A 2 Year Old Child Is Seen By A Pediatrician For Bowing Of Legs

A 2 year old child is brought to a pediatrician for the evaluation of delayed growth, muscle weakness and bowing of the legs. The mother gives the history that the child was weaned early as she was expecting again and since the child frequently suffered from diarrhea he was given almost little or no milk. They live in a close apartment with almost no sunlight exposure. The child's diet mainly consists of vegetables and rice. His mental development seems to be normal for his age but he has delayed walking and still falls while playing.
On examination, the child was quiet and cooperative. He looks malnourished with signs of growth delays. On standing he had bowing of the legs, the picture is shown below:

His wrists were widened and there was frontal bossing of the skull.
His vitals were normal. There were some coarse crackles on auscultation of the lung fields. The rest of the examination was within normal limits.

What is the Diagnosis?
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Rickets


Case Discussion
Rickets is defined as a condition in which the bones in children are softened and weakened because of extreme and prolonged deficiency of Vitamin D.
Vitamin D normally helps in the absorption of calcium and phosphorus from the gastrointestinal tract. A deficiency of Vitamin D leads to decreased calcium and phosphorus in the bones which can then lead to rickets.

Causes: A child may become deficient in Vitamin D due to causes like:

• Lack of proper exposure to sunlight resulting in decreased synthesis of Vitamin D.
• Diet that is deficient in Vitamin D
• Malabsorption diseases like Celiac disease, cystic fibrosis or severe malnutrition.
• Kidney problems due to which active form of vitamin D could not be synthesized. 
• Dark skin with little exposure to sunlight leads to reduced natural synthesis of Vitamin D in skin.

Clinical Features; Patients with rickets may present with one or more of the following:

• Bone tenderness
• Dental problems
• Muscle weakness
• Increased tendency for fractures even with minor trauma. 
• Skeletal deformities like bowing of the legs, knock knees, delayed closing of the fontanel, frontal bossing, Kyphosis, lumbar lordosis etc.
• Growth delays and delayed developmental milestones
• Softening of the skull known as craniotabes
• Swelling at the costochondral junctions ( Ricketic rosary)
• Widening of the wrists
• Frequent respiratory infections.
• Hypocalcemia that may lead to tetany or fits. 

Diagnosis: 

1. Blood tests shows decreased levels of calcium phosphorus and vitamin D

2. Alkaline phosphatase is raised

3. X ray may show reduced bone opacity and After treatment a distinct growth line is seen. 

Treatment: Most cases of Rickets are treated with calcium and vitamin D supplements. Exact dose is calculated for the age and weight of the child. Even after the deficiency is corrected the child should be given a diet rich in vitamin D like dairy products and fish, as well as should be exposed to sunlight daily. 

Sometimes surgical correction of skeletal abnormalities may be needed to prevent life long disability.