Analysis for rickets. Residual period

Quite often, at the next visit to the pediatrician with a 3-4 month old baby, parents can hear the diagnosis of rickets from the doctor. For many parents, the concept of this disease is very vague and superficial, they do not know the main symptoms of the disease and do not imagine a possible treatment. So what is rickets and why is it dangerous when found in children?

Rickets is a violation of the metabolism of phosphorus and calcium in the body, which occurs due to a lack of vitamins of group D. First of all, the absorption of calcium ions from the intestine worsens, and as a result of its lack, demineralization and bone curvature occur.

What is vitamin D for?

Vitamin D is produced in the skin under the influence of sunlight, and only a small part of it enters the body with food.

Promotes transport of calcium through the intestinal wall.
It enhances the retention of calcium and phosphorus ions in the renal tubules, which prevents their excessive loss in the body.
Promotes accelerated impregnation of bone tissue with minerals, that is, strengthens bones.
It is an immunomodulator (regulates the state of the immune system).
It has a positive effect on the exchange of tricarboxylic acids, as a result of which a lot of energy is released in the body, which is necessary for the synthesis of various substances.

Vitamin D (90%) is produced in the skin under the influence of ultraviolet rays, and only 10% of it enters the body with food. Thanks to him, calcium is absorbed in the intestines, which the body needs for the normal formation of bone tissue, the full functioning of the nervous system and other organs.

With a prolonged lack of vitamin D in children, the processes of demineralization of bone tissue begin. This is followed by osteomalacia (softening of tubular bones) and osteoporosis (rarefaction of bone tissue), which lead to a gradual curvature of the bones.

Most often, children aged 2-3 months to 2-3 years suffer from rickets, but babies under 1 year old are most vulnerable.

Causes of the disease

If there is only one cause of rickets - a deficiency in the child's body of vitamin D, and as a result - a decrease in calcium levels, then there are a lot of factors that provoke the disease. Conventionally, they can be divided into several groups:

Insufficient insolation due to the infrequent stay of the baby in the fresh air, and the associated decrease in the formation of vitamin D in the skin.

Nutrition errors:

artificial feeding mixtures that do not contain vitamin D, or the calcium-phosphorus ratio is disturbed in them, which makes it difficult to absorb these elements;
late and incorrect introduction of complementary foods;
someone else's breast milk often causes poor absorption of calcium;
the predominance in the diet of monotonous protein or fatty foods;
malnutrition of a pregnant woman and a mother who is breastfeeding a child;
the introduction of predominantly vegetarian complementary foods (cereals, vegetables) without enough in the diet of the baby protein of animal origin (egg yolk, cottage cheese, fish, meat), as well as fats (vegetable and animal oils);
the state of polyhypovitaminosis, the lack of vitamins of groups B, A and some trace elements is especially noticeable.

Prematurity and large fetus:

prematurity is one of the leading causes of rickets in a baby, since phosphorus and calcium begin to intensively enter the fetus only after 30 weeks (at 8 and 9 months of pregnancy), so premature babies are born with insufficient bone mass;
it should also be taken into account that due to the relatively rapid growth of premature babies in relation to babies who appeared on time, they need nutrition rich in calcium and phosphorus;
Large babies require much more vitamin D than their peers.

Endogenous causes:

malabsorption syndromes (malabsorption nutrients in the intestines), accompanying a number of diseases, for example, celiac disease;
which interfere with absorption and metabolic processes, including vitamin D;
weak activity of the lactase enzyme, which is responsible for the breakdown of milk sugar contained in dairy products.

Hereditary factors and predisposition to the disease:

anomalies of phosphorus-calcium metabolism and synthesis of active forms of vitamin D;
hereditary metabolic anomalies in the body (tyrosinemia, cystinuria).

Other reasons:

maternal illness during pregnancy;
environmental factor: pollution environment- soil, and then water and food - salts of heavy metals (strontium, lead, etc.) leads to the fact that they begin to replace calcium in bone tissue;
contribute to an increase in the need for vitamins, including group D, but at the same time worsen their absorption; also during illness, the number and duration of walks with the baby are reduced, which leads to insufficient insolation;
(decrease in motor activity), which can be caused by both a violation of the nervous system and the lack of physical education in the family (exercise, massage, gymnastics).

Changes in the body with vitamin D deficiency

Deficiency in the body of vitamin D leads to changes in many organs and systems.

The formation of a specific protein that binds calcium ions and promotes their permeability through the intestinal wall is reduced.
Due to low levels of calcium in the blood parathyroid glands begin to actively produce parathyroid hormone, which is necessary to ensure a constant level of calcium in the blood. As a result of this process, calcium begins to be washed out of the bone tissue, and the reabsorption of phosphorus ions in the renal tubules decreases.
Crashes start oxidative processes, demineralization of the bones continues, they become soft and gradually begin to bend.
In the zone of active bone growth, defective bone tissue is formed.
Acidosis develops acid-base balance body to the acid side), and then functional failures occur in the central nervous system and many internal organs.
It decreases, the child begins to get sick often, and the course of the disease is longer and more severe.

Groups of children most susceptible to rickets

Babies with the second blood group, mostly boys.
Children with overweight, big babies.
Premature babies.
Children living in large industrial cities, as well as northern climate zone and high mountain areas, where there are often fogs and rains and few clear sunny days.
There is a genetic predisposition due to the characteristics of the enzymatic system in the Negroid race.
Frequently and chronically ill children.
Babies born in autumn or winter.
Children who are bottle-fed.

Rickets classification

IN currently Several classifications of the disease have been adopted.

There are primary and secondary forms of the disease. The primary form is based on the lack of vitamin intake with food or the synthesis of its active forms. The secondary form of rickets develops as a result of a variety of pathological processes:

calcium malabsorption - malabsorption syndromes;
fermentopathy;
long-term use child medicines, in particular anticonvulsants, diuretics and;
parenteral nutrition.

Depending on the type of metabolic disorders, there are:

rickets with calcium deficiency (calcium penic);
rickets with phosphorus deficiency (phosphopenic);
without changes in the level of calcium and phosphorus in the body.

By the nature of the course of the disease:

an acute form in which softening of the bone tissue (osteomalacia) occurs and symptoms of a nervous system disorder are expressed;
subacute form, which is characterized by the predominance of the processes of growth of bone tissue over its rarefaction;
recurrent (undulating) rickets, in which there are frequent relapses after suffering an acute form.

By severity:

1 degree (mild), its signs are typical for the initial period of the disease;
Grade 2 (moderate) - changes from the side internal organs and the skeletal system are expressed moderately;
Grade 3 (severe course) - severe disorders of the internal organs, nervous and skeletal systems, a pronounced lag in the child's psychomotor development, the frequent occurrence of complications.

