From Big Medical Encyclopedia

RICKETS (rhachitis; Greek rhachis a spine, a backbone + - itis; synonym hypovitaminosis of D) — the disease of children's age caused by a lack of an organism of vitamin D, which is characterized by disturbance of phosphorus-calcium exchange, an osteogenesis and disorder of function of a nervous system and internals.

Rachitic deformations of a skeleton at children were observed still by Soran Efessky and K. Galen. In 1650 the English anatomist and the orthopedist F. Glissop for the first time described a clinical and pathoanatomical picture of rickets. In 1843 Elzesser (S. of L. Elsasser) characterized changes of bones of a skull, typical for R. Later Kassovitts (To. E. Kassowitz) noted seasonal nature a wedge, manifestations and exacerbations of a disease. To the middle of 19 century a wedge, a picture P. it was well studied. Opening in 1919 by Guldshinsky (To. Huldschinsky) antirachitic action of Uv-radiation, and in 1922 Mack-E. V. McCollum of vitamin D promoted clarification of an etiology and pathogeny of River. The significant contribution to the doctrine about R. was made by domestic researchers. In 1847 S.F. Hotovitsky in detail described a wedge, a picture and stated nek-ry questions of a pathogeny, prevention and treatment of a disease. N. S. Korsakov's works (1883), A are devoted to R.'s studying. A. Kissel (1887), M. S. Maslov (1913), I. A. Shabada (1909 — 1915). Development of a problem P. is connected with names of the Soviet pediatricians of A. F. of a tour, E. M. Lensky, K. A. Svyatkina, G. N. Speransky, Yu. F. Dombrovskaya, A. M. Hvul, E. M. Lukyanova, etc. In 60 — the 70th 20 century the individual so-called rakhitopodobny diseases connected with disturbance of exchange of vitamin D were allocated, the principles of their prevention and therapy are developed.

The river develops usually aged up to one year. Inborn R.'s cases are described, to-ry a thicket it is observed at the children who were born at the women who had heavy toxicosis of the second half of pregnancy. Active rachitic process at children is more senior than 3 — 4 years carry to late R. Izvestna late R.'s cases at the age of 10 — 12 years at change of the residence (e.g., at children — natives of the countries of Asia and Africa at their moving to England, Ireland), and also at the expressed proteinaceous deficit of food.

R.'s prevalence and expressiveness its wedge, manifestations in many respects depend on social and economic living conditions and klimatogeografichesky features of the area. After Great October socialist revolution as a result of improvement economic and a dignity. - a gigabyte. living conditions the frequency and R. V weight the developing countries of Asia and Africa in connection with heavy material living conditions decreased, insufficiency of food the problem P. remains very urgent.

The etiology

is the Leading reason of development of R. deficit in an organism of vitamin D (see. Calciferols ), arising because of insufficient receipt with food or disturbances of its natural education in skin of the child. The factor contributing to emergence with R. are unfavorable climatic conditions. The disease meets at the children living in areas with insufficient insolation including and in the southern countries at constant cloudiness, the increased air humidity, dust content of the atmosphere more often. Seasonal fluctuations of incidence of R. connect also with changes within a year of intensity of Uv-radiation. Unsatisfactory domestic conditions, bad care of babies and their wrong feeding also promote developing of a disease. Special value has a quantitative ratio calcium (see) and phosphorus (see) in food stuffs. In women's milk (see. Breast milk ) calcium and phosphorus contain in a ratio, optimum for assimilation, a cut at artificial feeding changes towards increase in amount of phosphorus that slows down absorption of calcium. And if the child eating breast milk acquires up to 75% of calcium and 50% of phosphorus, then at artificial feeding only 30% of calcium and 20 — 30% of phosphorus are acquired. R.'s emergence is promoted by abundance of farinaceous dishes in food of the child, in to-rykh phosphorus is preferential in a form of the phytin forming with calcium in intestines insoluble salts and promoting development acidosis (see).

Almost all premature children are ill R. Eto is explained by an insufficient stock in their organism of vitamin D and nek-ry mineral substances, and also the increased need for them in connection with more intensive growth and immaturity of the fermental systems participating in exchange of vitamin D and processes of digestion of salts of calcium and phosphorus (see. Premature children ).

