# Nutritional rickets (vitamin D deficiency rickets) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Rickets - StatPearls (NCBI Bookshelf NBK562285) - https://www.ncbi.nlm.nih.gov/books/NBK562285/ · MSF Essential Drugs 2024 (colecalciferol oral monograph, prevention and treatment of vitamin D deficiency) · Nutritional rickets - disease-level clinical article (nutritional-rickets-full.txt) · Nutritional rickets - disease-level clinical article (nutritional-rickets-clinical.txt) - Verified date: 2026-08 ## Verified against - Rickets - StatPearls (NCBI Bookshelf NBK562285) - https://www.ncbi.nlm.nih.gov/books/NBK562285/ - MSF Essential Drugs 2024 (colecalciferol oral monograph, prevention and treatment of vitamin D deficiency) - Nutritional rickets - disease-level clinical article (nutritional-rickets-full.txt) - Nutritional rickets - disease-level clinical article (nutritional-rickets-clinical.txt) ## Treatment metadata - Cholecalciferol — oral.liquid - Referral & safety-netting (no drug therapy) - Calcium carbonate — 500 mg — oral.solid ## Complete treatment card ```text NUTRITIONAL RICKETS (VITAMIN D DEFICIENCY RICKETS) Sources: Rickets - StatPearls (NCBI Bookshelf NBK562285) - https://www.ncbi.nlm.nih.gov/books/NBK562285/ · MSF Essential Drugs 2024 (colecalciferol oral monograph, prevention and treatment of vitamin D deficiency) · Nutritional rickets - disease-level clinical article (nutritional-rickets-full.txt) · Nutritional rickets - disease-level clinical article (nutritional-rickets-clinical.txt) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - A family history of skeletal problems, stunted growth, or consanguinity suggests a genetic cause [stunted growth] - Bone pain often shows as irritability, along with a gait problem and slowed growth [bone pain · irritability] - Tingling, tetany, muscle spasms, and convulsions can occur from the associated hypocalcemia [muscle cramps · seizures · tingling] - A full skeletal and dental exam should be paired with the history SIGNS - what you find (5) - Skull softening (craniotabes) past 3 months, with frontal bossing and wide fontanels, are signs - A rachitic rosary, pigeon chest, and Harrison's groove are chest exam findings - Bow legs, knock knees, and joint swelling emerge once the child starts walking [foot deformity · joint swelling] - Wrist widening reflects upper-limb involvement, mainly from rapid ulnar growth - Spinal deformity with kyphosis can be present [visible deformity] TESTS (9) - Serum alkaline phosphatase is the key marker, raised from increased osteoblast activity - ALP runs 400 to 800 IU/L in phosphopenic rickets and up to or above 2000 IU/L in calcipenic rickets - Most children with vitamin D deficiency rickets have a 25-hydroxyvitamin D under 10 ng/mL - Deficiency is set below 30 ng/mL, insufficiency 30 to 50 ng/mL, adequate above 50 ng/mL - Routine 25-hydroxyvitamin D testing is not advised for healthy children - Calcium and PTH stay normal in phosphopenic rickets, while calcipenic rickets keeps calcium low or normal via a PTH rise - The earliest x-ray sign is a widened, radiolucent growth plate at the epiphysis-metaphysis junction - Metaphyseal cupping, splaying, and fraying show up as rachitic x-ray changes - Diagnosis is confirmed by combining clinical signs, abnormal ALP/calcium/phosphate, and typical x-ray findings IF NOT THIS - what else fits (8) - Renal osteodystrophy arises from low active vitamin D, acidosis, and phosphate retention in kidney disease - Transient hyperphosphatasemia raises ALP in under-5s but keeps liver enzymes and vitamin D normal - Cholestatic liver disease raises ALP together with elevated gamma-glutamyl transferase - Primary hypoparathyroidism is a differential cause of low calcium - Osteogenesis imperfecta and congenital syphilis are other