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Osteomalacia Content Supplied by NHS Choices
Introduction

Rickets is a condition that affects bone development in children. It causes the bones to become soft and malformed, which can lead to bone deformities.

Rickets in adults is known as osteomalacia or soft bones.

The most common cause of rickets is a lack of vitamin D and calcium. Vitamin D comes from foods such as oily fish and eggs, and from sunlight on our skin. Vitamin D is essential for a child to form strong and healthy bones. 

In rare cases, children can be born with a genetic form of rickets. It can also develop if another condition affects how vitamins and minerals are absorbed by the body.

Read more about the causes of rickets.

Rickets causes the bones to become painful, soft and weak. This leads to deformities of the skeleton, such as bowed legs, curvature of the spine and thickening of the ankles, wrists and knees.

Read more about the symptoms of rickets.

When to seek medical advice

If your child has any symptoms of rickets, such as bone pain, delayed growth or skeletal problems, take them to your GP for a check-up.

Read more about how rickets is diagnosed.

Preventing rickets

Rickets can easily be prevented by eating a diet that includes vitamin D and calcium and spending some time in sunlight. The hands and face only need to be exposed to the sunlight a few times a week during spring and summer.

Read more information about preventing rickets, including a list vitamin D and calcium sources.

Treating rickets

Rickets can be successfully treated in most children by ensuring they eat foods that contain calcium and vitamin D or take vitamin and mineral supplements.

If your child has problems absorbing vitamins and minerals, they may need a higher dose or a yearly vitamin D injection.

Read more about how rickets is treated.

Who is affected?

Rickets was common during Victorian times, but mostly disappeared in the Western world during the 1940s thanks to the fortification with vitamin D of foods such as margarine and cereal.

However, there has been and increase in cases of rickets in the UK in recent years. Children of Asian, African-Caribbean and Middle Eastern origin have a higher risk because their skin is darker and they need more sunlight to get enough vitamin D.

Other groups who are at risk include children born prematurely and children taking medication that interferes with vitamin D. However, any child whose diet does not contain enough vitamin D or calcium can develop rickets.

Symptoms of rickets

Rickets causes a child's bones to become soft, weak and malformed, which can lead to bone deformities.

The signs and symptoms of rickets include:

  • Pain - the bones affected by rickets are often sore and painful, so the child may be reluctant to walk or may tire easily. 
  • Skeletal deformities - these include soft skull bones, bowed legs, curvature of the spine, and thickening of the ankles, wrists and knees. The breastbone can also stick out, which is sometimes called "pigeon chest".
  • Fragile bones - the bones become weaker and more prone to fractures.
  • Poor growth and development - the skeleton does not grow and develop properly so the child will be shorter than average.
  • Dental problems - these include weak tooth enamel, delay in teeth coming through and increased risk of cavities.

As your child gets older, the symptoms of rickets may also include:

  • waddling when walking
  • bent bones
  • muscle weakness and pain

These symptoms can also affect adults who have soft bones (osteomalacia).

When to seek medical advice

If your child has any symptoms of rickets, such as bone pain, delayed growth, muscle weakness or skeletal problems, take them to your GP for a check-up.

Causes of rickets

Rickets usually occurs because of a lack of vitamin D or calcium. It can also be caused by a genetic defect or another health condition.

Lack of vitamin D and calcium

The most common cause of rickets is a lack of vitamin D or calcium in a child's diet. Both are essential for children to develop strong and healthy bones. The main sources of vitamin D are:

  • Sunlight - your skin produces vitamin D when it is exposed to the sun. We get most of our vitamin D this way.
  • Food - vitamin D is also found in foods such as oily fish, eggs and fortified breakfast cereals.

Over a long time, vitamin D deficiency causes rickets in children and osteomalacia (soft bones) in adults.

Rickets is more common in children of Asian, African-Caribbean and Middle Eastern origin because their skin is darker and needs more sunlight to get enough vitamin D. However, any child who does not get enough sunlight, is frequently covered up or has a diet low in vitamin D or calcium is also at risk of getting rickets.

Babies born prematurely are also at risk of developing rickets because the foetus builds up stores of vitamin D while in the womb. As the amount of vitamin D in breast milk varies, the Department of Health recommends that all pregnant and breastfeeding women should take a daily supplement of 10 micrograms (mcg) of vitamin D.

This ensures that the mother's vitamin D requirements are met and that adequate foetal stores are built up for early infancy.

Genetic defect

Rare forms of rickets can also be inherited (passed on from a parent to a child).

Hypophosphatemic rickets is a genetic disorder in which the kidneys and bones deal abnormally with phosphate (calcium phosphate is what makes bones and teeth hard). This leaves too little phosphate in the blood and bones, leading to weak and soft bones.

Other types of genetic rickets affect special proteins in the body that are used by vitamin D.

Underlying conditions

Occasionally, rickets develops in children with rare forms of kidney, liver and intestinal conditions. These can affect the absorption and metabolism of vitamins and minerals.

Diagnosing rickets

If rickets is suspected, your GP may carry out a number of tests including a physical examination, an X-ray and blood tests.