Emergence at the child R. is promoted by disturbance and irrational food of mother during pregnancy, existence of heavy pathology of pregnancy (toxicoses of the second half, etc.) or extragenital pathology. The frequent diseases of children of chest age which are followed by acidosis (pneumonia, acute digestive disturbances, etc.), also contribute to development of River.

During the studying of phosphorus-calcium exchange at mono - and dizygotic twins and overseeing R.'s development in them proved existence of genetic predisposition to a disease. Genetic factors define the individual need of a children's organism for vitamin D, but developing of a disease depends hl. obr. from unfavorable conditions of the environment.

The pathogeny

the Pathogeny of rickets is difficult, is characterized by frustration of many types of exchange that leads to disturbance of processes of an osteogenesis (see. Bone ) and to functional changes of various bodies and systems. Fosfornokaltsiyevy exchange is preferential broken. Deficit of vitamin D is resulted by insufficient education in kidneys of its active form — 1,25-dioxy-vitamin D 3 , stimulating absorption in intestines and mobilization from bone depots of calcium (see Calciferols). Also inclusion of phosphorus in phospholipids of a mucous membrane of intestines and its absorption decreases. All this leads to decrease in concentration of calcium and phosphorus in blood, extracellular liquid and a bone tissue. Gipoka the tsiyemiya stimulates with l activity epithelial bodies (see), hormone to-rykh promotes mobilization from bones of salts of calcium and phosphorus and to excess receipt them in blood. At the same time synthesis of thyrocalcitonin is suppressed (see. Kaltsitonin ), having gipokaltsiyemichesky effect due to stimulation of processes of a mineralization of a bone tissue. It can lead to temporary increase in level of calcium in blood at the general deficit of calcium in an organism. As a result of effect of the parathyroid hormone braking a reabsorption of phosphates in proximal departments of nephrons of kidneys, the hypophosphatemia at R. is more expressed and accrues in development of a disease.

Normal development of a bone tissue and mobilization of calcium from it along with parathormone requires also 1,25 dioxyvitamin D 3 , therefore in process of deepening of deficit of vitamin D not only absorption of calcium in intestines, but also its mobilization from a skeleton is broken that leads to development of the deep and resistant hypocalcemia which is combined with a hypophosphatemia.

Processes of synthesis and a mineralization of an organic matrix of a bone tissue are at the same time broken, connect increase in activity of an alkaline phosphatase in blood serum with their disturbance. Inherent R. the acidosis connected with the strengthened removal by kidneys of inorganic phosphates promotes disturbance of processes of calcification of a bone tissue. Partially explain with a hypophosphatemia emergence of a rachitic hypomyotonia.

At R. also exchange of magnesium, potassium and a number of microelements is broken (copper, iron, zinc, cobalt) that is followed by change of activity of metalenzymes — ceruloplasmin (see. Respiratory pigments ), karboangidraza (see), etc.

Along with deficit of vitamin D also polyhypovitaminosis, especially a vitamin deficiency With and groups B is noted. Disturbances mineral metabolism (see) and the general hypovitaminosis (see. Vitamin deficiency ) cause dysfunctions of century of N of page — the vagotonia prevails. At experimental R. disturbances in exchange of proteins with change of quantitative and qualitative composition of free amino acids in blood serum, decrease in level of albumine and increase alfa1-, alfa2-and beta globulinovykh fractions, by disturbance of contents lipo-and glycoproteins are revealed. Disturbances of protein metabolism at R. connect with decrease in content of monoethanol amine (see. Ethanolamines ), the important biogenic stimulator strengthening synthesis of protein and oppression of a reabsorption of amino acids renal tubules under the influence of a superactivity of parathyroid hormone. Changes of lipidic and carbohydrate metabolism, falling of concentration of citrate in blood come to light.

Pathological anatomy

Fig. 1. Macrodrugs of the lower epiphysis of a femur (a frontal cut) are normal (and) and at rickets: sharply expanded vitreous strip of preliminary calcification at rickets between a cartilaginous and bone tissue of an epiphysis (it is specified by an arrow).

