Symptoms of rickets

Rickets is a disease of the whole organism with significant dysfunction of a number of organs and systems. The first clinical symptoms of rickets are found in children 2-3 months old. In premature babies, the disease manifests earlier (from the end of the 1st month).

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Disorders of mineral metabolism in rickets

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Calcipenic rickets

In addition to classic bone changes with a predominance of osteomalacia, symptoms of increased excitability (hand tremor, sleep disturbance, unmotivated anxiety) are noted. Children also have a pronounced disorder of the autonomic nervous system (increased sweating, tachycardia, white dermographism).

A biochemical blood test reveals a high concentration of parathyroid hormone and a low concentration of calcitonin against the background of a significant decrease in calcium levels. Increased calcium excretion in the urine is characteristic.

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Phosphopenic rickets

General lethargy, inhibition, pronounced muscle hypotonia and weakness of the ligamentous apparatus, “frog belly”, and signs of osteoid tissue hyperplasia are noted.

Characteristic features include severe hypophosphatemia, high levels of parathyroid hormone and calcitonin in the blood serum, and hyperphosphaturia in the urine.

Rickets without significant changes in calcium and phosphorus concentrations in the blood

Patients with this form of rickets, as a rule, do not have distinct clinical changes in the nervous and muscular systems. The disease is characterized by a subacute course with signs of osteoid tissue hyperplasia (parietal and frontal tubercles).

Symptoms of rickets: damage to the nervous system

Functional disorders of the nervous system are the initial symptoms of rickets. They manifest themselves as anxiety, tearfulness, sleep disturbances, twitching in sleep, and severe sweating. The head sweats especially heavily in the occipital region. Sticky sweat irritates the skin, causing itching. The child rubs his head against the pillow, and as a result, the back of the head becomes bald - a characteristic sign of incipient rickets.

An important symptom of rickets from the nervous system is hyperesthesia. Often, when trying to pick up the child, he cries and worries.

In severe rickets, changes in the central nervous system are observed: general motor retardation, children become sedentary, slow, and the development of conditioned reflexes is difficult.

Symptoms of rickets: damage to the skeletal system

The entire skeleton is affected, but clinical manifestations are more pronounced in those bones that grow most intensively at a given age. Thus, when rickets occurs in the first 3 months of life, changes are manifested in the bones of the skull. When the disease develops from 3 to 6 months, changes are found in the bones of the chest. When rickets affects children over 6 months, the bones of the limbs and pelvis are affected. There are 3 types of bone changes:

• osteomalacia;
• osteoid hyperplasia;
• osteoporosis.

Symptoms of Osteomalacia

• Damage to the cranial bones. Softening of the edges of the large fontanelle and sutures, craniotabes [areas of softening of the body of the cranial bone (most often the occipital bone is affected)] are noted. The sensation obtained when pressing on these areas can be compared to pressing on parchment or a felt hat. Softness of the cranial bones leads to its deformations: flattening of the back of the head or the lateral surface, depending on how the child lies more.
• Damage to the bones of the chest. As a result of softening of the ribs, a Harrison groove is formed (at the place of attachment of the diaphragm, a retraction of the ribs is noted, the lower aperture of the chest is deployed), curvature of the clavicles. The chest is compressed from the sides, the sternum protrudes forward or sinks in.
• Damage to the bones of the extremities. Their curvature is noted. The child's legs acquire an O- or X-shape.

Manifestations of osteoid hyperplasia

• Damage to the bones of the skull. An increase in the frontal, parietal, and occipital tubercles is noted.
• Damage to the bones of the chest. Formation of rachitic "rosary" on the ribs (V-VIII ribs) at the transition point of bone tissue to cartilage.
• Lesions of the limb bones. The appearance of "bracelets" in the wrist area, "strings of pearls" on the fingers.

Changes in the skeletal system in rickets

Skeletal department	Bone deformities
Head	Craniotabes (softening of areas of the parietal bones, less commonly - areas of the occipital bone) Deformation of the bones of the skull Frontal and parietal tubercles Violation of the relationship between the upper and lower jaws Late closure of the large fontanelle, disruption of teeth eruption (untimely, incorrect), defects in tooth enamel, tendency to caries
Rib cage	Deformation of the clavicles (increased curvature) Rib beads (hemispherical thickening at the junction of the cartilaginous part of the rib with the bone) Expansion of the lower aperture and narrowing of the upper one, compression of the chest from the sides Scaphoid depressions on the lateral surfaces of the chest Deformation of the sternum ("chicken breast", "shoemaker's chest")
Spine	Kyphosis in the lower thoracic region Kyphosis or lordosis in the lumbar region Scoliosis in the thoracic region
Pelvic bones	Flat pelvis Narrowing of the entrance to the pelvis
Lower limbs	Curvature of the hips forward and outward Various curvatures of the lower limbs (0- or X-deformations, K-shaped) Deformations in the joint area
Upper limbs	Curvature of the humerus and forearm bones Deformation in the area of the joints: “bracelets” (thickening in the area of the wrist joints), “strings of pearls” (thickening in the area of the diaphysis of the phalanges of the fingers)

Muscular system

Important symptoms of rickets are weakness of the ligamentous apparatus and muscle hypotonia. Weakness of the ligamentous apparatus leads to "looseness" of the joints, which enables the patient to perform movements of a greater volume (for example, lying on the back, the child easily pulls the foot to the face and even throws it behind the head). The patient's posture is characteristic - he sits with crossed legs and supports the body with his hands. Hypotonia of the muscles of the anterior abdominal wall is manifested by flattening of the abdomen with divergence of the rectus muscles ("frog belly"). Static functions are impaired: children begin to hold their heads up, sit, stand, walk later, and they develop a "rickety hump".