In relation to vitamin D, rickets is divided into two types:

vitamin D dependent (sometimes I and II types);
vitamin D resistant (resistant) - phosphate-diabetes, de Toni-Debre-Fanconi syndrome, hypophosphatasia, renal tubular acidosis.

Symptoms of the disease

Rickets is clinically divided into several periods of the course, which are characterized by certain symptoms.

Initial period.

It occurs at the age of 2-3 months and lasts from 1.5 weeks to a month. At this time, parents begin to notice the appearance of the first symptoms:

changes in the child's usual behavior: anxiety, fearfulness, startling at sudden and unexpected sounds, increased excitability;
loss of appetite;
the appearance of frequent regurgitation and vomiting;
the child sleeps restlessly, often waking up;
face and hairy part heads often sweat, this is especially noticeable during feeding and sleep; sweat with an unpleasant sour smell, constantly irritates the skin, thereby causing itching and prickly heat;
due to constant itching, the baby rubs his head against the pillow, hair rolls and characteristic baldness of the back of the head and temples appears;
there is a decrease muscle tone and weakening of the ligamentous apparatus;
intestinal cramps, or;
develops;
seizures are possible due to a lack of calcium in the body;
stridor - noisy, wheezing breath;
the pediatrician, when feeling the seams and edges of the large fontanel, notes their softness and suppleness;
thickenings resembling a rosary appear on the ribs.

There are no pathologies from the internal organs and systems.

The peak period of the disease

Usually occurs at 6-7 months of a child's life. The disease continues to attack in several directions at once. In this case, a number of new symptoms appear.

Bone deformity:

the process of bone softening is pronounced, this is especially noticeable if you feel the seams and a large fontanel;
a sloping, flat nape (craniotabes) appears;
dolichocephaly - elongation of the bones of the skull;
asymmetrical head shape, which may resemble a square;
saddle nose;
change in the shape of the chest - "chicken breast" or "keeled" (protrusion forward), or "shoemaker's chest" (depression in the xiphoid process);
marked curvature of the clavicles, flattening of the chest with simultaneous expansion downwards;
curvature of the legs - O-shaped or X-shaped (less common) deformation of the bones;
flat feet appear;
the pelvic bones flatten, the pelvis becomes narrow, "flat rachitic";
protruding parietal and frontal tubercles (“Olympic” forehead) may appear on the head, which develop due to excessive growth of non-calcified bone tissue, but over time they disappear;
"rachitic rosary" on the ribs, thickening in the wrist area ("rachitic bracelets"), thickening of the phalanges of the fingers ("strings of pearls") - this is all the growth of bone tissue where it passes into cartilage;
when palpating, there is pain in the bones of the legs, sometimes there is a thickening knee joints;
there is a retraction at the level of the diaphragm - Harrison's furrow;
belatedly, a large fontanel closes - at 1.5-2 years;
late and inconsistent teething, malocclusion, deformity hard palate and jaw arches, defects in tooth enamel.
rarely, children have pathological fractures, household injuries;
dwarfism.

Decreased muscle tone and weakness of the ligamentous apparatus:

the baby rolls over badly on his stomach and back, does it reluctantly and sluggishly;
does not want to sit down, even if he is supported by the handles;
because of weakness abdominal wall in children in the supine position, such a symptom as a "frog belly" is noted, and often the abdominal muscles can diverge;
curvature of the spine - rachitic kyphosis;
joint hypermobility is noted.

Children with rickets begin to hold their heads, sit and walk late. The gait of babies is uncertain and unstable, the knees collide during walking, the step width is sharply narrowed. The child often complains of fatigue and pain in the legs after walking.

From the side of the nervous system, the symptoms are aggravated:

excitability and irritability increase;
the child is less likely to babble, babbling is generally absent;
sleep is restless, intermittent;
children learn poorly, sometimes even lose the skills they have already acquired;
on the skin there is a pronounced red dermographism - a change in skin color after its mechanical irritation.

From the digestive tract:

a complete lack of appetite, and neither large intervals between feedings, nor small portions of food contribute to its excitation;
oxygen starvation resulting from anemia leads to a decrease in the production of many necessary for normal digestion enzymes.

On the part of the blood, severe iron deficiency anemia is observed:

increased fatigue;
pallor of the skin;
drowsiness and lethargy.

Is crashing the immune system- children get sick more often and more severely.

With severe rickets, almost all organs and systems suffer. Chest curvature and weakness respiratory muscles leads to insufficient ventilation of the lungs and frequent pneumonia. There is an increase in the spleen and lymph nodes. There are disturbances in protein and fat metabolism substances, there is a lack of vitamins A, B, C and E, as well as micro and macro elements, especially copper and magnesium.

It is the severe degree of the course of the disease that most often leads to complications:

heart failure;
laryngospasm;
frequent convulsions, tetany;
hypocalcemia.

convalescence period

It occurs by the age of 3 and is characterized by an improvement in the general condition of the child, the disappearance of neurological disorders and excessive growths of bone tissue. The child becomes active, easily rolls over from back to stomach and back, sits or walks better (depending on age). The pain in the legs goes away.

Unfortunately, muscle weakness and skeletal deformity disappear very slowly.

For some time, the level of calcium in the blood may still be reduced, and phosphorus, on the contrary, will be normal or even increased. Biochemical parameters of blood confirm the transition of the disease to the inactive phase and the final period.

Period residual effects

This stage of the disease is most often absent now, since rickets almost always occurs in a mild form.

Forecast and consequences of rickets

In the midst of rickets, a child develops bone deformities, in particular, an o-shaped or x-shaped curvature of the legs.

At early diagnosis and timely treatment started, the prognosis of the disease is favorable. And only when severe course rickets, some irreversible changes in the body are possible:

low growth;
curvature of tubular bones;
violation of posture - kyphosis;
uneven teeth, malocclusion;
defects in tooth enamel,;
underdevelopment of skeletal muscles;
fermentopathy;
narrowing of the pelvis in girls, which can lead to complications in childbirth.

Diagnosis of the disease

Most often, the diagnosis of rickets is based on a careful history taking and examination of the child, as well as clinical symptoms. But sometimes additional diagnostic measures can be prescribed to determine the severity and period of the course of the disease:

a clinical blood test shows the degree of anemia;
a biochemical blood test determines the level of calcium, phosphorus, magnesium, creatinine and alkaline phosphatase activity;
radiography of the lower leg and forearm with the wrist;
blood levels of vitamin D metabolites.

