Rickets – the disease of a fast-growing organism which is characterized by violation of mineral exchange and a kosteobrazovaniye. Rickets is shown by multiple changes from the musculoskeletal device (a softening of flat bones of a skull, flattening of a nape, deformation of a thorax, a curvature of tubular bones and a backbone, muscular hypotonia, etc.), nervous system, internals. The diagnosis is established on the basis of identification of layoboyorayotoryony and rentgenoloyogiyocheyosky maryokeyor of rickets. The Speyotsiyofiyocheyosky teyorayopiya of rickets assumes nayoznayocheyony vitamin D in a complex with leyochebyony bathtubs, masyosazhy, gymnastics, Ural federal district.
Rickets – a polietiologichesky disease of a metabolism which cornerstone the imbalance between the need of a children's organism for mineral substances (phosphorus, calcium, etc.) and their transportation and metabolism is. As rickets deyot aged from 2 months up to 3 years have preiyomuyoshcheyostyovenyono, in pediatrics often call it "a disease of the growing organism". At children of advanced age and adults for designation of a similar state use terms an osteomalyation and osteoporosis.
In Russia prevalence of rickets (including its easy forms) makes 54-66% among the full-term children of early age and 80% - among premature. Most of children in 3-4 months has 2-3 unsharply expressed symptoms of rickets in this connection some pediatricians suggest to consider this state as paraphysiological, boundary (similar to diathesis - to anomalies of the constitution) which is independently liquidated in process of an organism growing.
Pathogenesis of rickets
The defining role in development of rickets belongs ekzo-or to endogenous deficiency of vitamin D: to insufficient formation of a holekaltsiferol in skin, to insufficient intake of vitamin D with food and a nayoruyosheyoniya of its meyotayoboyolizyom that leads to disorder of phosphorus-calcium exchange in a liver, kidneys, intestines. Besides, development of rickets is promoted also by other metabolic violations – disorder of exchange of protein and minerals (magnesium, iron, zinc, copper, cobalt, etc.), activization of perekisny oxidation of lipids, polyvitaminic insufficiency (deficiency of vitamins A, B1, B5, B6, C, E) and so forth.
Serve as the main physiological functions of vitamin D (more precisely – its active metabolites of a 25-gidroksikholekaltsiferol and a 1,25-digidroksikholekaltsiferol) in an organism: strengthening of absorption of salts of calcium (Ca) and phosphorus (P) in intestines; an obstacle to removal of Ca and P with urine due to strengthening of their reabsorption in tubules of kidneys; mineralization of a bone tissue; stimulation of formation of erythrocytes, etc. At hypovitaminosis of D and rickets all above-mentioned processes are slowed down that leads to a gipofosfatemiya and a gipokaltsiyemiya (to the lowered maintenance of P and Ca in blood).
Owing to a gipokaltsiyemiya by the principle of feedback develops secondary . Increase in production of paratireoidny hormone causes Ca exit from bones and maintenance of its rather high level in blood.
Change of acid-base balance towards acidosis interferes with adjournment of connections P and Sa in bones that is followed by violation of calcification of the growing bones, their softening and tendency to deformation. Instead of a full-fledged bone tissue in zones of growth osteoidny not calciphied fabric which expands in the form of thickenings, hillocks etc. is formed.
Except mineral exchange, at rickets also other types of exchange are broken (carbohydrate, proteinaceous, fatty), disorders of function of nervous system and internals develop.
Development of rickets is more connected not with exogenous deficiency of vitamin D, and with its insufficient endogenous synthesis. It is known that more than 90% of vitamin D are formed in skin owing to insolation (Ural federal district) and only 10% arrive from the outside with food. In total 10-minute local radiation of the person or hands is capable to provide synthesis of the vitamin D level necessary for an organism. Therefore rickets meets at the children born in the fall and in the winter when solar activity is extremely low more often. Besides, rickets is most widespread among the children living in regions with a frigid climate, insufficient level of natural insolation, frequent fogs and overcast, an unsuccessful ecological situation (smog).
Meanwhile, hypovitaminosis of D is the leading, but not the only reason of rickets. Deficiency of salts of calcium, phosphates and others osteotropny micro and macrocells, vitamins can be caused in children of early age by multiple rakhitogenny factors. As the most strengthened receipt of Ca and P to a fruit is noted last months pregnancies, premature children are more inclined to development of rickets.