The pathoanatomical picture of bone changes at R. consists of three basic processes: disturbances in region of growth it is preferential an endostosis, excess accumulation of osteoid, disorder of processes of calcification in the growing bones. Disturbance in a zone of an endostosis is expressed first of all in sharp expansion of region of growth. Normal the zone of preliminary calcification of a cartilage of long tubular bones has an appearance of a narrow equal yellowish strip no more than 1 mm wide. At R. it is sharply expanded, uneven, vitreous, reaches sometimes width to 1 cm (fig. 1). Microscopically expansion of a zone of substitution of a cartilage with the wrong arrangement and alternation of cellular columns of an epiphyseal cartilage takes place. Excess cartilaginous tissue in the form of languages is located in slanting and even in transverse direction in relation to a longitudinal axis of a bone. Preliminary calcification of a cartilage is broken — its resorption and use is absent for creation of a bone tissue. Therefore, despite the slowed-down proliferation, there is an excess accumulation of cartilaginous tissue. The capillaries growing into a cartilage from a marrowy cavity lose the correct arrangement parallel to cellular columns of a cartilage, branch, in places deeply grow into a cartilage, crossing its columns, in places absolutely are absent. Under a regressive zone of a cartilage (a zone of a rassasyvaniye of a cartilage) the wide zone of ossiform fabric, also in the form of languages deeply getting into an epiphyseal cartilage is defined. Ossiform fabric, despite delay of processes of its education, collects, as well as cartilaginous since there is no its turning into a bone tissue. As a result of it region of growth extends and there is no accurate and equal ambit between cartilaginous and ossiform fabrics. In excess quantity ossiform fabric collects also in endo-and periosteal zones of an osteogenesis. All this promotes emergence osteophytes (see), rachitic «brasletok» and «is accurate «». In ossiform fabric reduction of number of osteoblasts is noted. Processes of calcification of osteoid are slowed down, adjournment of lime happens unevenly and not enough. The osteocytes concluded in the mass of not calciphied main substance are exposed to dystrophic changes and partially perish. Processes of a resorption of a bone tissue at R. proceed with the participation of osteoclasts therefore the quantity them in region of growth is, as a rule, increased. Excess proliferation of osteoclasts is result of washing away of calcium from a bone tissue under influence parathormone (see) for maintenance of its concentration in blood. The insufficient mineralization of bones leads to a softening of a bone tissue (a malacia of Recklinghausen), deformation of various parts of a skeleton (a rachitic hump, a craniotabes) is a consequence of what.

Despite strengthening of function of epithelial bodies, their hyperplasia at R. is observed not always. The hyperplasia of an adenoid tissue is found (a thymus, a spleen, limf, nodes, group and solitary follicles went. - kish. a path), edges is followed not by strengthening, but disturbance of its function what the frequent and adverse current inf testifies to. processes at the children suffering from River.

At a rachitogenic tetany (see. Spasmophilia ) R.'s manifestations from bone system are observed, a hyperplasia of an adenoid tissue, spasms of muscles of small bronchial tubes, and also the phenomena characteristic of acute respiratory viral infections — desquamation of an epithelium of bronchial tubes, an uneven plethora of capillaries of lungs, ochazhka of hypostasis and desquamation of alveolotsit; all this confirms opinion that sudden death at this state is provoked by an infection.

The clinical picture

In our country is accepted R.'s classification offered in 1947 by S. O. Dulitsky at the VI All-Union congress of children's doctors. Depending on weight a wedge, manifestations 3 degrees of rickets distinguish: I (easy), II (moderately severe), III (heavy). Depending on activity a wedge, manifestations four periods of R. distinguish: initial, period of a heat, period of reconvalescence and period of the residual phenomena.

In an initial stage against the background of a satisfactory general condition the child has an excessive sweating, the related intertrigo, a heat rash, baldness of a nape. The child is timid, whimsical, a dream its uneasy, alarming. The initial stage of R. proceeds of 2 — 3 weeks up to 2 — 3 months.