Treatment of rickets

Treatment of the disease depends on the severity and period, and is primarily aimed at eliminating the causes. It must be long and complex.

Currently, specific and non-specific treatment is used.

Non-specific treatment includes a number of measures aimed at improving the general condition of the body:

proper, nutritious nutrition, breastfeeding or adapted mixtures, timely introduction of complementary foods, and it is best to give the first such children vegetable puree from zucchini or broccoli;
to correct the mother's nutrition if the child is on breastfeeding;
compliance with the daily routine of the child according to his age;
long walks in the fresh air with sufficient insolation, avoiding direct sunlight;
regular airing of the room and its maximum natural light;
obligatory daily classes in therapeutic exercises and a course of massage;
air baths;
daily bathing in coniferous or herbal baths to calm the nervous system.

Specific Therapy rickets is the appointment of vitamin D, as well as drugs, which include calcium and phosphorus. Currently, there are many medicines containing vitamin D. But, in any case, they are prescribed only by a doctor, based on the condition of the child. Doses are selected individually, taking into account the severity of the disease. Usually, 2000-5000 IU (international units) are prescribed per day, the course is 30-45 days.

The most common drugs:

Aquadetrim is an aqueous solution of vitamin D 3. It is well absorbed, does not accumulate in the body and is easily excreted by the kidneys. Suitable for both treatment and prevention of rickets.
Videin, Vigantol, Devisol are oil solutions of vitamin D. They are hypoallergenic, suitable for children allergic to Aquadetrim. But they should not be given to babies suffering from or having problems with absorption.

After the end of specific treatment, the doctor may prescribe vitamin D preparations for prevention, but in much lower doses. Usually 400-500 IU per day is enough, which is given to the baby for two years and in the third year of life in the autumn-winter period.

Prevention of rickets

Important role in the prevention of rickets plays breastfeeding.

Prevention of rickets should begin long before the birth of the child, even during pregnancy. Therefore, all preventive measures are divided into two groups - before and after the birth of the baby.

During pregnancy, a woman must observe the following rules:

a complete fortified diet;
prolonged exposure to fresh air;
moderate physical exercise: special exercises for pregnant women with the permission of the supervising doctor;
reception of complex vitamin preparations throughout pregnancy, especially in the last trimester;
regular medical supervision to prevent complications during and after childbirth.

Prevention of rickets in a child:

mandatory prophylactic intake of vitamin D if the child was born in autumn or winter (the doctor prescribes the dose and drug); the duration of the course of prevention is 3-5 months;
proper nutrition, optimally - breastfeeding;
strict observance of the daily routine;
long walks in the fresh air, avoiding direct sunlight on children's skin;
air baths;
daily bathing;
gymnastics;
conducting massage courses;
complete nutrition of a nursing mother, rich in vitamins; with the permission of a doctor, taking multivitamin complexes.

Summary for parents

Rickets, like many other diseases, is much easier to prevent than to cure. Be attentive to the appointments of the pediatrician, do not forget to give healthy the child prescribed for a long time "droplets" - vitamin D preparations. These "droplets" will keep your baby healthy and save him from the occurrence of rickets - a rather severe disease, as you have seen.

Which doctor to contact

Treatment and prevention of rickets is carried out by a pediatrician. In severe disorders of the musculoskeletal system, an orthopedic consultation is indicated, with the development iron deficiency anemia- hematologist. If the lack of vitamin D is associated with intestinal diseases, you should contact a gastroenterologist. Violation of the formation of jaws and teeth can be corrected by a dentist.

Health status small child largely depends on what parents feed him, how long they walk with him on the street and how accurately they follow the recommendations of the pediatrician. If the baby is constantly at home, does not receive mother's milk, if complementary foods are not introduced into his diet in a timely manner, and all nutrition is limited to cow's milk or milk mixtures that are unbalanced in composition, he may develop rickets.

Rickets is a disease associated with a deficiency and violation mineral metabolism in organism. Children of the first year of life suffer from rickets, and among the sick most of all are premature babies and "artificial" (children who eat milk mixtures).

For the life of a child, rickets does not pose a danger, but in the absence of adequate treatment, this disease can leave a mark on itself for life - noticeable skeletal deformities, malocclusion, flat feet and other similar disorders.

Causes and mechanisms of development of rickets

It is known that calcium, phosphorus and vitamin D are necessary for the formation of a full-fledged bone tissue, which ensures the absorption of the first two substances in the intestine. All these compounds enter the child's body with food (breast milk, yolk, vegetable oil, fish, vegetables, etc.), and vitamin D is also synthesized in the skin under the influence of sunlight.

Newborn babies are born already with a supply of calcium, phosphorus, vitamin D (these substances are especially actively accumulated in the body of the fetus in recent weeks intrauterine life, but only on condition that the mother eats properly and regularly walks on the street), so up to 1-2 months their bone tissue develops normally. Subsequently, both because of the depletion of reserves and because of active growth, the child's body begins to need more and more more"building" material. If this need is not met, calcium and phosphorus are washed out of the bones. Because of this, the bone tissue becomes less dense and easily deformed. Hence all the unpleasant manifestations of rickets from the side of the skeleton.

In addition to the effect on bone tissue, the violation of phosphorus-calcium metabolism negatively affects the condition of the muscles and nervous system of the child. Patients have a delay in psychomotor development, muscle hypotension and other pathological symptoms.

Thus, the main cause of rickets is a deficiency of vitamin D, and a lack of calcium and phosphorus also plays a certain role in the development of the disease. There is such scarce state in the following cases:

If the child does not receive all the substances he needs with food. For example, when parents replace breast milk with unbalanced formulas or cow's milk when complementary foods are introduced late (after 6-8 months), when cereals, especially semolina, dominate in the baby's diet.
If the child's skin is not exposed to sunlight for a long time.
If the processes of digestion of food and absorption of nutrients are disturbed in the intestines (if the child has diseases gastrointestinal tract, even the most complete diet will not reduce the risk of developing rickets).

Risk factors for rickets

Apart from obvious reasons For rickets, a number of risk factors can be identified:

Prematurity (children born prematurely do not have time to make “reserves” of useful substances - this is, firstly, secondly, they have problems with the intestines and, in general, with the digestive system as a whole much more often).
The large weight of the newborn (the larger the baby, the more nutrients and vitamins he needs).
Multiple pregnancy. Babies born from such a pregnancy, as a rule, begin to feel a lack of calcium and phosphorus even in utero. In addition, these babies are more likely to be born prematurely.
Congenital disorders of the digestive system.
Dark skin color (in dark children, the skin produces less vitamin D).

