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TC(991).(05).Orthopedics Case No 69.Rickets

Rickets — রিকেটস

Definition: Rickets হলো growing child-এর metabolic bone disease, যেখানে growth plate ও osteoid mineralization ব্যর্থ হয়—সাধারণত vitamin D, calcium অথবা phosphate deficiency/imbalance-এর কারণে। ফলে bone soft, weak ও deformable হয়ে যায়। Diagnosis সাধারণত clinical signs + wrist/knee X-ray changes + raised ALP দিয়ে করা হয়।

1. Cause / Etiology — কারণগুলো

A. Nutritional rickets — সবচেয়ে common

  • Vitamin D deficiency: কম sunlight exposure, indoor lifestyle, covered clothing, dark skin, exclusive breastfeeding without vitamin D, maternal vitamin D deficiency।
  • Dietary calcium deficiency: দুধ/ডিম/মাছ/ক্যালসিয়াম-rich food কম খাওয়া।
  • Prematurity / low birth weight: mineral reserve কম থাকে।
  • Malabsorption: celiac disease, chronic diarrhea, cholestasis, pancreatic disease।
  • Drug-induced: anticonvulsants যেমন phenytoin/phenobarbital, glucocorticoid, rifampicin/isoniazid, cholestyramine, orlistat—vitamin D absorption/metabolism কমাতে পারে।

B. Renal / genetic rickets

  • Chronic kidney disease–mineral bone disorder
  • Renal tubular acidosis / Fanconi syndrome
  • Hypophosphatemic rickets / XLH
  • Vitamin D–dependent rickets type 1A/2A
  • ২০টির বেশি acquired/hereditary cause আছে, তাই non-response হলে biochemical ও genetic workup দরকার।

Pathophysiology — Core meaning

Vitamin D কম হলে intestine থেকে calcium ও phosphate absorption কমে → PTH বাড়ে → kidney দিয়ে phosphate loss হয় → growth plate mineralization fail করে → wrist/ankle widening, bowing, delayed growth হয়।

2. Symptoms / Clinical Features — লক্ষণগুলো

Infant

  • Craniotabes: skull soft feel করে।
  • Delayed fontanelle closure
  • Frontal bossing: কপাল উঁচু।
  • Delayed tooth eruption / enamel defect
  • Hypocalcemic seizure বা tetany হতে পারে।
  • Irritability, delayed motor milestone।

Older child

  • Wrist/ankle swelling — metaphysis widening-এর জন্য।
  • Bowed legs / knock-knee / genu varum-valgum
  • Rachitic rosary: costochondral junction বড় হয়ে bead-like chest।
  • Harrison sulcus / pigeon chest
  • Bone pain, tenderness।
  • Muscle weakness, waddling gait, walking delay
  • Growth failure / short stature।
  • Recurrent fracture বা bone deformity।

3. Clinical Diagnosis — clinically কীভাবে ধরবেন

রিকেটস সন্দেহ করবেন যদি child-এর মধ্যে থাকে:

  • Age: সাধারণত ৬ মাস–৩ বছর বা rapid growth period।
  • Risk factor: exclusive breastfeeding without D, poor diet, low sunlight, malabsorption, CKD, anticonvulsant use।
  • Examination:
    • wrist/ankle widening
    • leg bowing
    • rachitic rosary
    • frontal bossing/craniotabes
    • delayed walking/growth failure
  • Confirmation:
    • X-ray wrist/knee: metaphyseal cupping, fraying, splaying, widened growth plate।
    • Serum ALP high — active rickets-এর strong biochemical clue।

4. Investigations — specific list

First-line tests

  • Serum calcium
  • Serum phosphate
  • Serum alkaline phosphatase — ALP
  • Serum 25-hydroxyvitamin D — 25(OH)D
  • PTH
  • Albumin — corrected calcium হিসাবের জন্য।
  • Magnesium
  • Urea/creatinine/eGFR
  • LFT
  • Urine calcium/creatinine ratio
  • Urine phosphate ± TmP/GFR — hypophosphatemic rickets সন্দেহে।
  • X-ray wrist ± knee AP view — best screening radiograph।
  • ABG/electrolytes — renal tubular acidosis সন্দেহে।
  • Genetic test — recurrent/non-responsive/family history/very low phosphate with renal phosphate wasting হলে। Monitoring-এ growth, leg bowing, bone pain, serum phosphate, calcium, ALP, PTH, 25(OH)D and calciuria দেখা উচিত।

