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Osteomalacia

Rickets, Soft Bones

Facts

Bones need calcium and phosphorus to remain healthy and strong, but the body also needs vitamin D to be able to absorb these 2 minerals. Without this necessary vitamin, bones can become soft and flexible. This softening is called osteomalacia, or rickets when diagnosed in children. The condition is called osteomalacia when the bone softening occurs after the growth plates have closed.

Rickets was a common childhood illness in North America until the 1940s, when it was discovered that vitamin D, readily available from sunlight (which produces vitamin D in the body) and vitamin D-enriched milk, prevented this condition. Although we haven’t seen many cases of rickets in North America since the mid-1900s, this condition occasionally still appears, particularly among exclusively breast-fed babies.

Rickets is still a major childhood problem in poorer, colder countries where babies are kept mainly inside the home and foods rich in vitamin D are not readily available.

Osteomalacia is a disease of bone formation. It is important to differentiate it from osteoporosis, which is a disease of bone that is already formed.

Causes

Osteomalacia is caused by a lack of vitamin D in the body. Vitamin D deficiency can occur because of:

  • conditions that interfere with the body’s absorption of vitamin D, such as intestinal disorders (including Crohn’s disease and celiac disease)
  • conditions that prevent the body from producing or activating vitamin D, especially kidney disorders, where it can be a major problem (it can be brought on by liver disease and, rarely, by hypoparathyroidism)
  • lack of vitamin D in the diet
  • not enough exposure to sunshine–this commonly affects people who are confined indoors for prolonged periods of time because of age, disability, or illness (infants in tropical areas are often kept swaddled in clothes and get too little sun)
  • having dark skin, which interferes with the effects of sunlight on vitamin D
  • certain medications, including some medications prescribed for epilepsy
  • very rare tumours

In Canada, there is a greater proportion of exclusively breast-fed Indigenous infants that are diagnosed with rickets.

Although breast milk is the ideal food for babies, this source of milk does not provide enough vitamin D to meet the baby’s needs. Most breast-fed babies should receive a vitamin D supplement unless they are already getting vitamin D from another source.

There is also a rare form of inherited osteomalacia, called hypophosphatemic rickets.

Treatment and Prevention

If a lack of vitamin D is causing osteomalacia, the patient will be advised to increase their vitamin D intake. Some foods rich in vitamin D are:

  • enriched or fortified milk and milk products
  • herring, salmon, shrimp, sardines
  • fortified cereal
  • cod liver oil
  • egg yolks

The doctor may prescribe a concentrated supply of vitamin D as well as a calcium supplement. The doctor or dietitian may also suggest alternative sources of vitamin D for people who are lactose intolerant or are allergic to milk.

People who are feeding their babies only breast milk or partially feeding their babies infant formula are recommended to give their babies daily vitamin D supplements. Most infant formulas in Canada are fortified with enough vitamin D to fulfill the baby’s needs if fed regularly.

People with osteomalacia may be advised to get exposure to the sun but should be careful to avoid getting sunburned. It is better to stay in the sun for short periods (10 to 15 minutes) each day rather than for longer periods less frequently. This strategy, in addition to the use of sunscreen, decreases the chance of skin damage from the sun.

Some people may require braces to help realign the affected bones. Surgery may be necessary to realign severely deformed bones.

With successful treatment, osteomalacia can be eliminated and its effects completely healed within a modest period of time (usually several months).

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