The first signs of rickets, which parents should definitely pay attention to:

Increased sweating of the baby (mother should be alerted that even when it is cool, the baby sweats on the forehead and nose during feeding, that his arms and legs sweat a lot, etc.).
Poor sleep, causeless anxiety, startle.
Baldness of the neck.
Constipation (with rickets, hypotension of the muscles develops, including the intestinal wall, so peristalsis weakens, which leads to a delay in feces).

These symptoms may appear as early as 3-4 months of a child's life. If the disease is detected at this stage (it is called the initial stage) and treated, there will be no negative consequences for the baby's health. If this moment is missed, the disease will progress (it will go into the stage of peak), and the child will have more serious symptoms of the pathology:

Deformities of the skull, limbs and torso. An indicative sign is a flattened occiput, big forehead, O- or X-shaped change of legs, etc.
Severe muscle weakness, due to which another indicative symptom appears - "frog belly".
Lagging behind in motor development (the child does not begin to hold his head, roll over, sit, although his peers are already doing all this, etc.).
Late teething.
Various disorders of the internal organs (primarily the gastrointestinal tract).

Gradually, the child's condition, of course, improves (the stage of recovery begins about 6-7 months after the onset of the disease), but the formed bone deformities do not disappear completely, with many of them children remain for life. This is a narrow pelvis, and large frontal tubercles, and malocclusion, and a deformed chest (compressed laterally and protruding forward), and flat feet.

Diagnostics

Diagnose Rickets experienced doctor maybe, as they say, by eye, but to confirm the diagnosis, you still need to go through one simple study -. This is a qualitative test for calcium in the urine taken from the baby before the first morning feeding. For the analysis, you should prepare (purchase a urinal to make it more convenient to collect the urine of the child, make some dietary restrictions, etc.).

In severe cases, when doctors need to find out the degree of violation of phosphorus-calcium metabolism and the depth of bone tissue damage, the patient undergoes a more extensive examination, including:

Blood tests for electrolytes (calcium and phosphorus), alkaline phosphatase activity (an indicator of bone breakdown), and vitamin D metabolites.
Determination of calcium and phosphorus content in daily urine.
Ultrasound of the bones of the forearm.
X-ray (in Lately rarely used).

Treatment of rickets

It is necessary to treat children with rickets in a complex way, using specific and non-specific methods(be sure to take into account the cause of the disease).

Non-specific methods are nutrition, and the correct daily routine of the child, and various restorative procedures (massage, gymnastics, herbal, salt and coniferous baths, etc.). TO specific methods include the appointment of vitamin D, calcium and phosphorus preparations, artificial skin irradiation with ultraviolet radiation (recently used less and less and mainly in premature babies).

Nutrition and daily routine

The nutrition of children with rickets should be aimed at providing the body with all essential substances. For babies up to a year the best food is breast milk. If it is not possible to breastfeed the baby, you should choose adapted milk formulas, cow's and goat's milk is not suitable for this.

It is also important to introduce complementary foods in a timely manner, since the needs of the child are growing every month, and the amount of nutrients in women's milk, on the contrary, decreases every month. Therefore, pediatricians do not recommend exclusive breastfeeding after 6 months of age.

For a child with rickets, the first complementary foods can be introduced as early as 4 months, and it is better if it is a vegetable puree, to which over time it is necessary to add natural sources vitamin D - vegetable oil, egg yolk, and after 7-8 months - fish and meat. In addition, a sick baby needs fruit purees and juices, as well as cottage cheese and dairy products. But with cereals, especially manna, it is better to wait a little.

As for the daily routine, it should be organized in such a way that the child is outside for at least 2 hours a day. Moreover, it is not necessary to expose the baby to direct sunlight (this is even harmful), the light breaking through the greenery of the trees will be sufficient.

In addition, you should do exercises with your child, take him for a massage (or do it yourself after consulting a specialist). Also, children with rickets are shown saline, herbal, coniferous baths(which one to choose, the doctor will tell). After such procedures, the child will eat and sleep better.

Medical treatment of rickets

The basis of this treatment is the intake of vitamin D, and what drug to use and the dose should be prescribed only by a pediatrician, since with rickets it is dangerous as small dose medicines (there will be no effect), and overestimated (there will be hypervitaminosis).

In addition to vitamin D, I can prescribe calcium and phosphorus preparations to the baby (it is not advisable to take them without vitamin D). Premature babies are often recommended complex medications, in which, in addition to vitamin D, there are other vitamins, as well as all the necessary minerals.

Rickets is one of the diseases, the development of which is very easy to prevent with the help of a number of preventive measures. These measures include:

In addition, the prerequisites for a healthy future mother can give her child during pregnancy. To do this, a woman needs to eat a balanced diet, walk more in the air and take vitamin and mineral complexes, if they are prescribed by a doctor.

Rickets is a disease of children under three years of age associated with a lack of vitamin D, in which phosphorus-calcium metabolism is disturbed and specific damage to bone tissue occurs. Rickets is a state of a growing organism, since changes occur precisely in the growth zones. It is very important to deliver on time correct diagnosis(in the early stages, the symptoms of rickets are similar to those of malabsorption, phosphate diabetes, de Toni-Debre-Fanconi syndrome) and start treatment, since some disorders in the structure of bones and changes in internal organs can persist for life.

What are the signs of rickets in children?

At the initial stage, rickets affects the nervous system, and the first signs may appear in a child as early as the age of two to three months. Most often these are sleep disturbances, irritability, tearfulness, frequent shudders, poor appetite, big size fontanel, excessive sweating, baldness of the neck. If measures are not taken in time, the baby may begin to have disturbances in the bone tissue, softening of the bones of the skull and, as a result, flattening of the head, seals on the ribs (the so-called "rachitic rosary") and on the wrists ("rachitic bracelets"), curvature spine ("rachitic hump"), chest, pelvis and legs (X- and O-shaped), develop flat feet and malocclusion.

Why is rickets dangerous?

With an expanded form of rickets, a delay in psychomotor development is possible - the child begins to roll over, crawl, sit, walk late. Weakness of the muscles (“frog belly”) is also often noted, increased mobility in the joints, late teething. May reduce immunity and resistance to disease. In advanced stages, rickets can lead to dysfunction of internal organs - the liver, lungs, heart, gastrointestinal tract. Some changes in bones can last for a very long time or even last a lifetime.

What tests are required to make a diagnosis?

As a rule, the diagnosis of "rickets" is made when examining a child. Sometimes the doctor prescribes additional tests. In some cases, there is biochemical research blood (with rickets, alkaline phosphatase increases, the level of phosphorus decreases, less often - calcium). Urinalysis according to Sulkovich is now practically not used. X-ray of the bones of the skeleton is performed with rapidly progressing and non-treatable forms of rickets ( hereditary forms D-dependent and D-resistant forms of rickets; if these diseases are suspected, a number of additional biochemical tests are performed).

