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1、,Rickets of Vitamin D Deficiency维生素D缺乏性佝偻病,Definition,Rickets, a deformative disease that occurs among children, are characterized by deficient mineralization of the bone matrix（骨基质） as a result of deficiencies of calcium or phosphorus or both. Defective mineralization at the growth plate Osteomalac
2、ia（骨软化） at the corticoendosteal level,Source and Metabolism of Vitamin D,Animal food： Vit D3 Vegetal food: Vit D2ergosterin(麦角固醇) ergocalciferol(麦角骨化醇),Endogenic Vit D3main source,Ectogenic VitDfrom food,intestine,blood,liver 25-hydroxylase,DBP,kidney 1-hydroxylase,intestine、kidney、bone,Mother-fetus
3、 transportation,7-dehydrocholesterol,296310nm,ultraviolet rays,Cholecalciferol 胆骨化醇,Vit D,liver 25-hydroxylase,kidney 1-hydroxylase,25-（OH）D3,1，25-（OH）2 D3,Ca ,（-）,（-）,（-）,P,（+）,GH,（+）,（-）,维生素D,Regulation,（-）,Ca ,P,Etiology,less outdoor activityhigh buildingspollutionseason,Inadequate exposure to su
4、nlight,Prevalence,Spring Autumn,City Countryside,North South,Dark skin White skin,Etiology,VitD3calcium,inhibition,P,fibers,vegetable,Insufficient intake,little VitD in infant food,Etiology,prematurelow- birth weight twinsinfantsadolescents,Rapid growth,Etiology,Diseases,Celiac disease Cystic diseas
5、e Anticonvulsant therapy Glucocorticoid Others,VitD deficiency,Ca P ,Pathology,Clinical signs,rickets,tetany,Clinical manifestation,Most common in three months to two years oldSkeleton changesLoose muscleNeurologic excitement,Clinical manifestation,Initial stage,Below 6 monthNeurologic excitement :
6、restless, night cry or terror, sweatSkeleton changesLaboratorial tests: 25(OH)D3，Ca ， P ，PTH ，AKP ,Clinical manifestation,Active stage,skeleton,head,6mon epiphyseal enlargement at wrists and ankles12mon bowlegs, knock-knees,Clinical manifestation,Active stage,skeleton,Spine,kyphosis (驼背)Scoliosis (脊
7、柱侧突)Rachitic dwarfism(佝偻病矮小),Clinical manifestation,Active stage,muscle,Motor delayLoose muscle,Laboratory,change more obviously,Clinical manifestation,Active stage,X-ray,Rachitic metaphyses (干骺端改变)* 钙化带消失、杯口状、毛刷状* 骨骺软骨带增宽（2mm）* 骨质疏松、骨皮质变薄、骨干弯曲、青枝骨折,Clinical manifestation,Symptoms and signs 不规则钙化线，钙
8、化带致密增宽、骨质密度逐渐恢复,Recovery,Blood Ca、P,Blood AKP,X-ray,Several days,2 to 3 weeks,1 to 2 month,normal,X-ray,Clinical manifestation,Sequelae,Most after 2 years oldDeformity or dyskinesia,Diagnosis,History Clinical manifestation Serum calcium level () Serum phosphorus level Serum alkaline phosphatase leve
9、l 25(OH)D38ng/ml,Treatment,Natural sunlight Oral administration of VitDVitD 2000-6000 IU/d 2-4w 400IU/d Impulsive injection of VitDVitD 30-60万IU 2-3 times 400IU/d Calcium 0.5-1.0g/d Othopedics,Prevention,Nutrition Exposure to sunlight Oral administration of VitD 400IU/d (2w-2y) Double for LBW, prema
10、ture and twins EP: VitD 500-1000Iu/d,Differentiate diagnosis,男，12岁，因身材矮小、行走乏力而就诊 3岁前生长基本正常 家族中有类似患者 曾给予VitD治疗，无效；后服用罗钙全（活性VitD），并同时补充磷制剂 身高132cm 血钙正常，血磷明显降低，25(OH)D3正常 X线杯口状比去年更严重,Diagnosis？Why？,Case study,Summary,Pathology Clinical manifestation Diagnosis Treatment and prevention,Reference,维生素D缺乏性佝
11、偻病防治建议。中华儿科杂志2008，46（3）：190-191Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 2008; 122:1142-1152儿童低磷抗维生素D佝偻病23例。临床荟萃2008，23（3）：205-206,维生素D缺乏性佝偻病防治建议,我国儿科重点防治的四病之一 预防：妊娠后期（秋冬） VitD400-1000Iu/日有条件，妊娠后3个月监测25(OH)D3重点对象1岁内，系统管理到3岁积极预防上感、肺炎、腹泻、贫血等婴儿尽早户外
12、活动，逐渐达1-2小时/天生后2周补充VitD400Iu/日，直到2岁早产儿、低出生体重、双胎补充 VitD800-1000Iu /d， 3个月后改为400Iu/日,孕妇,婴 幼 儿,维生素D缺乏性佝偻病防治建议,诊断* VitD缺乏高危因素、临床症状和体征有助于诊断* 确诊需血生化、骨X线摄片* 血清25(OH)D是VitD营养状况的最佳指标，应逐步推广 治疗* 治疗原则以口服为主，强调个体化给药* Vit D 2000-4000 IU/日，1月后改为400 IU/日 * 口服困难或腹泻影响吸收时，大剂量突击疗法 Vit D15-30万 IU, 肌注，1-3个月后改为口服预防量400 IU/
13、日 * 用药1个月后随访，无改善应考虑其他疾病 * 避免高钙血症、高钙尿症、 VitD过量,Prevention of rickets and vitamin D deficiency in infants, children, and adolescents,The recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed and older children and ad
14、olescents. It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. The current recommendation replaces the previous recommendation of a minimum daily intake of 200 IU/day of vitamin D supplementation b
15、eginning in the first 2 months after birth and continuing through adolescence. These revised guidelines for vitamin D intake for healthy infants, children, and adolescents are based on evidence from new clinical trials and the historical precedence of safely giving 400 IU of vitamin D per day in the pediatric and adolescent population.,