Typical lab pattern

  • Nutritional vitamin D deficiency: 25(OH)D low, ALP high, PTH high, phosphate low, calcium low/normal।
  • Calcium-deficiency rickets: calcium intake low, ALP high, PTH high; 25(OH)D normal বা low হতে পারে।
  • Hypophosphatemic rickets: phosphate low, ALP high, calcium usually normal, 25(OH)D normal, renal phosphate wasting present।

5. Differential Diagnosis

  • Physiological bowing
  • Blount disease
  • Osteogenesis imperfecta
  • Skeletal dysplasia
  • Non-accidental injury / child abuse
  • Hypophosphatasia — ALP low থাকে, রিকেটসের মতো high নয়
  • CKD–mineral bone disorder
  • Renal tubular acidosis / Fanconi syndrome

6. Complications — রোগের জটিলতা

  • Permanent bone deformity: untreated থাকলে bow legs/knock knees স্থায়ী হতে পারে।
  • Short stature / growth failure
  • Delayed walking and motor development
  • Hypocalcemic seizure, tetany, laryngospasm
  • Recurrent fracture
  • Dental enamel defect, delayed dentition, dental caries
  • Chest deformity: recurrent chest infection risk বাড়তে পারে।
  • Pelvic deformity: মেয়েদের future obstructed labour risk হতে পারে।
  • Severe বা resistant rickets হলে chronic bone pain ও disability হতে পারে।

7. Treatment Management — Guideline-based

A. Nutritional rickets — main treatment

Vitamin D3 + calcium একসাথে দিতে হবে। Global consensus অনুযায়ী nutritional rickets treatment-এ minimum vitamin D 2000 IU/day for at least 3 months এবং oral calcium 500 mg/day routinely দেওয়া উচিত, age/weight যাই হোক।

Practical regimen

  • Cholecalciferol/Vitamin D3: 2000 IU/day PO for 3 months
    অথবা adherence problem হলে specialist-supervised weekly high-dose regimen ব্যবহার করা যায়।
  • Elemental calcium: 500 mg/day PO for at least 3 months; diet poor হলে longer।
  • Maintenance after healing: infant 400 IU/day; older child/adolescent 600–1000 IU/day depending risk। AAP recommends 400 IU/day from soon after birth for infants/children/adolescents to prevent deficiency.
  • Follow-up: 4–6 week পর Ca, PO₄, ALP, PTH; 3 month পর X-ray/ALP improvement।

8. Pharmacological drugs — Bangladesh prescription-style list

নিচের drug doseগুলো clinical education-এর জন্য। Child-এর weight, serum calcium/phosphate/PTH, renal function ও rickets type অনুযায়ী dose adjust করতে হবে।

1) Generic name: Cholecalciferol / Vitamin D3

  • Therapeutic category: Vitamin in bone formation
  • Pharmacological class: Vitamin-D preparation / fat-soluble vitamin
  • কেন use হয়: intestinal calcium-phosphate absorption বাড়ায়, bone mineralization restore করে, nutritional rickets-এর first-line drug। MedEx-এ Vitamin D3 rickets/osteomalacia prevention-এর জন্য indicated।
  • Dose & duration:
    • Nutritional rickets: 2000 IU/day PO × minimum 3 months
    • Alternative: 50,000 IU once weekly × 6 weeks বা high-dose regimen — specialist supervision
    • Maintenance: 400–1000 IU/day
  • Side effects: nausea, vomiting, constipation, abdominal pain, headache, anorexia; overdose হলে hypercalcemia, polyuria, thirst, renal stone/calcification।
  • Drug interaction:
    • Phenytoin/barbiturate ↓ vitamin D effect
    • Glucocorticoid ↓ effect
    • Cholestyramine/paraffin oil ↓ absorption
    • Digoxin/cardiac glycoside + hypercalcemia → arrhythmia risk
    • Thiazide diuretic + vitamin D → hypercalcemia risk।
  • Bangladesh available brand examples from MedEx:
    • D3 — 200 IU/ml pediatric drop, 2000 IU tablet, 20000 IU capsule, 40000 IU capsule, 200000 IU/ml oral/IM solution — ACI
    • D-Balance — 2000 IU, 20000 IU, 40000 IU, 50000 IU capsule; 200000 IU/ml; 2000 IU/ml solution — Square
    • D-Rise — 1000 IU chewable, 2000 IU tablet, 20000/40000/50000 IU capsule, 200000 IU/ml, 2000 IU/ml solution — Beximco
    • Osteo-D — 200 IU/ml drops, 1000/2000 IU chewable, 20000/40000 IU capsule, 200000 IU/ml, 2000 IU/ml oral solution — Incepta
    • Vita D3 — 1000/2000 IU tablet, 20000/40000 IU capsule, 200000 IU/ml — Renata
    • Radivit-D — 2000 IU tablet, 20000/40000/50000 IU capsule — Radiant
    • Padi-D — 400 IU/ml oral solution — Drug International; PD3 — 400 IU/ml oral solution — Pharmik