How to protect a child from rickets?

Prevention of rickets should begin already during pregnancy. The expectant mother should walk every day, take multivitamins. The cause of congenital rickets in a child can be late toxicosis in the mother. Preventive measures against rickets include daily walks, regular gymnastics, massage, swimming, timely introduction. For children older than 6 months, baths with sea salt. Prophylactic intake of vitamin D or other multivitamins is best started only after consulting a pediatrician - this is especially important for artificial children, since most milk formulas contain vitamin D.

How to treat rickets in a child?

Treatment of rickets must necessarily be complex - specific (drug) and non-specific (properly organized daily routine, walking, long-term, proper nutrition, massage and swimming). As the first complementary food for children with rickets, vegetable puree is recommended (from six months) followed by the addition of egg yolk to it (from seven to eight months). You should limit the amount of flour products, as they impair the absorption of calcium in the intestines. specific treatment rickets is the appointment of vitamin D, as well as calcium and phosphorus preparations. Calculate the dosage and duration of administration can only pediatrician. Incorrect dosage can lead to hypervitaminosis D, which is also a serious disease.

Can rickets be vaccinated?

All vaccinations for rickets can be done.

What are the main causes of rickets?

Pathologies of pregnancy, incorrect, lack of sun, prematurity, large body weight of the child at birth, multiple pregnancy, artificial feeding, late or incorrect introduction of complementary foods, hereditary predisposition.

What foods contain vitamin D?

Vitamin D is found in dairy products, butter, fish oil, egg yolk, vegetable oil, liver, wheat germ, nuts and other products. Vitamin D is produced naturally in the human body by exposure to sunlight.

Rickets is a disease that is associated with an insufficient amount of vitamin D in the body of a newborn. Alas, it is still found in our kids. The disease is dangerous for the little man, as it disrupts calcium-phosphorus metabolism. To notice the symptoms in time and start treatment is the primary task of parents and doctors.

What is rickets in children up to a year. Stages of development of the disease

The formation of the baby's bone tissue, which began in the womb, continues throughout the first year after birth. With a lack of vitamin D, the baby may develop rickets - a dangerous childhood disease accompanied by softening musculoskeletal tissue. As a result, the child's bones are bent, and the normal functioning of a number of internal organs is disrupted.

Rickets can be recognized by a variety of signs.

This and softening around a large fontanelle of bone tissue , an increase in the frontal tubercles and a thickening of the occiput. Subsequently, the curvature of the bones begins.
Malfunctions in the work of the central nervous system . The baby often cries, gets scared for no reason, becomes lethargic.
The child develops unreasonable sweating . The baby's head is often wet, usually after feeding or sleeping.
Weakening of muscle tone , manifested in flabbiness of the muscular system;
appearance skin itching and hair loss.
Slowdown of physical development.
Late teething.
Dense formations on the ribs baby (rachitic rosary).

The first symptoms of the disease may appear as early as 2-3 months. Sometimes babies are born with initial signs rickets.

The disease is divided into 3 stages

Light form when minor changes are noticeable on the part of the muscle tissue. The disease lasts from a week to a month, then progresses to next stage. At timely treatment passes without consequences for the health of the crumbs.
Medium when the deformation of the limbs and skull of the baby is clearly noticeable.
Severe form manifested by softening and deformation of the bones not only of the limbs, but also of the chest. At the same time, it is difficult for the baby to breathe, he has a disorder in the work of all internal organs.

Why is my child diagnosed with rickets? Understanding the reasons

Why in our time, when replenishing the body with the missing vitamins and minerals is not difficult, children are still diagnosed with rickets?

Certain categories of children are primarily at risk.

premature babies in which, due to the underdevelopment of a number of body functions, the absorption and assimilation of vitamin D is difficult.
big kids born with high birth weight and requiring high content D vitamins in the body.
Babies deprived of breast milk and receiving nutrition in which there is not enough phosphorus-calcium elements.
Babies breastfed by mother , but at the same time she eats improperly, which is why the milk lacks substances that ensure the healthy development of the crumbs.

It may happen that the diagnosis is made erroneously, based on only one of the signs. To complete the picture, the doctor must prescribe a series of tests to determine the content of calcium and phosphorus in the blood, the activity of alkaline phosphatase.

Allow to clarify the diagnosis and x-ray, ultrasound data.

The signs by which the doctor diagnoses rickets may correspond to others, no less dangerous. Therefore, in order to understand what exactly the little man is sick with, accurate diagnosis is so important.

What signs determine rickets in a child up to a year

The first symptoms of the disease appear on

The child is often naughty and sleeps little.
If you carefully consider a large fontanelle and feel its edges, you will notice marked thinning of the bone tissue .
The child has increased sweating , which is accompanied by a sour smell, as well as itching, especially in the back of the head. The baby feels discomfort and rubs his head against the pillow. At the same time, his hair is worn out.
Rickets manifests itself slower bone growth especially the legs. The baby has a growth retardation and a distortion of body proportions.
Possible muscle hypotonia or looseness of the joints, an increase in the size of the tummy.
Decreases physical activity crumbs , the child becomes lethargic and phlegmatic, does not eat well.

To more late manifestations rickets refers to limb deformity . The baby's legs are bent, forming the letters O or X. In the area of \u200b\u200bthe shins and forearms, rickety bracelets are observed - thickenings on the bone tissue.

Children who have rickets, lying on their backs, easily pull the leg to the head and can even put the heel on their shoulder.

How to treat rickets in babies

If the diagnosis of the disease is confirmed, treatment should be started immediately.

You need to start with non-specific forms of treatment - a properly balanced diet and regimen.

The kid should walk in the fresh air for at least 4 hours a day . In spring and summer, he needs to be in the sun more often.
The best food for babies is mother's milk , which contains the necessary amount of phosphorus and potassium. If breastfeeding is not possible, you need to use mixtures that are adapted to the child's body and contain a complete set of vitamins and minerals needed by the baby.
A sick child needs to introduce complementary foods on time from one-component puree (broccoli, zucchini), gradually add butter and vegetable oil, fruits, juices, cereals, vegetables, cottage cheese and meat products to baby food.
Daily baths are beneficial for a child. coniferous extract or saline solution calming the nervous system and supporting the immune system.
Massage and hardening will help to quickly cope with the disease.

Drug treatment is carried out as prescribed by the pediatrician and under his supervision. The baby is prescribed medications that contain vitamins of group D, calcium and phosphorus.

