Rickets

What is Rickets?

Rickets occurs when growing bones and growth plates do not receive or use enough calcium and phosphate for normal mineralisation. Growth plates are areas of developing tissue near the ends of long bones where new bone forms as a child grows.

Vitamin D helps the body absorb and regulate calcium and phosphate. When the availability or metabolism of these minerals is disrupted, growth plates may widen and growing bones can become softer and weaker.

Rickets occurs while the skeleton is still growing and the growth plates remain open. After skeletal growth is complete, a similar mineralisation disorder affecting mature bone is called osteomalacia.

What are the Types of Rickets?

Rickets can be broadly classified according to the mineral imbalance responsible for abnormal bone mineralisation. These types of rickets are mentioned below:

How Common is Rickets in India?

Rickets is a prevalent childhood bone disorder in India, particularly among younger children. As per a clinical study in 2020, 46% of children aged under 10 years are at risk of developing rickets. However, a national survey to provide the exact number of rickets cases in India is unavailable.

What are the Stages of Rickets?

Rickets does not have a universal staging system that applies to every type of the condition. Three biochemical stages have been described for vitamin D-deficiency rickets, but these should not be applied to inherited, kidney-related or phosphate-wasting forms.

The table below shows the typical features of vitamin D deficiency rickets based on its stages:

What are the Symptoms of Rickets?

The signs of rickets vary according to the child's age, severity and stage of skeletal development. Infants may first develop skull or muscle changes, while leg deformities become more noticeable after a child begins standing and walking.

The early warning signs and advanced stage symptoms of rickets are listed in the table below:

Craniotabes refers to unusual softness of the skull bones and may appear in infants. A large or slow-closing fontanelle can also occur.

As children grow and begin bearing weight, the ends of long bones may widen, causing noticeable enlargement around the wrists and ankles. Bowed legs or knock knees may then become more apparent.

A rachitic rosary refers to bead-like enlargements where the ribs meet their cartilage along the front of the chest.

Diseases Similar to Rickets

Several childhood skeletal disorders like Blount disease or hypophosphatasia can resemble rickets, as they may cause bowed legs, bone deformity, abnormal growth or difficulty walking.

A comparative overview of these three conditions is given below, highlighting their distinct features:

Rickets Vs. Blount Disease Vs. Hypophosphatasia

Blood tests and X-rays help distinguish rickets from conditions that produce similar skeletal changes.

What Causes Rickets?

Rickets develops when growing bones do not have enough available calcium or phosphate to mineralise properly. The possible causes of rickets are given below:

• Vitamin D Deficiency: Inadequate vitamin D reduces calcium absorption from the intestine and can lead to nutritional rickets.

• Low Calcium Intake: A diet that provides too little calcium can impair bone mineralisation even when vitamin D levels are not severely reduced.

• Phosphate Loss: Certain kidney disorders cause excessive phosphate loss in urine, leaving too little available for growing bones.

• Inherited Vitamin D Disorders: Rare genetic conditions can interfere with vitamin D activation or prevent the body from responding normally to active vitamin D.

• Kidney Disorders: Chronic kidney disease and renal tubular disorders can disturb calcium, phosphate and vitamin D regulation.

• Malabsorption: Intestinal conditions that interfere with nutrient absorption can reduce the availability of vitamin D and calcium.

• Liver Disease: Significant liver disease can interfere with vitamin D metabolism and contribute to abnormal mineral balance.

What are the Risk Factors for Rickets?

Risk factors depend on the underlying type of rickets. These factors are listed below:

• Inadequate Vitamin D: Low vitamin D intake or inadequate supplementation can increase the risk of deficiency-related rickets.

• Low Calcium Intake: A diet consistently low in calcium can interfere with normal bone mineralisation.

• Limited Sunlight Exposure: Very limited ultraviolet exposure can reduce vitamin D production in the skin.

• Darker Skin Pigmentation: Higher melanin levels can reduce vitamin D production from sunlight.

• Rapid Growth: Infants, children and adolescents have greater mineral requirements during periods of rapid skeletal growth.

• Malabsorption Disorders: Conditions that reduce absorption of vitamin D or calcium can increase the risk of rickets.

• Kidney Disease: Kidney disorders may interfere with phosphate balance and activation of vitamin D.

• Liver Disease: Chronic liver disease can affect vitamin D metabolism.

• Family History or Genetic Disorders: Inherited abnormalities involving vitamin D or phosphate metabolism are known to cause certain forms of rickets.

• Certain Medicines: Long-term use of some medicines may interfere with vitamin D or bone metabolism.

What are the Complications of Rickets?

Untreated or severe rickets can affect skeletal growth, bone strength and development. Complications associated with rickets are mentioned below:

• Persistent Skeletal Deformities: Bowed legs, knock knees and other limb deformities can become more pronounced as a child grows.

• Growth Impairment: Long-standing disease can slow normal skeletal growth and contribute to short stature.

• Bone Fractures: Poorly mineralised bones are weaker and may fracture more easily.

• Delayed Motor Development: Muscle weakness and skeletal changes can delay sitting, standing or walking.