Fig. 1 — 4. Children sick with rickets; external displays of a disease. Fig. 1. Garrisonova a furrow — impression of a thorax and expansion of its bottom. Fig. 2. A rachitic hump — the arc-shaped rachiocampsis. Fig. 3. Au-shaped curvature of the lower extremities. Fig. 4. Increase in a stomach owing to decrease in a tone of muscles of an abdominal wall.

In the period of a heat along with dysfunctions of a nervous system changes of bone and muscular systems are accurately shown. In the field of edges of back and front fontanels, and also on the course of seams of a skull sites of a softening, and on scales of an occipital bone are noted (occipital scales, T.) the craniotabes, characteristic of R., can develop. At premature children the softening extends almost on a gkha of a bone of a skull. Softness of bones of a skull promotes its easy deformation and flattening from that party, on a cut the child preferential lies. If the period of a heat is observed aged after 3 months, the most frequent signs of R. are changes of a thorax. On edges, in the place of transition of a costal cartilage to a bone part thickenings — the so-called beads which are most expressed on the V—VIII edges are formed. The softening and a pliability of edges, strengthening of curvature of clavicles, a prelum of a thorax, expansion of its lower aperture according to the line of an attachment of a diaphragm with the advent of a so-called garrisonovy furrow is noted (tsvetn. fig. 1). At heavy R. in the period of a heat sometimes there is a softening of bones of a base of skull, retraction of a nose bridge, there are an exophthalmos and the hung «Olympic» forehead, the forefront of a thorax together with a breast acts forward, reminding a chicken breast, in lumbar department of a backbone the kyphosis — a rachitic hump develops (tsvetn. fig. 2).

Deformation of long tubular bones concerns to later izmeneniyakhm during this period (aged after 6 — 8 months): a thickening of an epiphysis of bones of a forearm (rachitic «brasletka») and shins reminding threads of pearls of a thickening of manual phalanxes About - or a X-figurative curvature of the lower extremities (tsvetn. fig. 3).

At heavy and medium-weight degrees of R. formation of a mandible, structure of teeth and an order of their eruption is broken. Deformations of clavicles, bones of a forearm, a shoulder, a basin (a rachitic basin) meet very seldom now.

In the period of R.'s heat hypotonia of muscles is expressed, owing to a cut there is big, so-called frog, a stomach (tsvetn. fig. 4). In connection with a relaxation of ligaments the arrest of development of static and motive functions is noted: children begin to sit, stand and go later, than usually. Disorder of function of breath in the form of the asthma resulting from deformation of a thorax, hypotonia of a diaphragm and intercostal muscles, disturbance of le - exact ventilation is observed. There can be atelectases of lungs contributing to development of pneumonia. Weakening of cardiac sounds, tachycardia, sometimes systolic noise are noted. Stagnation in system of a portal vein leads to increase in a liver and spleen. Hypochromia anemia develops, in genesis the cut has value not only deficit of iron, but also structural change and function of erythrocytes (see. Iron deficiency anemia ). Arise persistent anorexia (see), the unstable chair as a result of disturbance of motor and secretory activity went. - kish. path. Also functional changes of kidneys and closed glands are observed. Now even in the period of a heat not all symptoms of R. come to light, prevail separate of them more often; hypotonia of muscles is more expressed, than bone deformations.

One of manifestations of R. is the rachitogenic tetany, at a cut there are spasms of different groups of muscles owing to falling of level of the calcium in blood leading to a hyperexcitability of a nervous system. This state can be followed laryngospasm (see), bronchospasm (see), a tetany of a myocardium that sometimes leads to sudden death (see. Spasmophilia ).

The period of reconvalescence is characterized by involution of a disease. Symptoms of defeat of a nervous system disappear, bones are condensed, teeth are cut through, static and motor functions are recovered, activity of internals is normalized.

The period of the residual phenomena is observed at the age of 2 — 3 years and is more senior when rachitic process at the child in essence comes to an end and there are only his effects, to-rye usually are result of the postponed heavy or moderately severe Ruble. At the same time deformation of a skeleton, sometimes increase in the sizes of a liver and spleen, a deviation in formation of second teeth, etc. is noted.