Recently, doctors prefer to prescribe vitamin D in the form of aqueous solution, since it is quickly absorbed into the baby's blood and does not lead to gastric disorders. (Akvadetrim). Oil solutions(Videhol, Vigantol or other drops) are prescribed to children if they are allergic to water preparations.

These medicines regulate the exchange of phosphorus and calcium in the body and contribute to the formation of bones and teeth.

When treating a baby, it is important to strictly observe the dosage of the medicine that the attending physician prescribes, based on the stage of the disease. For each child, the dose is selected individually. This takes into account age, heredity, diet and other factors.

As a rule, the daily dose of the drug is from 2 to ten drops. Begin treatment with a minimum dose, gradually increasing it to a therapeutic norm that can produce a therapeutic effect.

If taking vitamin D does not lead to the desired result, then the baby lacks not only this drug, but also other vitamins. In this case, he is prescribed multivitamins (Biovital gel, Multitabs and other children's vitamin preparations).

For complex treatment rickets crumbs are prescribed physiotherapy exercises and massage sessions, which are selected based on the condition of the child and the stage of the disease. Massotherapy activates metabolic processes in the skin. This helps the body produce vitamin D.

When conducting therapeutic exercises, you need to remember that a sick baby gets tired quickly, so it is advisable to strictly dose the exercises.

IN exercise therapy classes be sure to include exercises that develop proper breathing. To do this, very young children lightly press on the chest, for a grown-up baby they combine pressure with crossing the arms.

Since children become excitable with rickets, more stroking exercises are used during massage sessions, reducing or eliminating shock and patting techniques.

Prevention of rickets in children up to a year

It is necessary to engage in the prevention of rickets not from the first days of a child's life, but at a time when he is still in the womb. Then the probability of occurrence of the disease will be minimized. The exception is congenital rickets, when the mother's pregnancy is very difficult, for example, with a prolonged period of toxicosis.

In other cases, if the mother walked a lot during pregnancy, went in for physical education, ate well and took multivitamin complexes, the baby’s body received everything necessary for its healthy development even before birth. Among these children, the incidence of rickets is significantly reduced.

Preventive measures to prevent rickets in infants are carried out from the age of three weeks. At this time, the pediatrician prescribes the baby 2 drops of Aquadetrim per day.

In addition, doctors recommend once a month to take a urine test (Samples according to Sulkovich) to determine the amount of calcium in it. This study should not be neglected, since with non-specific prophylaxis there may be an overdose of vitamin D. This is also harmful for child's body as its disadvantage.

Dr. Komarovsky advises children from 6 months of age to use sea salt baths as preventive measures.

It is impossible to leave rickets without attention and treatment, since the consequences of this unsafe disease will remain in a person for life, making their own unpleasant and sometimes unsafe adjustments. Start taking care of your baby from the first days of pregnancy!

Proper nutrition of a pregnant woman, nursing mother and child is the key to the health of the baby and eliminates the development of rickets.

source of vitamin D during prenatal development is the placenta postnatal period- mother's milk and synthesis in the skin under the influence of sunlight. The concentration of vitamin D in infants up to 2 months. correlates with its levels in their mothers. In the following months and years of life, the determining factors are nutrition and exposure to sunlight. Given this, maternal vitamin D deficiency, as well as exclusive breastfeeding without vitamin D supplementation, are significant risk factors for rickets in early childhood.

The most common factors of rickets in developed countries are presented. It should be noted that one of them is exclusive breastfeeding. Mother's milk is unquestionably ideal nutrition for an infant, however, it contains only 15-10 IU / l of vitamin D. As for the effect of sunlight, to ensure normal level vitamin D fully clothed the child should be outside 2 hours a week, and in children with dark skin this time can increase by 6-10 times. Sunscreens and other products with a 15 filter reduce vitamin D synthesis by ~98%. The American Academy of Pediatrics recommends keeping babies under 6 months of age. out of direct sunlight and wear protective clothing and protective cosmetical tools to prevent sunburn and reduced risk of skin cancer. This, again, increases the risk of vitamin D deficiency.

The causes of rickets may be low vitamin content in the diet; lagging behind in growth and development; chronic systemic diseases that can affect vitamin D metabolism; long-term medication (antikolvunsantiv, corticosteroids). During history taking, all of the following factors should be considered. possible cause rickets. History should also include data on gestational age, exposure to sunlight, and the area in which the child lives. For the implementation of differential diagnosis, it is necessary to find out the presence in the family history of short stature, alopecia, dental deformities, orthopedic anomalies and marriages between blood relatives. Special attention should be addressed for orthopedic problems and symptoms associated with hypoxia (muscular, paresthesia, tetany and convulsions). IN differential diagnosis late neonatal seizures should also take into account hypocalcemia, which is a consequence of vitamin D deficiency in the mother.

Cause of Vitamin D Deficiency

Associated with effects on vitamin D synthesis
Increased skin pigmentation
Physical factors that block exposure to UV rays
Sunscreens (protection factor > 8)
Clothing that blocks the rays
Stay in the shade
Features of the area of residence, time of year
Geographic latitude greater than 40° (both north and south)
Polluted air, frequent cloudy weather, high altitude
winter season
Withdrawal from sunlight for fear of getting cancer
Inadequate dietary intake of vitamin D
Maternal vitamin D deficiency and exclusive breastfeeding
premature birth
Malabsorption
celiac disease
cystic fibrosis
Atresia of the bile ducts
Reduced intensity of synthesis or elevated level decay 25(OH)D
Chronic liver disease
Medications (rifampicin, isoniazid, anticonvulsants)
Genetic factors

Physical examination

Rickets is a disease of a growing organism; therefore, deformations and clinical signs are more manifested by the skeletal system, it begins to grow actively. Growth is slowed down due to malnutrition and hypothyroidism, so the clinical signs of rickets in such cases are less pronounced. The clinical picture of rickets depends on the stage and, most likely, on the duration of vitamin D deficiency. In stage I, symptoms of hypocalcemia predominate. Skeletal deformities become evident at the stage of IS and increase at the stage of IS.

If rickets is suspected, a physical and dental examination should be performed, bones should be palpated to identify possible sensitivity or deformation.

Skeletal manifestations of rickets include craniotabes in infants 2–3 months of age, late fontanelle closure, hand enlargement, rickety rosary, late dentition, caries, enamel hypoplasia, type B or X leg deformity, kyphosis and a narrow pelvis (which can make childbirth difficult in the future), chest deformity (Harrison's sulcus and chicken breasts), rib fractures or lower extremities(especially greenstick fractures) square head, protruding frontal tubercles, osteoclasts and pain in the extremities. Deformities caused by osteomalacia of the lower extremities (tibia or thigh bones), occur as soon as the child begins to walk. Knee varus occurs when the distance between the hip bones exceeds 5 cm. This deformity is most common in infants with untreated rickets. Knee valgus and other bone deformities tend to appear later in life. Kyphoscoliosis due to rickets occurs after 2 years of age. Rachitic "beads", which occur as a result of hypertrophy of the costal-cartilaginous joints, are clearly manifested after 1 year.