2) Generic name: Calcium carbonate

  • Therapeutic category: Minerals in bone formation
  • Pharmacological class: Specific mineral preparation
  • কেন use হয়: calcium deficiency correct করে; vitamin D therapy-এর সাথে দিলে bone mineralization দ্রুত improve হয়। MedEx calcium carbonate class হিসেবে minerals in bone formation উল্লেখ করে।
  • Dose & duration:
    • Target: elemental calcium 500 mg/day PO × at least 3 months
    • Severe dietary calcium deficiency হলে 500–1000 mg/day divided dose, dietary intake অনুযায়ী।
  • Side effects: constipation, bloating, GI irritation; high dose/renal disease হলে hypercalcemia, nephrolithiasis।
  • Drug interaction: tetracycline/quinolone antibiotic, iron, zinc, levothyroxine, bisphosphonate absorption কমায়—২–৪ ঘণ্টা gap; digoxin ব্যবহার করলে calcium monitor।
  • Bangladesh available brand examples:
    • A-Cal 500 mg — ACME
    • Acical 500 mg / Acical Jr 250 mg — ACI
    • Calbo 500 mg / Calbo Jr 250 mg — Square
    • Calcicar 500 mg — Incepta
    • Calcin 500 mg — Renata
    • Calcid 1000 mg chewable — Opsonin
    • Cal 250/500 mg — Pacific
    • Calcium-A 500 mg — Ad-din
    • Caldil 500 mg — Drug International

3) Generic name: Conventional Calcium + Vitamin D3

  • Therapeutic category: Specific mineral & vitamin combined preparation
  • Pharmacological class: Calcium salt + vitamin D preparation
  • কেন use হয়: maintenance/adjuvant হিসেবে; osteomalacia/rickets/tetany/parathyroid disease-এ MedEx indication উল্লেখ করে।
  • Dose & duration: সাধারণত 1 tab OD/BID; তবে active rickets-এর initial high-dose vitamin D requirement পূরণে শুধু 500 mg + 200 IU tablet যথেষ্ট নয়।
  • Side effects/interactions: calcium ও vitamin D-এর মতোই—constipation, hypercalcemia; tetracycline/quinolone/iron/thyroxine absorption কমে।
  • Bangladesh available brand examples:
    • Calbo-D 500 mg + 200 IU — Square
    • Calcin-D 500 mg + 200 IU / Calcin-DX 600 mg + 400 IU — Renata
    • Calvimax D 500 mg + 200 IU — Incepta
    • Ostocal D 500 mg + 200 IU / Ostocal DX 600 mg + 400 IU — Eskayef
    • Oscal-D Forte 600 mg + 400 IU — UniMed UniHealth
    • Calfix-D 500 mg + 200 IU / Calfix-Dx 600 mg + 400 IU — Maks
    • Ipical-D 500 mg + 200 IU / Ipical DX 600 mg + 400 IU — Ibn Sina
    • Protebon-D 500 mg + 200 IU — Beacon