• Dental Problems: Delayed tooth eruption and enamel abnormalities may occur in some forms of rickets.

• Severe Hypocalcaemia: Very low calcium levels can lead to muscle spasms, tetany or seizures and require urgent treatment.

When Should I See a Healthcare Provider?

Seeking medical assessment is recommended if a child develops:

• Bowed legs or knock knees that appear excessive or worsen

• Widening of the wrists or ankles

• Delayed growth

• Delayed sitting, standing or walking

• Persistent muscle weakness

• Bone pain

• Frequent or unexplained fractures

• Delayed tooth eruption

• Skull or chest-wall changes suggestive of rickets

Urgent medical attention is required if a child develops seizures, severe muscle spasms, difficulty breathing or other symptoms that could indicate severely low calcium levels.

How is Rickets Diagnosed?

Rickets is diagnosed using a combination of medical history, physical examination, blood tests and X-rays.

The following tests and assessments may be conducted by doctors to diagnose rickets:

Diagnostic Summary Table

Children whose results do not fit the criteria for nutritional rickets may require urine studies, specialised hormone testing or genetic investigations.

How is Rickets Treated and Managed?

Treatment depends on the specific cause of rickets. Vitamin D and calcium treatments are appropriate for nutritional deficiency, but other forms require different treatment.

Common treatment and management approaches of rickets are given below:

Common Medicines Used to Treat Rickets

Medicines depend on the specific form of rickets. Common medicines that may be prescribed by doctors to treat rickets are given below:

• Cholecalciferol: Vitamin D3 used for vitamin D-deficiency rickets.

• Calcium Supplements: It can be used when dietary calcium intake is inadequate during treatment.

• Calcitriol: An active form of vitamin D used in selected inherited or kidney-related forms rather than routine nutritional rickets.

• Phosphate Supplements: May be prescribed in selected phosphate-wasting disorders under specialist supervision.

• Disease-Specific Medicines: Some inherited forms of hypophosphataemic rickets may require targeted treatment under specialist supervision.

Note: Vitamin D, calcium, calcitriol and phosphate treat different metabolic abnormalities and should not be used interchangeably. Treatment should follow an appropriate diagnosis and medical advice.

Living With Rickets: Daily Challenges and Care

Children recovering from rickets may need temporary support with movement, daily activities and follow-up while normal mineralisation and skeletal development improve.

Some of the challenges and essential care points for rickets patients are listed below:

What is the Prognosis for Rickets?

The prognosis for nutritional rickets is usually favourable when vitamin D or calcium deficiency is recognised and treated early. Blood test abnormalities generally improve first, while skeletal changes take longer to heal. As children still have significant growth ahead of them, some leg deformities can improve as normal mineralisation resumes.

Long-standing or severe deformities may persist and require orthopaedic assessment. In inherited, renal or metabolic forms, the long-term outlook depends on the underlying disorder and response to treatment.

How Can I Prevent Rickets?

Not all forms of rickets can be prevented, particularly those caused by inherited, kidney-related or metabolic disorders. However, the risk of some forms can be reduced by supporting healthy bone development and addressing nutritional or medical problems early.

Some preventive measures for rickets are given below:

• Ensure children receive enough vitamin D and calcium for their age.

• Provide vitamin D supplements when recommended, particularly during infancy or when deficiency risk is high.

• Include calcium-rich foods as part of a balanced diet.

• Encourage safe and appropriate sunlight exposure to support vitamin D production.

• Identify and treat conditions that affect the absorption or metabolism of vitamin D, calcium or phosphate.

• Monitor children taking long-term medicines that can interfere with bone or mineral metabolism.

• Attend regular health checks when a child has kidney, liver, intestinal or inherited conditions that increase the risk of rickets.

Rickets Treatment Cost in India

Treatment costs vary according to whether a child has uncomplicated nutritional rickets or requires specialist investigation for an inherited, kidney-related or phosphate-wasting condition.

An overview of the approximate costs of rickets treatment in India is provided in the table below:

Note: These are indicative prices rather than fixed charges. Costs may vary depending on the hospital, location and treatment required. For more accurate estimates, consult a hospital representative.

Does Health Insurance Cover Rickets in India?

Yes, health insurance provides coverage for rickets. Most uncomplicated nutritional rickets is managed through outpatient consultations, blood tests and medicines. These expenses are covered under a mediclaim policy only if it includes the OPD benefit.

If rickets requires a medically necessary admission for severe complications or surgery for a persistent deformity, the insurance company will pay for the expenses as per the policy terms and conditions. However, a waiting period may apply before a claim can be raised.

Make sure to review the coverage, exclusions, co-payments, sub-limits and other conditions before filing claims.

How Much Health Insurance Coverage is Needed for Rickets?

There is no fixed disease-specific sum insured recommended for rickets, as uncomplicated nutritional rickets is usually treated through relatively low-cost outpatient care.

A health insurance cover of around ₹5 - ₹10 lakh may meet basic hospitalisation needs for rickets treatment. A higher coverage of ₹15 - ₹20 lakh can offer broader protection against major hospitalisation, surgery or other healthcare expenses resulting from inherited or chronic metabolic rickets.