bone-disease mimics - Bowlegs can be a normal finding under age 2 - Achondroplasia is a skeletal dysplasia differential - Blount disease causes pathologic bow legs from disrupted growth at the medial proximal tibia Source StatPearls "Rickets" - disease-level clinical article Status traced to the source above 1. CHOLECALCIFEROL [1st line] Adult 50,000 IU of vitamin D weekly for six weeks, then maintenance at 400-600 IU daily (U.S. Endocrine Society, as reported in the disease article) x 2-3 months intensive, then daily maintenance Peds Under 1 month: 1000 IU once daily for 2 to 3 months, then 400 IU daily 1 to 12 months: 1000 to 5000 IU once daily for 2 to 3 months, then 400 IU daily Over 12 months: 5000 IU once daily for 2 to 3 months, then 400 IU daily (Daily oral treatment (disease article): infants < 1 month 1000 IU; 1-12 months 1000-5000 IU; > 12 months 5000 IU - each once daily for 2-3 months. Maintenance after that is 400 IU daily. The article prefers the oral route because it restores vitamin D faster.) Source Nutritional rickets - disease-level clinical article (nutritional-rickets-full.txt) Why Indication and dose come from the same disease-level article, which states both. The intensive phase runs two to three months and is given together with calcium. The daily amounts by age: under 1 month, 1000 IU; 1-12 months, 1000 to 5000 IU; over 12 months, 5000 IU - each for 2-3 months. Named Cholecalciferol because that is the Egyptian register's spelling - it resolves 65 oral-liquid products, while Colecalciferol (the MSF/INN spelling) resolves none. Caution GIVE CALCIUM WITH IT. The intensive stretch of vitamin D treatment runs two to three months, and alongside it goes calcium - 500 mg, from food or from a supplement - for any child whose diet does not supply enough. Vitamin D alone can precipitate hypocalcaemia as bone remineralises. MSF Essential Drugs 2024 gives lower figures for the same treatment. Under 3 months: 2 000 IU daily, for 3 months. Age 3 months and over, but under 12 months: give 2 000 IU daily for 3 months - or a single 50 000 IU dose. Age 12 months and over, but under 12 years: give 3 000 to 6 000 IU daily for 3 months - or a single 150 000 IU dose. The two documents disagree on the >12-month daily figure (5000 IU vs 3000-6000 IU, which overlaps) and on the under-1-month figure (1000 IU vs 2000 IU). Either schedule is sourced; do not average them. SINGLE HIGH-DOSE (stoss) therapy exists but is not a routine clinic dose: 100,000 to 600,000 IU (international units), given by mouth or into muscle, in an infant older than 1 month. (Rickets - StatPearls - NCBI Bookshelf, NBK562285) Not for infants under 1 month. MSF ceiling: do NOT go above 600 000 IU in a year. Contra-indications (MSF): do NOT give it where there is hypercalcaemia, hypercalciuria, calcic lithiasis, or severe renal impairment. MSF: STOP the treatment where signs of overdose appear - headache, loss of appetite, nausea, vomiting, thirst that has increased, passing a lot of urine. And do NOT combine it with a thiazide diuretic. MONITOR - measure a random urine calcium-to-creatinine ratio, to see whether the calcium in the urine is rising, to pick up hypercalciuria, and so to head off nephrocalcinosis. MSF adds that the calcium in blood and in urine should be watched where it can be, while the curative course runs. PREVENTION, which is the point in Cairo: rickets is preventable by giving every infant vitamin D by mouth, 400 IU a day, through the first year of life - to any breastfed baby, and to any baby taking under 500 mL of fortified formula a day. The number of IU per drop differs between Egyptian brands. MSF notes that how many IU a drop of the oral solution holds depends on the manufacturer, and asks you to read the instructions. Read the specific bottle before counting drops. Egypt UR-D 200 I.U./ML ORAL DROPS 25 ML HI-PHARM 21.60 EGP D3 BOX DROPS 15 ML ORGANIX INDUS... 