Posted on
December 26, 2009 by
Claire Newell
The words Vitamin D and Rickets usually come to mind when someone asks you to describe a common childhood disease.

- Rickets
Rickets is one of the three bone diseases related to Vitamin D Deficiency and can be very debilitating if untreated.
At the beginning of the 20th century, rickets reached epidemic levels among infants and young children in many areas of Asia, North America, and northern Europe. However, with the discovery of the role sunlight in curing rickets and the isolation of Vitamin D, inexpensive methods of preventing and treating nutritional rickets became available. Unfortunately, despite these developments, rickets remains a major public health problem in many developing countries and its prevalence is on the rise in many developed countries.
Firstly, let’s look at bone development in children
During childhood, bones continually grow and develop. Peak growth is through infancy and puberty. Growth stops once your child’s bones and skeleton are fully developed.
The strength of your child’s bones depends on the amount of minerals that are laid down in them. This is done through a process called “mineralisation”. Minerals such as calcium and phosphorus are taken from the food your child eats and deposited in their bones. Vitamin D is important in this process, helping the body absorb calcium and making sure it gets to where it’s needed. During childhood, mineralisation ensures that bones grow and develop, whereas in adulthood it maintains and repairs them.
So what is rickets?
Rickets is a disease that affects growing bones, causing them to soften, weaken and break easily. As your child grows, his/her increased body weight can cause soft, weak bones to become bowed and deformed.
Soft bones can also affect adults (after their bones have stopped growing); this condition is called osteomalacia.
Low Vitamin D and Rickets – how does Vitamin D affect bone development?
In children more than 80 percent of Vitamin D comes from sunlight with the rest from their diet.

Deformed bones
The active form of Vitamin D3, calcitriol, acts as a hormone to regulate calcium absorption from the intestine and to regulate levels of calcium and phosphate in the bones. If Vitamin D levels are low, the body is unable to regulate calcium and phosphate levels. The body detects low serum levels of calcium and phosphate and stimulates the release of parathyroid hormone (PTH). PTH helps release calcium and phosphate from the bones to the bloodstream. Decreased amounts of calcium and phosphate prevent the bones from calcifying properly and weak, soft bones are produced.
The long-term consequences of low Vitamin D include permanent bends or disfiguration of the long bones, and a curved back.
How common is rickets?
Although rickets has been uncommon in the western world in recent years, levels of Vitamin D deficiency are on the rise again. Two 2009 studies show that approximately 20% of US children (between 1 and 11 years) and 15% of teenagers are Vitamin D deficient. Rates are higher for children and teens with darker skins, with one study showing that over 50% of African-American female teenagers are Vitamin D deficient.
Data from the US National Health and Nutrition Examination Survey 2001-2004, which collected information on more than 6,000 children between the ages 1 and 21 has shown an alarming trend. Nine percent (7.6 million) of children are vitamin D deficient. Another 61 % (50.8 million) were vitamin D insufficient. Low levels are especially common in:
- girls,
- African-Americans and Mexican-Americans,
- the obese,
- those who drank milk less than once a week,
- those who spent more than four hours a day watching TV, playing videogames, or using computers.
Studies from the UK show that rickets affects less than 1% of UK children although levels are much higher in children of South Asian or African-Caribbean origin. Approximately 20 children per year are seen at a hospital clinic with a diagnosis of rickets.
In developing countries, rickets is one of the most common childhood diseases reaching epidemic proportions in some countries.
What causes rickets?
Nutritional rickets is the most common type of rickets. It is caused by low levels of Vitamin D or calcium, or a combination of both in your child’s diet. Both these minerals are essential for forming strong, healthy bones.
Typically rickets results from Vitamin D deficiency. Factors causing rickets include exclusive breast feeding, breastfeeding mothers who are Vitamin D deficient, as well as lack of sun exposure due to too much time indoors, covering up due to social and religious customs, or climatic conditions can prevent adequate skin exposure to sun light.
