Which of the following is the most appropriate approach to manage nutritional rickets?

Explanation

Core Concept: Nutritional rickets is treated with cholecalciferol — vitamin D3 — together with adequate calcium intake. D3 is the physiological human form and raises and sustains 25-hydroxyvitamin D more effectively than ergocalciferol (D2).

Clinical Presentation:

• Delayed closure of fontanelles, craniotabes, frontal bossing, rachitic rosary, wrist widening, bowed legs and delayed walking.
• Hypocalcaemic seizures or tetany in severe deficiency.

Diagnosis:

• First-line: serum calcium, phosphate, alkaline phosphatase (raised), parathyroid hormone (raised) and 25-hydroxyvitamin D (low).
• Radiographs of the wrist or knee show cupping, fraying and widening of the metaphyses.

Management:

• Acute: daily oral vitamin D3 for several weeks-to-months (dose by age), always with calcium supplementation to prevent hungry bone syndrome.
• Long-term: maintenance vitamin D, sunlight exposure and dietary advice; recheck biochemistry and radiographs for healing. Vitamins D1 and D4 are not agents used in clinical practice.