4) Generic name: Calcitriol

  • Therapeutic category: Vitamin-D preparation
  • Pharmacological class: Active vitamin D analogue
  • কেন use হয়: nutritional rickets-এর routine first-line নয়; CKD-related rickets, hypoparathyroidism, vitamin D–dependent rickets, severe hypocalcemia with impaired activation—এগুলোতে specialist use করে। Calcitriol intestinal calcium absorption ও bone mineralization regulate করে।
  • Dose & duration:
    • Initial: 0.25 mcg/day PO, response না হলে 2–4 week interval-এ titrate।
    • Many cases: 0.25 mcg BID used.
    • Genetic/hypophosphatemic rickets: specialist dose, e.g., calcitriol 20–40 ng/kg/day divided; phosphate co-therapy may be needed।
  • Side effects: hypercalcemia, hypercalciuria, vomiting, constipation, weakness, nephrocalcinosis।
  • Interaction: thiazide ↑ hypercalcemia; digoxin arrhythmia risk; magnesium antacid avoid in renal failure; calcium/vitamin D high dose together হলে toxicity risk।
  • Bangladesh available brand examples:
    • Calcitrol 0.25 mcg capsule — Square
    • Colitrol 0.25 mcg capsule / 1 mcg/ml IV — Incepta
    • Dicaltrol 0.25 mcg capsule — Drug International
    • Caltrol 0.25 mcg capsule / 1 mcg/ml IV — Pacific
    • Raditrol 0.25 mcg capsule — Radiant
    • Improcal 0.25 mcg capsule — Opsonin

5) Generic name: Alfacalcidol

  • Therapeutic category: Vitamin-D preparation
  • Pharmacological class: Vitamin D analogue / prodrug of calcitriol
  • কেন use হয়: CKD/mineral bone disease, vitamin D activation problem, selected refractory rickets—specialist indication। Alfacalcidol calcium/phosphorus absorption বাড়ায় এবং bone pain/muscle weakness improve করতে পারে।
  • Dose & duration: specialist titration; commonly 25–80 ng/kg/day in selected hypophosphatemic/genetic protocols; serum Ca/PO₄/PTH/urine Ca monitor।
  • Side effects: hypercalcemia, hypercalciuria, nephrocalcinosis, nausea, constipation।
  • Bangladesh available brand:
    • Viva-D pediatric drops 2 mcg/ml
    • Viva-D capsule 1 mcg — Incepta

6) Generic name: Calcium gluconate injection

  • Therapeutic category: Minerals in bone formation
  • Pharmacological class: Injectable calcium salt
  • কেন use হয়: রিকেটসের সাথে acute symptomatic hypocalcemia, seizure, tetany, laryngospasm হলে emergency correction। MedEx calcium gluconate severe hypocalcemic tetany/vitamin D deficiency indications উল্লেখ করে।
  • Dose: acute severe hypocalcemia হলে hospital setting-এ 10% calcium gluconate IV slow with ECG monitoring; pediatric dose institution protocol অনুযায়ী। IV calcium bolus-এ ECG monitoring recommended।
  • Side effects: rapid IV দিলে nausea, vomiting, flushing, sweating, hypotension, arrhythmia, tissue necrosis/extravasation risk।
  • Interaction: digoxin/cardiac glycoside use করলে arrhythmia risk; ceftriaxone-calcium incompatibility neonate-এ avoid।
  • Bangladesh available brand example:
    • Cal. Gluconate Injection 500 mg/5 ml — Edruc Ltd.

9. Bangladesh doctors commonly prescribe — practical prescription list

  • Nutritional rickets:
    • Cholecalciferol/Vitamin D3: D3 / D-Rise / D-Balance / Osteo-D / Vita D3 / Radivit-D
    • Plus calcium carbonate: Calbo / Calcicar / Calcin / A-Cal
    • কারণ: vitamin D deficiency + calcium deficiency একসাথে correct করতে।
  • Mild deficiency / prevention / maintenance:
    • D3 drops 400 IU/day equivalent, Padi-D 400 IU/ml, PD3 400 IU/ml, Osteo-D drops
    • কারণ: recurrent deficiency prevent করতে।
  • Older child/adolescent poor compliance:
    • D-Balance 50000 IU / D-Rise 50000 IU / Radivit-D 50000 IU / Defrol 50000 IU weekly regimen
    • কারণ: adherence ভালো হয়; তবে overdose risk আছে, monitoring দরকার।
  • Calcium support:
    • Calbo 500, Calcin 500, Calcicar 500, Acical Jr 250
    • কারণ: bone mineralization-এর substrate calcium দিতে।
  • CKD/genetic/refractory rickets:
    • Calcitriol: Calcitrol, Colitrol, Dicaltrol
    • Alfacalcidol: Viva-D
    • কারণ: kidney activation defect বা vitamin D–dependent state-এ active vitamin D দরকার।
  • Seizure/tetany:
    • Calcium gluconate IV
    • কারণ: acute hypocalcemia দ্রুত correct করতে।