At the other end of the spectrum rickets can be caused by low dietary calcium. This is apparent for older toddlers and children from developing countries such as Bangladesh, Nigeria and South Africa. Low calcium is characteristic of diets that are cereal-based, with little variety, and where there is limited access to dairy products. Research has shown in these countries calcium supplements alone can reduce rickets.
Rickets can also be caused by a combination of low dietary calcium and Vitamin D deficiency. This has been found in Asian children and African American toddlers. The low calcium levels cause excessively high breakdown rates of Vitamin D and this leads to Vitamin D deficiency and rickets.
Famine or starvation during early stages of childhood results in a lack of Vitamin D and/or calcium.
Rickets can be caused by other medical conditions which affect the way the body processes Vitamin D or calcium. Some examples are:
- Problems affecting the gut such as celiac disease, Crohn’s disease or malabsorption.
- Some types of liver or kidney disease (the liver and kidneys are involved in processing Vitamin D).
- Medicines which interfere with Vitamin D: carbamazepine, phenytoin, primidone and barbiturates.
- A few rare conditions, including some inherited ones, which affect the way the body uses Vitamin D and calcium.
Which groups of children are at risk from rickets?
Lack of Vitamin D is caused by problems with our lifestyle and diet. Most of our Vitamin D is synthesised when our skin is exposed to the sun.
Children ages 6 months to 24 months are at the highest risk of rickets because their bones are growing very rapidly during this period. Risk groups include:
- Breastfed babies whose mothers lack Vitamin D or breastfed babies where weaning is delayed. (Do not stop breastfeeding just add a Vitamin D supplement.)
- Children who spend too much time indoors, cover up when outside, or wear sunscreen.
- Children with medical conditions which affect the way the body handles Vitamin D.
- Children with dark skins from Asian, African Caribbean and Middle Eastern origin. The dark skin requires longer sun exposure than light skin for the same levels of Vitamin D.
- Children living in higher latitudes where the sun is not strong enough to produce Vitamin D for much of the year.
- Children with a family history of Vitamin D deficiency.
- Children who do not get enough Vitamin D, calcium or phosphorus in their diet.
- They may have diets that limit certain food groups (for example vegetarians, vegans or macrobiotics).
- They may have diets lacking in foods that contain Vitamin D (liver, oily fish (such as sardines, herring, tuna, salmon, and mackerel), and egg yolk).
- Children who do not consume milk, such as those who are lactose intolerant.
What the symptoms of rickets?
The symptoms of rickets may include:
- soft skull bones
- delayed closing of the soft spot at the top of your baby’s head (the anterior fontanelle)
- delayed growth (your child may be short for his or her age)
- pain in the bones of the spine, pelvis and legs
- floppiness in the limbs and body due to muscle disease or weakness
- teeth taking longer to come through
- weak tooth enamel which may lead to tooth decay
- bone pain in the arms, legs, spine and pelvis (but this is rare)
- fractures, as the result of a fall
Your child may also have skeletal deformities, such as:
- thickening of their ankles, wrists or knees (“knock-knees”)
- legs that curve outwards (“bow legs”)
- a breast bone that sticks out (“pigeon chest”)
- ribs that stick out – this may look like a set of beads on their chest (“rachitic rosary”)
- an asymmetrically shaped skull
- spinal deformities (eg a hunched back, scoliosis)
- pelvic deformities (eg a beaked pelvis)
If your child has any of these symptoms or skeletal deformities, you should see your GP.
How can my doctor tell if my child has rickets?
Your doctor will ask about your child’s health and diet and your family health history. Your child will need a full physical exam. A physical exam may reveal tenderness or pain in the bones, rather than in the joints or muscles. Blood tests and x-rays of the arms or legs can also help your doctor determine if your child has rickets.
How is rickets treated?
