The role of risk factors in child rickets Authors: Cosmin Oprea Coauthors: Maria Oana Mărginean, Răzvan Mareș, Cristina Câmpean Coordinator: Prof. Cristina Oana Mărginean

Introduction Rickets An osteodistrophy deficiency, characterised by an inadequate mineralization of the bone osteoid A disease of the growing bone, occurs before the fusion of the epiphyses, unlike osteomalacia, which affects bones which do not grow Growth plate continues to expand, but mineralization does not occur → growth plate tickens → bone diformities Etiology: vitamin D (most often), Ca or P defficiency

Decisive factors in the development of rickets Background Decisive factors in the development of rickets Vitamin D defficiency: insufficient intake or insufficient cutaneous synthesis Lack of exposure to the sun: limits cutaneous synthesis of vitamin D The homeostasis of Ca and P : vitamin D plays a major role in the intestinal absorption of Ca and P Other processes which are affected by vitamin D: muscular ATP synthesis iron absorption metabolic processes

Risk factors in rickets Background Risk factors in rickets small age ( from 3 months up to 2 years) rapid growth nutritional factors- inadequate diets: life conditions pigmentation artificial nutrition (cow milk) dairy products which lack sufficient vitamin D vegan diet food rich in flour, oxalates, P total parenteral nutrition temperate climate poluted environment sun exposure

Risk factors in rickets Background Risk factors in rickets conditions which prevent hydroxilation (hepatic, renal) conditions which prevent intestinal absorption (cystic fibrosis, celiac disease) medicines: maternal factor: cortisone anticonvulsivants iron heparin chelating agents exposure to sun rickets prophilaxy

Clinical manifestations of rickets Background Clinical manifestations of rickets Debut- unspecific symptons: irascibility anxiety capricious apetite agitation sweat reduced sleep

Clinical manifestations of rickets Background Clinical manifestations of rickets State period- specific symptoms: Craniotabes: parietal and occipital softening,“ping-pong” ball sensation Teeth: tardive eruption, hypoplasia, dental caries Head and Forehead: high forehead, brachicephaly, plagicephaly, delayed fontanelle closure, frontal bossing, craniosynosthosis Thorax: deformations, rachitic rosary, Harrison groove Spine: scoliosis, kyphosis, lordosis Upper limbs: “rachitic bracelets”, enlargement of the wrists Lower limbs: varum or valgum diphormities Hypocalcemic symptoms: tetany, seizures, laryngeal spasm

Objective The objective of this study was to assess whether the most frequent risk factors known to be involved in the pathogenesis of rickets are positively correlated with different manifestations of the disease in the patients included in this study. 

Material and methods Prospective study conducted on 66 hospitalised children admited in the Pediatrics Clinic I, in the period November 2014- March 2015 Questionnaires which were filled in by their mothers Questions related to the main predisposing factors involved in the development of rickets, including: alimentation aspects, sun exposure, life conditions, the presence of other related diseases, medication, maternal factor, vitamin D prophylaxis and the patients’ birth and development aspects

Material and methods

Material and methods We divided the 66 hospitalised children into two groups: a control group of 34 children a study group of 32 children, which had manifestations of the disease: 19 with skeletal manifestations 13 with subclinical manifestations Statistical calculation: Microsoft Office Excel 2007 Graph Pad 3.6 Software, San Diego, California, United Stated of America t- Student test

Material and methods Inclusion criteria: Exclusion criteria: control group–hospitalised children without any manifestations of the disease study group- hospitalised children with skeletal and subclinical manifestations of the disease Exclusion criteria: children with hematologic or oncologic diseases children with genetic syndromes

Results Sex and age distribution Control group Study group Mean age 17,03 months 8,05 months

Results- risk factors p= 0,048 OR=3,2

Results- risk factors p= 0,03 OR=3,4

Results- risk factors p<0,01 OR=6,2

Results-risk factors Study group Control group Poluted environment 18 14 P=0,32 No polution 20 OR=1,83 Study group Control group Urban 16 17 P=1,19 Rural OR=1 Skeletal manifestations Control group Child profilaxy 17 27 P= 0,46 No child profilaxy 2 7 OR=2,2

Skeletal manifestations Results-risk factors Study group Control group Intense pigmentation 5 11 P=0,15 Normal pigmentation 27 23 OR=0,38 Study group Control group Mature at birth 19 24 P=0,43 Premature 13 10 OR=0,6 Skeletal manifestations Control group Breast fed min 6 months 12 14 P=0,15 Breast fed for less than 6 months 17 8 OR=0,4

Results- symptoms p< 0,01 OR=6,42

Results-symptoms p<0,01 OR=7,23

Conclusions The main risk factors which were linked in our study with the pathogenesis of the disease included: cereals consumption, low exposure to the sun, anemia and male sex. A late closure of the fontanella is significantly correlated with the development of the disease There is also a positive correlation between neck sweats and skeletal manifestations of the disease With proper and early prophilaxy, the incidence of rickets can be drastically decreased By continuing the screening on additional cases, the role of the main risk factors could be further determined

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