The increased physiological need for mineral substances in the conditions of intensive growth contributes to developing of rickets. Deficiency of vitamins and minerals in an organism of the child can be a consequence of the wrong diet of the pregnant woman or the feeding woman, or the baby. Violation of absorption and transportation of Ca and P is promoted by immaturity of fermental systems or pathology of a GIT, liver, kidneys, thyroid and parathyroid glands (gastritis, dysbacteriosis, a malabsorption syndrome, intestinal infections, hepatitis, an atresia of bilious ways, HPN, etc.)
Children with the unsuccessful perinatal anamnesis treat risk group on development of rickets. As adverse factors from mother serve gestoza of pregnant women; a hypodynamia during pregnancy; expeditious, stimulated or rapid childbirth; the age of mother is younger 18 and 36 years are more senior; ekstragenitalny pathology.
From the child a part in development of rickets can be played the big weight (more than 4 kg) at the birth, an excessive increase in weight or a hypotrophy; early transfer to the artificial or mixed feeding; restriction of the motive regime of the child (too hard swaddling, lack of baby massage and gymnastics, need of a long immobilization at a dysplasia of coxofemoral joints), reception of some drugs (phenobarbital, glucocorticoids, heparin, etc.). The role of gender and hereditary factors is proved: so, boys, children with swarty skin, II (And) a blood type are more predisposed to development of rickets; less often rickets occurs among children with the I (0) blood type.
Classification of rickets
Etiologichesky classification assumes allocation of the following forms of rickets and rakhitopodobny diseases:
- Vitamin - D-scarce rickets (kaltsiypenichesky, fosforopenichesky option)
- Vitamin - D-dependent (pseudo-scarce) rickets at genetic defect of synthesis in kidneys of a 1,25-digidroksikholekaltsiferol (type 1) and at genetic resistance of receptors of target organs to a 1,25-digidroksikholekaltsiferol (type 2).
- Vitamin of D-resistant rickets (congenital gipofosfatemichesky rickets, disease to Debre-de-Tony-Fankoni, gipofosfataziya, renalny tubulyarny acidosis).
- Secondary rickets at gastrointestinal diseases, kidneys, a metabolism or induced by medicines.
The clinical course of rickets can be sharp, subsharp and recidivous; severity – easy (I), medium-weight (II) and heavy (III). In development of a disease allocate the periods: initial, heat of a disease, convalescence, residual phenomena.
The initial stage of rickets falls on the 2-3rd month of life, and at premature in the middle-the end of the 1st month of life. Changes are early signs of rickets from nervous system: a playokyosiyovost, fearfulness, concern, hyper excitability, a superficial, disturbing dream, chayosyoty a vzdrayogiyovayoniya in a dream. At the child perspiration, osoyobenyono in the field of a hairy part of the head and a zayotylyok amplifies. Kleyyoky, with a sourish smell sweat razyodrayozhat a koyozha, causing emergence of a resistant intertrigo. Friction by the head about a pillow leads to education on a nape of the centers of baldness. From bone and muscular system emergence of muscular hypotonia (instead of a physiological hyper tone of muscles), a pliability of cranial seams and edges of a fontanel, thickenings on edges ("rachitic beads") is characteristic. the periyooyoda of rickets soyostayovyolyayot current duration 1–3 months.
In the period of a heat of rickets which usually falls on the 5-6th month of life, progressing of process of an osteomalyation is noted. As the investigation of a sharp course of rickets the softening of cranial bones () and unilateral flattening of a nape can serve; deformation of a thorax with a vdavleniye ("the shoemaker's breast") or a breast vybukhaniye (a keeled breast); formation of a kifoz ("a rachitic hump"), is possible - a lordoza, scoliosis; Au-shaped curvature of tubular bones, flat-footedness; formation of a ploskorakhitichesky narrow basin. Except bone deformations, rickets is followed by increase in the liver and spleen expressed by anemia, a muscular gipotoyoniya ("lyayoguyoshayochy" zhiyovoyoty), suyosyotayov.
At the subsharp course of rickets there is a hypertrophy of frontal and parietal hillocks, a thickening of interphalanx joints of fingers of hands ("pearls thread") and wrists ("brasletka"), costal and cartilaginous joints ("rachitic beads").
Changes from internals at rickets are caused by acidosis, a gipofosfatemiya, disorders of microcirculation and can include short wind, tachycardia, a loss of appetite, an unstable chair (diarrhea and locks), pseudo-ascites.
In the period of a convalescence the dream is normalized, perspiration decreases, static functions, laboratory and radiological data improve. The period of the residual phenomena of rickets (2-3 years) is characterized by residual deformation of a skeleton, muscular hypotonia.