R.'s current can be acute, subacute and recurrent.

The acute current meets much less often in recent years, is observed more often aged up to 6 months, especially at the premature and quickly putting on weight children, characterized by bystry progressing of a disease, sharply expressed disturbances of century of N of page, the dominance of processes of a softening of bones over processes of a hyperplasia of ossiform fabric and also expressed by an aberration of biochemical indicators of blood (reduction of content of inorganic phosphorus, increase in activity of alkaline phosphatase). At an acute current the initial stage quickly passes into the period of a heat of a disease. The acute current is more often observed at children, the Crimea specific prevention of River was not carried out.

The subacute current is characterized by slow development of a disease. Symptoms of a hyperplasia of ossiform fabric prevail: increase in frontal and parietal hillocks, emergence of «beads» on edges, a thickening of an epiphysis of tubular bones, and also a hypomyotonia and anemia. The subacute current is more often observed at R.'s development after 6 months if the child for the purpose of prevention received insufficient amount of vitamin D.

The recurrent current is characterized by alternation of the periods of remissions and aggravations that can be connected with unfavorable conditions of the environment, existence of intercurrent diseases, a lack of fresh air and a sunlight, irrational food.

The diagnosis

the Diagnosis of rickets in most cases does not cause difficulties and is based on data of the anamnesis and objective survey. In difficult cases as the most reliable and specific method of identification of a lack of vitamin D serves definition in blood serum of its basic of the metabolite circulating in blood — 25 D3 oxyvitamins. For this purpose use methods of competitive binding with specific vitamin - D - the connecting serum protein. Normal concentration makes 25 D3 oxyvitamins apprx. 20 ng/ml, decreasing at deficit of vitamin D to 0 — 10 ng/ml.

Widely apply to R.'s diagnosis also definition of concentration of inorganic phosphorus and calcium in blood serum, activities of an alkaline phosphatase, concentration of parathyroid hormone, nucleotide phosphates in erythrocytes, daily excretion of cyclic adenosinemonophosphate and some other researches. At children 3 — 4 months are more senior apply rentgenol. methods of a research.

Depletion of a skeleton salts comes to light radiological on development incremental osteoporosis (see). In early phases P. development of osteoporosis is defined better in intensively growing departments of bone system where the vascular network is plentifully developed — in zones of an endostosis and a periosteum, for the account to-rykh a bone grows in length and thickness. For R.'s identification (considering need to spare the child from excess beam influence) to enough make structural pictures of a shin and forearm. For receiving a picture of a shin of the child put on a back, turn foot of a dischargeable shin inside to receive the separate image of tibial and fibular bones. Other parts of a body protect the leaded rubber.

Fig. 2. The diagrammatic representation of the changes found at X-ray inspection in a zone of an endostosis of a long tubular bone at rickets: and — a normal picture (it is given for comparison); — in the period of a heat of rickets depression of a zone of preliminary ossification with formation of a wide epimetafizarny enlightenment (it is specified by an arrow) and scyphoid deformation of a metaphysis is found; in — at the beginning of the period of reconvalescence there is a zone of preliminary calcification in a metaphysis (it is specified by an arrow); — at the end of the period of reconvalescence further expansion of a zone of calcification comes to light (it is specified by an arrow).
Fig. 3. The roentgenogram of bones of a forearm at rickets (a direct projection): shooters specified zones of reorganization of Loozer.

In structural pictures of bones of a shin and forearm at initial manifestations of R. thinning and disappearance of bone crossbeams ^ (trabeculas) — osteoporosis is defined. Further the trabecular structure of a bone due to development of vessels is broken. Zones of calcification of a cartilage on the ends of metaphyses lose the clearness of a structure and intensity, getting corroded outlines (fig. 2). The distance between ossification centers of an epiphysis and an epiphyseal bone plate increases. Ossification centers also gradually lose bone structure and do not come to light on the roentgenogram. In places of the continuous raised load, napr, from draft of muscles, the bone tissue resolves, forming so-called zones of reorganization of Looze-r (see. Loozera of a zone , fig. 3). Under a periosteum instead of normal bone substance also ossiform fabric giving on the roentgenogram an enlightenment in comparison with a shadow of compact substance of a diaphysis of a bone — a picture of a so-called periostosis is laid. At further development of R. system osteoporosis accrues, bones become soft, pliable, are easily deformed therefore are formed About - and H-shaped curvatures of the lower extremities; scyphoid deformation of the ends of a diaphysis of long tubular bones (fig. 2) comes to light.