22.00 EGP VIDROP 2800 I.U./ML ORAL DROPS 15 ML MUP 26.00 EGP ONEFEROL BONE 2800 I.U./ML ORAL DROPS 30 ML PHARMAZAD > PHARMA ONE 46.00 EGP CHILDAL ORAL DROPS 30 ML BRAND PHARMA ... 60.00 EGP CHOLETRIX-D3 400 IU ORAL DROPS 30ML COPAD EGYPT > IBM PHARMA 75.00 EGP VITAMIN D 2000IU 30ML ORAL DROPS ORGANIX > SOU... 165.00 EGP KIDDO 3 ORAL DROPS 10 ML PRO-BIO PHARMA > 300.00 EGP D3-TAG 1000 IU/ML ORAL DROPS 30ML > TAG PHARMA 27.00 EGP -> ? strength differs, ? different route - not oral liquid PEDYANO D SYRUP15ML ORGANIX > PED... 35.00 EGP -> ? strength differs, ? different route - not oral liquid 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Nutritional rickets - disease-level clinical article (nutritional-rickets-clinical.txt) Why Carries the referral criteria, the emergency complication, and the normal finding that is most often mistaken for rickets. Caution RED FLAG - a low calcium that persists leads on to complications: myopathy of skeletal muscle and of the heart, seizures, and in the end death. (Rickets - StatPearls - NCBI Bookshelf, NBK562285) A rickets child with tetany, stridor or a seizure is an emergency, not a clinic follow-up. REFER - where rickets arises from a genetic condition, the right hands are a paediatric endocrinologist's, a metabolic bone specialist's, or both. (Rickets - StatPearls - NCBI Bookshelf, NBK562285) Rickets that does not respond to adequate vitamin D and calcium is not nutritional rickets. DO NOT OVER-DIAGNOSE - bowing of the legs is a normal finding in a child under 2 years. (Rickets - StatPearls - NCBI Bookshelf, NBK562285) Bowing alone in a toddler is not rickets. Nutritional rickets is a diagnosis made on biochemistry and radiology, not on appearance alone. Confirm before committing a child to months of high-dose vitamin D. 3. CALCIUM CARBONATE [add-on - not a substitute] Adult 500 mg of calcium once daily alongside the vitamin D, where dietary calcium is insufficient - The first 3 months of curative treatment Peds 500 mg of calcium once daily, by diet or supplement, for the first 2-3 months of treatment. Both documents give one figure for all paediatric ages and neither states a mg/kg dose, so none is printed here. Source Nutritional rickets - disease-level clinical article (nutritional-rickets-full.txt) Why Indication and dose both stated by the disease article: the intensive phase of vitamin D runs two to three months alongside calcium - 500 mg of it, from the diet or as a supplement - for any child whose dietary calcium falls short. MSF Essential Drugs 2024 gives the same figure under colecalciferol: through the first 3 months of curative treatment, 500 mg of calcium once daily. Healing rickets is a calcium sink; vitamin D without calcium is half a treatment. Caution ELEMENTAL CALCIUM, NOT TABLET WEIGHT. Both documents say 500 mg of CALCIUM. An Egyptian product labelled "500 mg" is usually 500 mg of calcium carbonate SALT, which is about 200 mg of elemental calcium. Read the elemental figure on the pack before deciding how many to give; a 500 mg carbonate tablet is not a 500 mg calcium dose. Dietary calcium counts - the article lets the 500 mg come from food just as well as from a supplement (Rickets - StatPearls - NCBI Bookshelf, NBK562285). Milk, yoghurt and cheese may already cover it. Give it with the vitamin D course, not instead of it. Watch for the same overdose picture as vitamin D: constipation, thirst, polyuria, vomiting. Egypt OSCASEEF 500MG 30 CAPS. SAFE PHARMA 21.75 EGP (0.72/unit) CALCIMATE 500 MG 12 CAPS. EL NASR 20.00 EGP (1.67/unit) CARIBO 500MG 50 CHEW. TABS. AL ESRAA PHAR... 18.00 EGP CALCINEX PLUS SYRUP 120 ML FAMILY PHARMA... 59.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)