At many children rickets proceeds benign and is not diagnosed at children's age. The children having rickets often have a SARS, pneumonia, bronchitis, infections of urinary tract, atopic dermatitis. Close connection of rickets and a spazmofiliya (a children's tetaniya) is noted. Further at the children who had rickets violation of terms and the sequence of a teething, violation of a bite, an enamel hypoplasia is often noted.
Diagnosis of rickets
Diyoagyonoz of a rayokhiyot is established on the basis of the clinical signs confirmed with laboyorayotoryony and rentyogeyonoyoloyogiyocheyosky data. For specification of extent of violation of mineral exchange biochemical blood test and urine is conducted. As the major laboratory signs allowing to think of rickets serve the gipokalyyotsiyoeyomiya and a giyopoyofosyofayoteyomiya; increase in an akyotivyonoyosta of alkaline phosphatase; decrease in level of a liyomonyony kiyosyoloyota, kalyyotsiyodiyooyol and kalyyotsiyotyoriyooyol. At a research of BRAIDS of blood comes to light . Changes in analyses of urine are characterized by a giperaminoayotsiyoduyoriya, giyoperyofosyofayotuyoriy, giyopoyokalyyotsiyouyoriy. Sulyokovich's Proyoba at rickets otyoriyotsayotelyyony.
At a X-ray analysis of tubular bones changes, characteristic of rickets, come to light: scyphoid expansion of metafiz, illegibility of grayonitsa to a meyozhyod meyotayofiyozy and epiyofiyozy, isyotonyocheyony layer of diayofiyoz, vague visualization of kernels okoyosteyoneyoniya, osteoporosis. For assessment of a condition of a bone tissue densitometry and KT of tubular bones can be used. Carrying out a X-ray analysis of a backbone, edges, skulls, is inexpedient in view of expressiveness and specificity in them clinical changes.
Differential diagnostics at rickets is carried out with rakhitopodobny diseases (D-resistant rickets, vitamin - D-dependent rickets, a disease de Tony-Debra-Fankoni and renal tubulyarny acidosis, etc.), hydrocephaly, a cerebral palsy, congenital dislocation of a hip, a hondrodistrofiya, imperfect osteogenesis.
Treatment of rickets
Complex medical care to the child with rickets consists of the organization of the correct day regimen, a balanced diet, medicamentous and non-drug therapy. The sufficient insolation, earlier introduction of a feeding up tempering procedures (air bathtubs, rubdowns) are necessary for the children having rickets daily stay in the fresh air within 2-3 hours. The healthy nutrition of the feeding mother with reception of vitamin and mineral complexes is important.
Specific therapy of rickets demands purpose of vitamin D in medical doses depending on severity of a disease: at the I Art. – in a daily dose of 1000-1500 ME (a course of 30 days), at II - 2000-2500 ME (a course of 30 days); at III - 3000-4000 ME (a course – 45 days). After the termination of a basic course vitamin D is appointed in a preventive dose (100-200 ME/days). Treatment of rickets should be carried out under control of test of Sulkovich and biochemical markers for an exception of development of a gipervitaminoz of D. As at rickets polyhypovitaminosis is often noted, reception of multivitamin complexes, medicines of calcium, phosphorus is shown to children.
Nonspecific treatment of rickets includes massage with the LFK elements, the general Ural federal district, a balneoterapiya (coniferous and hloridno-sodium bathtubs), applications of paraffin and therapeutic muds.
Forecast and prevention of rickets
Initial stages of rickets will well respond to treatment; after adequate therapy the remote consequences do not develop. Severe forms of rickets can cause the expressed deformations of a skeleton, delay of physical and psychological development of the child. Observation of the children who had rickets is carried out quarterly, not less than 3 years. Rickets is not a contraindication for preventive vaccination of children: carrying out inoculations perhaps in 2-3 weeks after the beginning of specific therapy.
Prevention of rickets shares on antenatalny and poyostyonayotalyyony. Prenatal prevention includes reception of the pregnant woman of special mikronutriyentny complexes, sufficient stay in the fresh air, good nutrition. After the delivery it is necessary to continue reception of vitamins and minerals, to carry out breastfeeding, to adhere to an accurate daily routine, to carry out to the child preventive massage. During daily walks it is necessary to leave a face of the child open for access to skin of sunshine. The Speyotsiyofiyocheyosky proyofiyolayokyotiyoka of a rayokhiyot is carried out by the newborn who is on natural feeding in osenyone-zimyone-veyosenyony by means of a viyotayomin of D and Ural federal district.