Rickets

What Is Rickets?

[dropcap]R[/dropcap]ickets is a disorder of cartilage cell growth and enlargement of epiphyseal growth plates in young children that is characterized by inadequate mineralization of developing cartilage and newly formed bone.

The epiphyseal growth plate is located at the ends of the long bones of the arms and legs and controls the growth of these bones. Enlargement of the plate area gives the physical appearance of thick joints at the wrists, knees, and ankles.

Q: What is inadequate mineralization of bone tissue?

A: Inadequate mineralization means there is not sufficient calcium, magnesium, phosphorus and other minerals available to give bone that is replacing cartilage in a young child its necessary strength during the period of enchondral bone formation. Consequently, long bones bend under the weight of the body and become deformed.

Children 4 to 18 months of age worldwide are at risk of developing rickets.

What Is Rickets In Celiac Disease and/or Gluten Sensitivity?

• Relationship between rickets and celiac disease. Rickets is a serious complication of celiac disease and may be a presenting feature of untreated celiac disease.
• Relationship between rickets and presentation. Rickets was found to be a presenting complaint in 6% of patients diagnosed with celiac disease at a hospital endocrine department.¹
• Relationship between rickets and fetal development. Undiagnosed celiac disease in a mother is reported to have caused fatal rickets in her unborn baby who was stillborn due to impaired fetal development.²..

How Prevalent Is Rickets In Celiac Disease and/or Gluten Sensitivity?

Rickets has increased frequency in celiac disease. 8% of pediatric patients diagnosed with celiac disease at a hospital endocrinology department in India had rickets.¹

What Are The Symptoms Of Rickets?

The symptoms of rickets include the following:

• Abnormalities in the shape of the skeleton, including bowlegs (knees are wide apart) or knock knees (knees hit each other or cross over), and pigeon breast, meaning the breast bone protrudes forward.
• Abnormalities in the structure of the skeleton, including enlargement of wrists and ankles and beading of ends of ribs (called rachitic rosary).
• Abnormalities in the strength of the skeleton causing deformities.
• Lethargy.
• Muscle weakness advancing to flaccid muscles.
• Delayed tooth eruption.
• Bone pain and tenderness.
• Early signs are profuse sweating, restlessness and irritability.
• In infants, delayed closure of the fontanels (soft spots in skull) and softening of the skull occur.

How Do Rickets Develop In Celiac Disease and/or Gluten Sensitivity?

• Rickets results from deficiency of vitamin D and phosphorus due to malabsorption in gluten sensitive enteropathy.

Do Rickets Respond To Gluten-Free Diet?

Yes. Rickets in celiac disease respond to gluten free diet.³

6 Steps To Improve Rickets In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both rickets and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁴
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁵
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁵
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁵.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁵
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁵
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁵[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications deplete vitamin D and phophorus that are the cause of rickets. Ask your doctor or pharmacist about this possible adverse effect if taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

DIURETICS

• Loop Diuretics (Lasix®, Bumex®, Edecrin®) deplete Phosphorus.
• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Phosphorus.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) bind and deplete Vitamin D, phosphorus.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin D, Phosphorus.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin D. [/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin D3 as prescribed following blood test for status.
• Phosphorus as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Rickets In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Endocrine manifestations of celiac disease.” This study investigating the prevalence of endocrinopathies in 36 patients who were diagnosed with celiac disease at a hospital endocrinology department found rickets in 6%.

The endocrine manifestations include (after complete evaluation) short stature (58%), delayed puberty (31%), elevated alkaline phospahatase (67%), low calcium (22%), X-rays suggestive of osteomalacia or rickets (8%), carpopedal spasm (6%), and night blindness (6%). Anti-TPO antibody positivity was found in 53%, hypothyroidism in 28%, subclinical hypothyroidism in 17%, and type-1 DM in 25% of the patients. A total of 14% patients had no GI symptoms.¹

CASE REPORT SUMMARIES

“Severe rickets in a young girl caused by celiac disease: the tragedy of delayed diagnosis: a case report.” This case report describes diagnosing celiac disease in a 13 year old female from the middle east with an 8 year history of severe rickets causing multiple bone deformities due to malabsorption. The child became crippled with bowing of both of her arms and legs. The patient was also found to have growth failure and anemia. The reporting physicians state, ” Celiac disease should be kept in mind as a cause of rickets in patients not responding to usual forms of treatment or when associated with other manifestations of malabsorption.”⁶

“Fatal rickets in the fetus and undiagnosed maternal celiac disease.” This case report describes the effect of undiagnosed celiac disease in a pregnant woman who gave birth to a stillborn fetus via normal delivery after 34 weeks of gestation. The fetus presented severe morphological alterations due to hypomineralization which were compatible with rickets. In the medical literature congenital rickets secondary to maternal celiac disease due to malabsorption is rare. The reporting physicians state, “We discuss the current knowledge on maternofetal phospho-calcium metabolism and relate active celiac disease with severe hypocalcaemia during pregnancy and fatal rickets in the fetus. We recommend screening for celiac disease in pregnant women with signs of malabsorption or impaired fetal development.”².

“Proximal muscle weakness-an unusual presentation of celiac disease.” This case report of an 11 year old girl with Celiac Disease who had rickets masquerading as proximal muscle weakness and bone pain describes the importance of identifying the etiology of metabolic bone disease that leads to myopathy (muscle problems). This type of muscle weakness often responds fully to treatment.³

Sources:

1. Philip R, Patidar P, Saran S, Agarwal P, Gupta K. Endocrine manifestations of celiac disease. Indian J Endocrinol Metab. 2012 December; 16(Suppl 2): S506–S508. [↩] [↩] [↩]
2. Soler-Bel J, Veganzones I, Navarro A, Ramos F, Serra-Buxeda E, Ferreres JC. Fatal rickets in the fetus and undiagnosed maternal celiac disease. Gastroenterol Hepatol. 2011 Dec;34(10):678-82. doi: 10.1016/j.gastrohep.2011.05.006. [↩] [↩]
3. Jain V, Angitii RR, Singh S, Thapa BR, Kumar L. Proximal muscle weakness-an unusual presentation of celiac disease. Journal of Tropical Pediatrics. Dec 2002;48(6):380-1. [↩] [↩]
4. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
5. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
6. Al-Sharafi BA, Al-Imad SA, Shamshair AM, et al. Severe rickets in a young girl caused by celiac disease: the tragedy of delayed diagnosis: a case report. BMC Res Notes. 2014 Oct 8;7:701. doi: 10.1186/1756-0500-7-701. [↩]