-8: 800 mg (two to three servings of dairy products per day).
  • Ages 9 to 18: 1,300 mg (four servings of dairy products a day, as most bone mass production occurs during this period).
  • Ages 19-50 : 1,000 mg per day (three servings of dairy products per day).

Some good sources of vitamin D, calcium, and phosphorus are:

  • Dairy products like milk, cheese, and yogurt.
  • Walnuts.
  • Green leafy vegetables, such as kale, lettuce, spinach, and broccoli.
  • Tuna, salmon, eggs, beef, chicken, cod liver oil.