These are described in more detail below:

  • Physical examination - this will check for any obvious problems with your child's skeleton, such as bone pain and tenderness.
  • Medical history - your GP will discuss your child's medical history, diet, family history and any medication they are currently taking.
  • Blood tests - your GP may arrange for your child to have some blood tests to measure calcium, phosphorous and vitamin D levels.
  • X-ray - your child may also have some X-rays and sometimes a bone densitometry scan (DEXA scan), which is a special type of X-ray that measures the calcium content in the bones.
Treating rickets

Most cases of rickets are caused by a vitamin D and calcium deficiency. Therefore, rickets is usually treated by increasing a person's intake of vitamin D and calcium.

Vitamin D and calcium can be increased by:

  • eating more foods rich in calcium and vitamin D
  • taking daily calcium and vitamin D supplements
  • having a vitamin D injection each year (this is only necessary if the child cannot take the supplements by mouth or has intestinal or liver disease)

Sunlight also contains vitamin D, so you may be advised to increase the amount of time your child spends outside.

Read more about sunlight and foods that are rich in calcium and vitamin D.

Your GP will advise you about how much vitamin D and calcium your child will need to take. This will depend on their age and the cause of the rickets. If your child has problems absorbing vitamins, they may need a higher dose.

When rickets occurs as a complication of another medical condition, treating the underlying condition will often cure the rickets. For example, people who have kidney disease and rickets may require dialysis (treatment that replicates many of the kidneys' functions).

If your child has a bone deformity caused by rickets, such as bowed legs or curvature of the spine, your GP may suggest treatment to correct it. This might be a brace to support the affected area of your child's body as their bones grow, or they may need surgery.

Genetic rickets

People with genetic forms of rickets need slightly different treatment.

For hypophosphatemic rickets (where a genetic defect causes abnormalities in the way the kidneys and bones deal with phosphate), a combination of phosphate supplements and a special form of vitamin D is required.

Children with other types of genetic rickets need very large amounts of a special type of vitamin D treatment.

Side effects

It is very unusual to get side effects from vitamin D, calcium or phosphate supplements if they are given in the correct dose.

However, if the dose of vitamin D or calcium is too high, it can raise calcium levels in the blood. This can result in a condition called hypercalcaemia. Symptoms of hypercalcaemia include:

  • passing a lot of urine
  • feeling thirsty
  • reduced appetite
  • nausea, abdominal pain, constipation and vomiting
  • dizziness and headaches

See your GP immediately if you or your child has any of these symptoms.

Preventing rickets

There are several steps you can take to help prevent rickets developing. These include ensuring that your child has a healthy, balanced diet and spends some time outside in the sun.

Diet

Make sure your child has a healthy, balanced diet that contains plenty of calcium and vitamin D.

Sources of vitamin D include:

  • oily fish
  • liver
  • eggs
  • margarine
  • breakfast cereals with added vitamin D

Sources of calcium include:

  • dairy products, such as milk, cheese and yoghurt
  • green vegetables, such as broccoli and spinach
  • wholemeal bread
  • dried fruits
  • beans and pulses, such as lentils

If you have a restricted diet - for example if you are vegetarian or vegan - you may not be getting essential vitamins and minerals and may need to take a vitamin supplement (see below).

Sunlight

Sunlight is a good source of vitamin D and it is where most of our vitamin D comes from. The vitamin forms under the skin as a result of sun exposure.

In the UK, about 10-15 minutes of exposure on the hands and face, a few times a week, during the spring and summer is enough.

However, it is very important to be aware that too much sun is bad for your skin. Therefore, you and your children should not spend long periods in the sun and should always use sunscreen with a sun protection factor (SPF) of at least 15.

Babies and young children have very sensitive skin that burns easily so they need to use stronger sunscreen and keep covered up when out in the sun.

Read more about staying safe the sun.

Supplements

Most people can get all the vitamin D they need through their diet and by getting a little sun.

However, certain groups of people have an increased risk of developing a vitamin D deficiency and may need to take supplements to avoid getting rickets and osteomalacia (the adult form of rickets). These at-risk groups are discussed below.

Pregnant and breastfeeding women

The Department of Health recommends that all pregnant and breastfeeding women should take a daily supplement of 10 micrograms (mcg) of vitamin D.

Children

In the UK, the Department of Health recommends the use of vitamin D supplements for:

  • breastfed infants from six months of age (or from one month if there is any doubt about whether the mother was getting enough vitamin D during pregnancy)
  • formula-fed infants who are over six months old and taking less than 500ml of infant formula a day
  • children under five years of age 

It is important that children in high-risk groups take supplements. These include children who do not get enough vitamin D from their diet and those with certain medical conditions such as kidney disease. They may need to take extra supplements to prevent rickets and ensure that they develop strong and healthy bones.

Your GP can advise you about how much vitamin supplementation is needed.

Other risk groups

Other people who have an increased risk of developing a vitamin D deficiency and who may need to take supplements include:

  • elderly people 
  • people of Asian, African-Caribbean and Middle Eastern origin
  • people who always cover up all their skin when they are outside
  • people who are rarely able to go outside
  • people who do not eat meat or oily fish
 
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