10. Prevention — কীভাবে রিকেটস প্রতিরোধ করবেন

  • জন্মের কয়েক দিনের মধ্যে breastfed infant-কে Vitamin D 400 IU/day শুরু করা।
  • মা pregnant/lactating হলে vitamin D deficiency screen/treat করা, বিশেষ করে low sunlight বা poor diet থাকলে।
  • প্রতিদিন safe sunlight exposure: সকাল/বিকেলের mild sun; sunburn এড়াতে হবে।
  • diet:
    • দুধ, দই, cheese
    • ডিমের কুসুম
    • oily fish
    • fortified milk/cereal
    • calcium-rich local food
  • prolonged exclusive breastfeeding হলে vitamin D drop miss করা যাবে না।
  • chronic diarrhea, liver disease, renal disease, anticonvulsant use থাকলে periodic 25(OH)D, Ca, PO₄, ALP monitor।
  • high-dose vitamin D OTC হিসেবে বারবার দেওয়া যাবে না—hypercalcemia/nephrocalcinosis হতে পারে।

Overview / Summary

Rickets হলো growing child-এর mineralization failure। Commonest cause হলো vitamin D deficiency ± calcium deficiency। Diagnosis: clinical deformity + high ALP + X-ray wrist/knee metaphyseal cupping/fraying/widening। Main treatment: Vitamin D3 + elemental calcium, আর renal/genetic rickets হলে calcitriol/alfacalcidol ± phosphate specialist supervision-এ।

Actionable Plan / Steps

  1. Child suspected rickets হলে: Ca, PO₄, ALP, PTH, 25(OH)D, creatinine, urine Ca/Cr + X-ray wrist/knee করুন।
  2. Nutritional rickets হলে: Vitamin D3 2000 IU/day × 3 months + elemental calcium 500 mg/day × 3 months শুরু করুন।
  3. 4–6 week পর Ca/PO₄/ALP/PTH recheck করুন; ALP না কমলে adherence, malabsorption, renal/genetic cause দেখুন।
  4. Severe hypocalcemic seizure/tetany হলে hospitalize করে IV calcium gluconate with ECG monitoring দিন।
  5. Maintenance prevention: infant/child 400 IU/day minimum, adequate calcium diet, safe sunlight।

Reference List — Textbook + Guideline + DOI

Textbooks

  • Nelson Textbook of Pediatrics, latest edition: “Rickets and Vitamin D Deficiency,” Pediatric Endocrinology/Bone metabolism section.
  • Harrison’s Principles of Internal Medicine, latest edition: “Osteomalacia and Vitamin D Deficiency.”
  • Davidson’s Principles and Practice of Medicine, latest edition: “Metabolic Bone Disease.”
  • Robbins & Cotran Pathologic Basis of Disease, latest edition: “Bone and mineral metabolism disorders.”
  • Guyton and Hall Textbook of Medical Physiology, latest edition: “Parathyroid hormone, calcitonin, calcium and phosphate metabolism.”

Guidelines / Consensus

  • Global Consensus Recommendations on Prevention and Management of Nutritional Rickets, 2016 — minimum vitamin D 2000 IU/day and calcium 500 mg/day for treatment. DOI: 10.1210/jc.2015-2175 / 10.1159/000443136.
  • Endocrine Society Clinical Practice Guideline, Vitamin D Deficiency, 2011. DOI: 10.1210/jc.2011-0385.
  • Endocrine Society Vitamin D for Prevention of Disease Guideline, 2024.
  • American Academy of Pediatrics: Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents, Pediatrics 2008. DOI: 10.1542/peds.2008-1862.

Peer-reviewed reviews / DOI

  • Haffner D, et al. Rickets guidance: part I—diagnostic workup. Pediatric Nephrology. 2022. DOI: 10.1007/s00467-021-05328-w.
  • Haffner D, et al. Rickets guidance: part II—management. Pediatric Nephrology. 2022. DOI: 10.1007/s00467-022-05505-5.
  • Baroncelli GI, et al. Diagnosis, treatment, and management of rickets. Frontiers in Endocrinology. 2024. DOI: 10.3389/fendo.2024.1383681.
  • Carpenter TO, et al. Rickets. Nature Reviews Disease Primers. 2017. DOI: 10.1038/nrdp.2017.101.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday Time:-2-40-27 Pm

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