Manifestations of rickets from other systems include hypocalcemic convulsions, hypotension, constipation, proximal myopathy, heart failure, anemia, pancytopenia, cardiomyopathy, qualitative intracranial hypertension lagging behind in development and growth. BK Bhakri et al. (2010) described a case of myelofibrosis associated with rickets and accompanied by anemia and hepatosplenomegaly in a 10-month-old boy who was breastfed. Treatment with vitamin D reduced the size of the liver and spleen, the severity of rickets and anemia, improved growth parameters and developed. Rickets is also an important and modified factor in the development of dilated cardiomyopathy in children.

TD Thacher et al. (2002) conducted a study that included 738 children aged 18 months and older. with rickets. The authors concluded that among all clinical signs wrist enlargement along with rickety "rosary" is the most sensitive parameter on physical examination. E. Orhan (2006) found that rachitic "rosary" (62.1%), craniotabes (49%), occipital alopecia (31.4%) and enlargement of the hands (27.1%) were common signs, appeared during physical examination in children 0-6 months. In this study, the positive predictive value of a physical examination for the diagnosis of rickets in children 0-6 months of age. was 60.9%, and the negative predictive value was 74.6%. So, the diagnosis of rickets in the early childhood only on the basis of a physical examination can give false results.

Lab tests

In patients who are suspected of having rickets based on clinical picture, the diagnosis should be confirmed by biochemical and radiological data. Table 2 lists the limits for vitamin D according to the Lawson Wilkins Pediatric Endocrine Society. According to the society's definition, severe vitamin D deficiency is defined as a 25(OH)D level below 5 ng/mL. The PD Robinson study (2006) reported that 86% of children with 25(OH)D levels below 8 ng/ml had clinical rickets, and 94% of children with hypocalcemia and vitamin D deficiency had levels below 8 ng/ml. Before vitamin D deficiency manifests clinically and radiographically as rickets, certain time. During this period, hypo- / normo / hypercalcemia may occur, high levels parathyroid hormone, normo/hypophosphatemia, high levels of alkaline phosphatase, high/normal/low levels 1.25(OH)2D; subclinical rickets progresses to clinical (stages I-III). In 60% of cases of rickets due to vitamin D deficiency, hypocalcemia is observed, and alkaline phosphatase activity is high in almost all cases. Calcium and phosphorus levels are low, and parathyroid hormone and alkaline phosphatase levels are high, especially in stage III rickets. Because most cases of rickets in early childhood are stage i, clinical and radiological findings may not be obvious. In addition, although hypocalcemia is the main laboratory manifestation in these cases, serum phosphorus levels may be normal or high, and alkaline phosphatase levels may be within normal limits.

X-ray examination

Early radiological manifestations of rickets are limited to the distal ulnar area in infants and the metaphysis of the knee in older children. First, there is an "enlightened" line, which is the result of the formation of a non-calcified area between the epiphysis and metaphysis. In classical cases, there is an increase in metaphyses, the irregularity of their edges, thyroid view, concavity and general osteopenia. On the other hand, certain radiological changes may be absent in early childhood and adolescence.

The scale developed by Thacher is used to assess the severity of rickets radiographically. However, the use of this scale in young children may not be practical. Distortions, fractures of tubular bones, loss of costal-cartilaginous joints (rachitic "rosary") also appear on x-rays of children with rickets. 3-4 weeks after the start of therapy, radiography can be performed: a conditional line of calcification at the ends of the metaphyses will indicate a positive dynamics of treatment.

Treatment

The main goal of rickets therapy is to correct clinical, biochemical and radiological changes and restore vitamin D reserves. To do this, prescribe an inactive form of vitamin D (cholecalciferol [vitamin D 3 ] or ergocalciferol [vitamin D 2 ]). It is believed that vitamin D 3 is 3 times more powerful than vitamin D 2 , so vitamin D 3 should be preferred.

Long-term therapy at low doses. There are different views on the dosage and duration of vitamin D therapy. Typically, vitamin D is prescribed at a dose of 1000-10,000 IU / day, depending on age, for 2-4 months. For example, according to the age of the child, the dosage might be: 1000 IU/day for infants up to 1 month old, 1000-5000 IU/day for children from 1 to 12 months old, 5000 IU/day for children from 12 months old, 10,000 IU/day for teenagers. After normalization of laboratory parameters, a course of maintenance therapy at a dose of 400 IU / day is recommended. After such treatment, the levels of calcium and phosphorus are normalized within 6-10 days, and the concentration of parathyroid hormone reaches normal levels in 1-2 months. Depending on the severity of the disease, the normalization of serum alkaline phosphatase and the disappearance of radiographic signs of rickets may take 3 months. It should be remembered that the lack of compliance is important reason lack of response to treatment.

Short-term therapy with high doses (stoss therapy). For patients after 1 year of age who are suspected of poor compliance, high doses (100,000-600,000 IU) of vitamin D orally or intramuscularly can be administered once or over 1-5 days, if necessary after 3 months. you can repeat the high dose. There are reports that the introduction of 600,000 units of vitamin D to newborns with rickets causes hypercalcemia. According to Y. Cesur et al. (2003), 150,000-300,000 units of vitamin D is a safe and effective treatment. A single intramuscular dose of 300,000 IU of vitamin D has also been found to be effective in cases of nutritional malnutrition with rickets. In addition, the effectiveness of the introduction of 100,000 IU of vitamin D every 2:00 during the day. Such treatment caused a rapid clinical response, restoration of biochemical parameters after a few days and radiological after 10-15 days.

Some authors recommend calcium treatment for 1-2 weeks in patients without symptoms of hypocalcemia to provide elemental calcium, although the appropriateness of this approach is controversial. Parenteral calcium is usually given as calcium gluconate (1-2 ml/kg of 10% calcium gluconate at 10-20 mg/kg of elemental calcium) intravenously slowly over 5-10 minutes. The appointment of calcium is necessary if there are signs of tetany or a trial. In such cases, calcium levels should be maintained with oral medications.

Prevention

Most physiological method prevention of deficiency/deficiency is to educate society, the purpose of which is to realize that mothers and babies should be sufficiently exposed to sunlight and have balanced diet food rich in vitamin D and calcium. Identifying the causes of maternal vitamin D deficiency and taking action to address them is essential to prevent rickets in young children.