In the course of treatment there is a bystry recovery of bone structure at the expense of a delay of salts and their adjournment much in places of the greatest destructions, i.e. in zones of an endostosis and under a periosteum. Regions of growth are unevenly reinforced, compact substance massive, structure of a bone tissue rough and shirokopetlisty. Gradually this changed part of metaphyses is removed by again created bone tissue with an equal zone of preliminary calcification, and its detection testifies to the postponed rickets (fig. 2, in, d). Deformation of a diaphysis of bones at the children who transferred R. is gradually leveled.

Differential diagnosis — The ruble called by deficit of vitamin D differentiate with rakhitopodobny diseases (see. Osteodystrophy ), arising owing to disturbances of exchange of vitamin D or a functional condition of the cells responsible for a homeostasis of calcium and phosphorus, at normal security with them. Treat such diseases pseudo-scarce vitamin - D-dependent rickets and vitamin - D-resistant rickets. At pseudo-scarce vitamin - D-dependent rickets is noted inborn disturbance of education 1,25 D3 dioxyvitamins in kidneys. Distinguishing characters of such R. are more expressed, than at usual R., a hypocalcemia with frequent attacks of spasms and inefficiency of treatment fiziol. doses of vitamin D (see. Osteopathy nephrogenic ). At inborn vitamin - D-resistant rickets (phosphate diabetes) the reabsorption of phosphorus in renal tubules is broken that causes a resistant hypophosphatemia (see. Phosphate diabetes ). Rakhitopodobny changes are noted also at de Tony's syndrome — Debra — Fankoni (see. De Tony — Debra — Fankoni a syndrome ) and renal canalicular acidosis (see. Laytvuda — Albright a syndrome ), a Down syndrome (see. Down disease ). At a chronic renal failure (see), Gee's diseases (see), a kistofibroza of a pancreas (see. Mucoviscidosis ), a sprue (see. Malabsorption syndrome ) in differential diagnosis symptoms of a basic disease are main.

At patients with chondrodystrophia (see) at rentgenol. a research intensive blackout of long tubular bones, fungoid thickenings in the field of an epiphysis, quite often osteophytes comes to light that is not characteristic of River. Contents at the same time 25 D3 oxyvitamin, calcium, phosphorus and activity of an alkaline phosphatase in blood remain within norm.

Hypotonia of muscles, a relaxation of ligaments, the centers of a softening in bones of a skull, characteristic of R., can be observed at inborn fragility of bones (see. Bone formation imperfect ). Existence of multiple, is frequent with shift, changes, sometimes pre-natal, absence rentgenol. changes in regions of growth of bones and characteristic biochemical shifts of blood allow to differentiate these diseases.

Mistakenly for R. it can be taken hypothyroidism (see), but lack of changes of metaphyses of bones, the corresponding biochemical shifts, characteristic of R., in blood, bystry development typical for a hypothyroidism a wedge, symptoms (a myxedema of skin, etc.) help with diagnosis.


R.'s Treatment complex taking into account the reasons promoting development of a disease. Correctly organized sleep pattern and wakefulnesses with sufficient stay in the fresh air, a balanced diet is of great importance (see. Feeding of children ). To children, sick R., the first feeding up (vegetable puree) is entered for a month before usual, the second feeding up is appointed from 4,5 months in the form of porridge on vegetable broth. Food shall contain enough complete protein that is provided with early introduction to a diet of cottage cheese, egg yolk, the wiped liver, meat, fish. It is necessary to avoid a large number of bread and flour products, and also fats, to-rye worsen absorption of calcium in intestines.

