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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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. 

9. Material and methods
Prospective study conducted on 66 hospitalised children admited in the Pediatrics Clinic I, in the period November 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

10. Material and methods

11. 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

12. 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

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

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

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

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

17. Results-risk factors Study group Control group Poluted environment 1814
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

18. 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

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

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

21. 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

22. Thank you for your attention!