Earlier in the US, the recommended dose of vitamin D was 100-200 IU/day to prevent rickets. In 1963, the American Academy of Pediatrics issued a protocol that for the prevention of rickets, vitamin D at a dose of 400 IU / day should be given to the child, starting from the second month of life. The latest guidelines from the American Academy of Pediatrics, approved in 2008, are:

For the prevention of vitamin D deficiency and rickets in newborns, children and adolescents minimum dose 400 IU/day of vitamin D.
Vitamin D at a dose of 400 IU / day should be added to the diet of infants who are exclusively or partially breastfed until they begin to receive at least 1 liter of formula per day.
Vitamin 400 IU/day should be given to all infants who consume less than 1 liter of formula milk per day and are not receiving breast milk. Evaluation of vitamin D content in other types of food that a child may receive should be carried out on an individual basis.
Vitamin D at a dose of 400 IU/day should be given to all children who do not receive this dose from milk or other foods fortified with vitamin D.
According to the latest data, the serum 25(OH)D level should be above 20 ng/ml, especially in infants and children.
Vitamin D 400 IU/day should continue to be given to children in cases of malabsorption of fat, chronic use of anticonvulsants, and other conditions that may increase the risk of vitamin D deficiency. In these cases, high doses of vitamin D may be necessary to maintain normal levels in blood serum.

In Canada, the prophylactic dose of vitamin D is 800 IU/day in winter and 400 IU/day in summer, in Bulgaria it is 800 IU/day whole year, in Romania - 400 IU / day. The Turkish Ministry of Health recommends at least 400 IU/day of vitamin D from birth (regardless of feeding type) to 1 year of age. It should be noted that this dose of vitamin D prevents the onset of clinical signs of rickets, but is not able to prevent the development of vitamin D deficiency.

Today, vitamin D prophylaxis is understood not only to prevent clinical rickets, but also to maintain an optimal serum 25(OH)D level to avoid vitamin D deficiency. Normal 25(OH)D values are necessary to achieve peak bone mass and prevent undesirable consequences vitamin D deficiency, such as diabetes and certain oncological diseases. It is reported that the prophylactic dose of vitamin D, capable of providing an optimal level of serum 25 (OH) D (28-32 ng / ml), should be in the range from 400 to 1000 IU / day. In order to prevent rickets at an early age, vitamin D at a dose of 2000 IU / day is recommended for women in the third trimester of pregnancy who are not sufficiently exposed to sunlight or have high risk vitamin D deficiency. Many studies have shown that a daily dose of 2000 IU of vitamin D is not toxic in either adults or children.

The need of the child's body is growing, in vitamin D has not been precisely established. However, it is clear that children need high doses vitamin than recommended today. Mothers have the choice to give their baby more calcium-fortified foods and to take her out in the sun more to get vitamin D and calcium naturally.

Clinical case

IN medical Center a 6-month-old boy, black (African American), was examined for examination, whose mother complained about poor growth child. According to the mother, the patient received adequate nutrition, was defined as consumption of 4 ounces (≈ 115 g) of expressed breast milk every 2-3 hours. The boy had a height and weight inappropriate for his age, although other key developmental parameters were normal. The child was exclusively breastfed, and complementary foods had not yet been introduced.

The boy was full-term, born spontaneously through the birth canal; There were no complications during pregnancy or childbirth. During a 2 month visit life indicators of height and body weight corresponded to the 50th percentile, and then decreased to the 3rd percentile (Fig. 1). The patient did not receive medical treatment. He didn't have any siblings who had growth problems. Mother did not have postpartum depression but was not dependent on any substances. Mother and father are of normal height. There is no family history of malabsorption.

The boy did not experience vomiting, diarrhea, fever, change in appetite, swallowing disorder, respiratory symptoms, apnea, repeated acute diseases or frequent injury.
During a visit for a routine examination at the age of 4 months. weight was 6477 g, and height - 63.5 cm. These figures increased, respectively, to 6761 g and 66 cm at 6 months of age. All other vital signs were stable. The child was lively, playful, with normal development but was small for her age. Examination of the head/neck, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and nervous systems revealed no abnormalities.

Thus, the patient was diagnosed with a delay in physical development based on deviation from standard growth curves. The child's need for weight gain was estimated at 0.33 kg/month. A re-examination was scheduled after one month. During this month, the child was to receive solid complementary foods and expressed milk with the addition of formula milk to increase its calorie content. Mothers were also advised to keep a food diary.

Despite taking in adequate calories and additional use milk formula, the desired weight gain has not been achieved. The child underwent the following laboratory tests: metabolic profile, levels of thyroid-stimulating hormone, lead, complete blood count. Indicators of electrolytes, kidney function, bilirubin, AST, ALT, protein, albumin, thyroid-stimulating hormone, lead and complete blood count were within normal limits. The activity of alkaline phosphatase was increased to 4280 (when measured again - up to 6310). Normally, this figure should be less than 500 IU / l in newborns and 1000 IU / l in children under 9 years old. Repeated lab tests included measurements of glutamyltransferase (which was within normal limits, possibly through bone resorption), C-reactive protein, triiodothyronine, free thyroxine, phosphates, parathyroid hormone and 25 (OH) D. The level of phosphates was 2.9 (normal should be 3-4.5), and vitamin D - 11 (normal 45-50 ng / ml).

X-ray examination showed typical bilateral changes in the bones of the limbs, characteristic of rickets: wear of the metaphysis and concavity in the distal parts of the femur, proximal and distal parts of large, small tibia And humerus, distal parts of the radius and ulna, and distal parts of the 2-5 metacarpal bones (Fig. 2). According to the literature data, with rickets, separation of the periosteum from the diaphysis due to bone demineralization can also be observed. Positive changes to x-ray should appear within 3 months. after the start of appropriate treatment. If there are no such changes, malabsorption syndrome or poor adherence to treatment should be suspected. A month after the start of therapy, laboratory tests of calcium, phosphorus, alkaline phosphatase are also prescribed, and after 3 months. - Indicators of magnesium, parathyroid hormone and 25 (OH) D.

Thus, the boy was diagnosed with rickets. The patient is prescribed 2000 IU of vitamin D and 1000 mg of calcium daily. On the advice of an endocrinologist and a nutritionist, the boy also started taking ferrous sulfate 22 mg daily and zinc 20 mg daily. At the age of two years, the boy's body weight corresponded to the 45th percentile of age norms, and height - to the 30th percentile. An increase in the concentration of vitamin D in the blood up to 29 ng/ml was observed. Vitamin D intake was extended.