Lech. the dose of vitamin D is defined by severity of R., living conditions, the nature of feeding of the child and makes from 500 000 to 800 000 ME on a course of treatment. Drug is appointed daily in individually picked up dose under control of test of Sulkovich (see. Sulkovich test ), with the help a cut determine the content of calcium in urine. At positive test the dose of drug should be reduced. Duration of treatment is various and depends on normalization of activity of an alkaline phosphatase of blood and the condition of structure of a bone tissue defined at rentgenol. research.

For the purpose of normalization of exchange during 2 — 3 weeks appoint vitamins of group B (B1, B2, B6), pantothenate of calcium, nicotinic to - that, redoxons and E, citrates in the form of juice of a citrus or citrate mix on 1 chayn. l. 2 — 3 times a day within 10 — 12 days.

At medium-weight and heavy degree of R. for normalization of the broken energy balance disodium salt adenosine triphosphoric to - you intramusculary, daily on 0,5 — 1,0 ml of 1% of solution is recommended; on a course 20 — 40 injections.

At hypochromia anemia orally enter solutions of salts of copper, zinc, cobalt, and also appoint Haemostimulinum, ironic lactate, folic to - that, etc. during 2 — 5 weeks

Due to the disturbance of protein metabolism to especially premature children, with a hypotrophy, badly putting on weight, appoint nonsteroid anabolic drugs (orotat potassium at the rate of 10 — 20 mg to 1 kg of weight a day during 3 — 4 weeks).

At decrease in a muscle tone apply Dibazolum, prozerin in the dosages corresponding to age within 10 — 12 days.

1,52 — 2 months later after the end of treatment for prevention of a recurrence appoint a half dose of vitamin D to a course (under control of content of calcium in urine and blood) or the general UF-radiation. Drugs of calcium are appointed only to children with the expressed hypocalcemia and a rachitogenic tetany. To children 6 months are more senior are useful salt and coniferous bathtubs (see). At the expressed bone deformations and a hypomyotonia applications of paraffin, peat, therapeutic muds are effective heated sand (to children up to 2 years only on the lower extremities). Since the end of the 2nd week include the general massage and LFK in complex treatment.

LFK at R. apply as means of nonspecific therapy. Lech. gymnastics in combination with massage (see) exerts the normalizing impact on the broken exchange processes, promotes reduction of acidosis, normalization of function of a nervous system, helps more bystry recovery of psychomotor development, warns and korrigirut deformations of bones, exerts the general tonic impact on an organism of the sick child. Massage in combination with physical exercises strengthens exchange processes in skin that promotes formation of vitamin D in it. Classes of LFK can be given during the entire periods of a disease taking into account a wedge, courses of a disease, age and specific features of the child.

Contraindications to purpose of LFK are: general serious condition of the patient, phenomenon of toxicosis, sharp morbidity of muscles and bones, predisposition to fractures of bones.

The technique of LFK is defined by the period of a disease. In the period of a heat give individual classes lasting 8 — 10 min. with use of methods of the stroking massage of a trunk and extremities, passive gymnastic exercises at slow speed in limits fiziol. amplitudes of movements of a joint (to avoid overextension). Initial positions — lying on spin, on a stomach. Static loads are completely excluded.

In the period of reconvalescence the choice of physical exercises and methods of massage depends on the general condition of the child and level of its psychomotor development. All methods of massage (stroking, puddling, grinding, vibration), first of all for the most affected muscles are used (spins, a prelum abdominale, a rump). Gymnastic exercises are appointed according to the movement skills which are available for the child. Classes are given individually by 2 — 3 times a day, their duration of 12 — 15 min., initial is a prone position.

In the period of the residual phenomena use all means of LFK corresponding to age of the child. Physical exercises begin from various initial positions (lying, sitting, standing). Special attention should be paid to prevention of flat-footedness, correction of deformations of a backbone and shins. For this purpose apply massage and complexes to lay down. gymnastics, in to-rye include the special physical exercises promoting correction of specific rachitic deformations and exercises for strengthening of the struck muscular groups. Classes are given 2 — 3 times a day, duration of everyone increases up to 18 — 20 min. In summertime classes should be given in the fresh air or at an open window at a temperature not below 20 °.