Dysfunction of other organs and systems

• In some children, hypochromic anemia is detected during the peak of rickets.
• Enlargement of the liver and spleen (hepatosplenic syndrome) is often noted.
• Changes in the chest and muscle hypotonia lead to respiratory disorders in rickets of grades II-III. Children develop shortness of breath, cyanosis, and pulmonary ventilation is impaired. Areas of atelectasis in the lungs may develop, predisposing to the development of pneumonia.
• Disturbances in chest excursion and insufficient contraction of the diaphragm lead to hemodynamic disturbances, which are manifested by tachycardia, muffled heart sounds, and functional systolic murmur.
• In some cases, pathology of the digestive and urinary systems is noted.

Periods of rickets

The period of the disease is determined by the clinical picture, the degree of osteomalacia and biochemical changes.

Symptoms of rickets in the initial period

It most often occurs in the 2nd-3rd month of life and lasts from 2-3 weeks to 2-3 months.

Disturbances of the autonomic nervous system are characteristic, and only at the end of this period do changes in the skeletal system appear in the form of flexibility of the edges of the large fontanelle and the sagittal suture.

From the muscular system, hypotension and constipation are noted.

A biochemical blood test shows a slight decrease in phosphorus content, while calcium levels remain normal. An increase in alkaline phosphatase activity is characteristic.

Symptoms of rickets during the peak period ("blooming" rickets)

Progression of lesions of the nervous and skeletal systems is typical. Bone changes come to the fore. All 3 types of changes are noted (osteomalacia, osteoid hyperplasia, osteogenesis disorder), but their severity depends on the severity and course of the disease.

In addition, the peak period is characterized by:

• distinct muscle hypotonia;
• weakness of the ligamentous apparatus;
• enlargement of the liver and spleen;
• hypochromic anemia;
• functional disorders of other organs and systems.

The number of systems involved and the severity of their changes depend on the severity of the process.

Biochemical blood tests reveal significantly reduced levels of calcium and phosphorus and increased alkaline phosphatase activity.

Symptoms of rickets during the convalescence period

The reverse development of rickets symptoms is noted. The symptoms of nervous system damage disappear first, then the bones become denser, teeth appear, changes in the muscular system disappear (static and motor functions are normalized), the size of the liver and spleen decreases, and dysfunctions of internal organs are restored.

Phosphorus levels increase to normal values; calcium concentration may remain reduced, alkaline phosphatase activity is increased.

Symptoms of rickets in the period of residual effects

It is observed in children over 2-3 years old. During this period, only the consequences of rickets in the form of bone deformation remain, which indicate that the child has suffered from the disease in a severe form (grade I or III). No deviations in laboratory indicators of mineral metabolism are noted.

Due to subsequent processes of bone tissue remodeling, which are most active after 3 years, deformations of tubular bones disappear over time. Deformations of flat bones decrease, but remain. In children who have had rickets, enlargement of the parietal and frontal tubercles, flattening of the occiput, malocclusion, deformations of the chest and pelvic bones persist.

Severity of rickets

I degree (mild)

A small number of weakly expressed signs of rickets from the nervous and skeletal systems with the involvement of the 1-2 sections of the skeleton. Sometimes, mild muscle hypotonia is observed.

After stage I rickets, no residual effects are observed.

II degree (moderate severity)

III degree (severe)

Nowadays it is almost never encountered. It manifests itself with significant changes in the central nervous system: sleep disturbance, appetite disturbance, lethargy, delay in speech development and motor skills. Changes in the skeletal system have the character of multiple, clearly expressed deformations (softening of the bones of the skull base, sunken bridge of the nose, "Olympic" forehead, gross deformation of the chest, limbs, pelvic bones). Bone fractures without displacement or with angular displacement are possible. There are pronounced changes in the muscular system (impaired static functions). The liver and spleen significantly increase in size, there are distinct functional disorders of the cardiovascular system, respiratory organs. Gastrointestinal tract, severe anemia.

The nature of the course of rickets

Acute course

Rapid increase in symptoms, prevalence of osteomalacia processes over osteoid hyperplasia processes. It is observed more often in the first half of life, especially in premature, overweight, and frequently ill children.

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Subacute course

Slow development of the disease. Symptoms of osteoid hyperplasia are mainly noted: frontal and parietal tubercles, "rosary" on the ribs, "bracelets", "strings of pearls". Craniotabes is not typical. More common after 6 months in children with increased nutrition and in those who have received insufficient amounts of vitamin D to prevent rickets.

Relapsing course

Periods of improvement are followed by exacerbations of the rachitic process. This may be due to early interruption of treatment, the presence of concomitant diseases, or poor nutrition. A characteristic radiographic symptom of rickets is the appearance of ossification bands in the bone growth zone, the number of which corresponds to the number of exacerbations.

Principles of classification of rickets

Severity

• I degree - mild.
• II degree - moderate severity.
• III degree - severe.

Period of illness

• Initial manifestations.
• The height of it.
• Subsidence.
• Convalescence.
• Residual effects.

Nature of the flow

• Spicy.
• Subacute.
• Recurrent.

Nature of mineral metabolism disorder

• Calcipenic rickets.
• Phosphopenic rickets.
• Rickets without significant changes in calcium and phosphorus content.

Examples of diagnosis formulation

• Rickets I, initial period, acute course.
• Rickets I, peak period, subacute course.
• Rickets I, convalescence period, subacute course.
• Rickets II, peak period, acute course.
• Rickets II, peak period, relapsing course.
• Rickets III, peak period, acute course.

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