Take Vitamin D supplements. Vitamin D3 (cholecalciferol) is the preferred form since it is more readily absorbed than Vitamin D2. Check our Vitamin D Dosage chart to find the recommended dosage for infants and children.
If low calcium is part of the problem, calcium supplements can also be taken. These can be liquids or tablets. If calcium levels are severely low and causing problems, calcium can be given by an infusion (a ‘drip’) in hospital.
Your child’s pain and muscle weakness will probably get better within a few weeks of treatment. If your child has inherited rickets or has an illness causing the problem, you may need to see a doctor who specializes in rickets.
If your child has bone deformities caused by rickets, he or she may need braces or surgery to correct the problem.
Are there any side effects of treatment?
It is very unusual to get side effects from Vitamin D or calcium if taken in the correct dose.
What is the outlook?
If treated promptly, the outlook is very good. Most cases of rickets can be cured by Vitamin D treatment. If rickets is untreated for a long time, there is a possibility that bone deformities could result. If these are a problem, they might need surgery.
With prolonged or untreated rickets, the risk of getting osteoporosis (bone thinning and fractures in old age) may be increased. the risks of getting other diseases may well be increased because Vitamin D is involved in preventing some conditions such as diabetes, heart disease and cancer.
How can I prevent my child getting nutritional rickets?
Babies
All breastfed babies should be given vitamin drops. (Note that formula baby milk contains Vitamin D.) Toddlers who drink cows milk should have supplements, as this milk contains very little Vitamin D.
Pregnant and breastfeeding women
Take Vitamin D supplements, both for your own health and to help prevent rickets in your baby. This is particularly important for mothers of high risk groups. Supplements must be suitable for use in pregnancy and can be either a calcium/Vitamin D tablet, or a multivitamin tablet. Check our article on Vitamin D dosage to see how much Vitamin D you will need.
Note: if you are pregnant, do not take supplements containing large amounts of vitamin A, as too much can harm the baby. Take supplements that are labelled as suitable for pregnancy. Also, do not eat liver which contains large amounts of vitamin A. Vitamin A can be taken if you are breastfeeding.
Children
Supplements: The American Academy of Pediatrics, in its clinical report, Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents, recommends all children, from aged two months, and teens should have at least 400 IU of Vitamin D each day. Check our article on Vitamin D dosage to see how much Vitamin D your child will need.
Supplements are especially important for children and mothers in at risk groups, such as those with darker skins or living in higher latitudes.
Sunshine: Expose your child to 15 minutes of sunshine three times weekly. Darker-skinned people will need more sunshine. Be careful because babies and young children have very sensitive skin and can burn easily. Always apply sunscreen to the face and neck.
Remember that many countries in winter do not have enough sunshine to maintain adequate Vitamin D levels.
Diet: Ensure your child has plenty of foods that are rich in calcium and Vitamin D.
Good sources of calcium include:
- dairy products (eg milk, yoghurt and cheese)
- bread made with fortified flour
- beans and pulses (eg kidney beans and lentils)
- dried fruits
- green vegetables (eg broccoli and cabbage)
Not many foods contain enough of the Vitamin D your child needs, the main source is sunlight. However, it can be found in:
- oily fish
- eggs (cooked, not raw)
- margarine
- breakfast cereals fortified with vitamin D
Rickets and Vitamin D – the two are inextricably linked. Rickets is an exceptionally debilitating bone condition. It can be easily avoided by taking regular supplements of Vitamin D.
As a parent it is exceptionally important to make sure your child gets enough Vitamin D and calcium. Make sure they spend time outside and don’t apply sunscreen on them until they’ve been out in the sun for 10 minutes, so they can synthesise Vitamin D before sun damage.
Please read our article on Vitamin D Supplements or if you would like to find out how to choose the right supplement click here.
Make sure you read the article on Vitamin D Deficiency Symptoms in children.
We also have articles on osteomalacia and osteoporosis, the other two bone diseases relating to Vitamin D deficiency.
Here’s to your long-term health!
Claire