Lech. gymnastics it is necessary to apply a long time both in a hospital, and in house conditions.

Forecast and Prevention

Forecast favorable.

Prevention begins till the birth of the child and consists in strict observance of the mode of work, rest and food of pregnant women. Vitamin D for the purpose of antenatal prevention of R. it is necessary to appoint pregnant only in the presence at them a wedge, symptoms of a D-hypovitaminosis and disturbance of phosphorus-calcium exchange, and also to pregnant women with extragenital pathology (diseases of a liver, kidneys, went. - kish. a path, rheumatism and defeats of cardiovascular system), at patol. course of pregnancy (toxicoses of the first and second half). Vitamin D appoint with 28 — 30th week of pregnancy daily. The daily dose is defined by specific features of the pregnant woman, season, klimatogeografichesky conditions.

R.'s prevention at the child is begun from the first days of life, paying special attention to nonspecific preventive actions (to the correct leaving, rational feeding, the maximum stay in the fresh air, to holding the tempering procedures).

Specific prevention of R. is appointed taking into account the state of health of the child at the birth, features of its bone system, the nature of feeding, living conditions. It is necessary to begin specific prevention to the full-term children with 3 — 4 weeks, premature with 2 weeks age. The preventive dose on a course makes 150 000 — 300 000 ME of vitamin D. Daily administration of vitamin D in a dose of 400 — 500 ME for all first year of life is recommended.

For the artificial and early mixed feeding use the nutritious mixes enriched with vitamin D — «Baby», «Kid», «Vitalakt» (see. Milk mixes ).

On the second year of life during the autumn and winter period to children with the preventive purpose appoint 1 — 2 course of UF-radiation on 20 — 25 sessions everyone (see. Ultraviolet radiation ) or citrate mix with simultaneous introduction of a half dose of vitamin D and vitamins of group B. In order to avoid D-vitamin intoxication it is not recommended to apply vitamin D and UF-radiation at the same time.

The children who transferred R. shall be under dispensary observation not less than 3 years, at the same time in the first 2 years they need systematic performing complex antirecurrent and rehabilitation treatment.

Bibliography: Bessonova M. N. Rickets, M., 1960, bibliogr.; Ginzburg E. Ya. and With about r about the h e to R. G. Remedial gymnastics and massage at rickets and a hypotrophy, M., 1952; Streets D to y S. O. Rakhit, M., 1953; Ivanovskaya T. E. and C and N-z e r l and N of A. V. Pathological anatomy (disease of children's age), page 38, M., 1976; Physiotherapy exercises at diseases at children's age, under the editorship of S. M. Ivanov * M., 1975; Maksudov G. B., etc. About radiodiagnosis of bone changes at vitamin - D-dependent rickets at children, Vopr. okhr. mat. also it is put., t. 26, No. 10, page 68, 1981; Sirs N. A., Gingold A. 3. Moskachev K. A. l. Radiodiagnosis in pediatrics, page 151, etc., M., 1972; Svyatkina K. A. Topical issues of fight against rickets, Pediatrics, century 9, page 50, 1964; Svyatkina K. A., Hvul A. M. and the Brine about' - in and M. A. Rakhit, M., 1964, bibliogr.; Round A. F. Rakhit, L., 1966, bibliogr.; Moustaches I. N. and Stankievich 3. And. Rickets at children, M., 1980, bibliogr.; F onarev M. I. and Fonarev T. A. Medical physical culture at children's diseases, L., 1981; Glisson F. and. lake of De rachitide, sive morbo puerili qui vulgo «the rickets», dicitur, tractatus, L., 1650; Huldschinsky K. Heilung von Rachitis durch kiinstliche Hohensonne, Dtsch. med. Wschr., S. 712, 1919; Stowens D. Pediatric pathology, p. 147, Baltimore, 1966.

E. M. Lukyanova, V. B. Spirichev; S. M. Ivanov (to lay down. physical.), T.E. Ivanovskaya (stalemate. An), K. A. Moskacheva (rents.).