Rickets or just underfed with growing pains?

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Dear All,
Just had a patient in who really tested my skills, I can't fully work out if it's normal for their age and the recent vitamin D press is warping my mind into thinking it's something else or... if I'm right in thinking that this is just not right in a child of this age.

. 4 years 9 months boy, recently moved from Eastern Europe
. Small for age (I didn't have a measuring scale in this particular room but I am 5'10 and the top of his head came to the top of my femur, sorry for crude measurement)
. Flagged up as underweight at school assessments, weighs approximately 14kg, referred to paediatric dietician but DNA's appointments
. VERY thin legs with no muscle development, I can grasp his femur and my fingers and thumb will touch
. Genu valgum with medial protrusion of femur, typical windswept knee appearance. Although legs are tiny his knee joints are like tennis balls and huge in respect to his legs.
. Pain in knees and along line of tibia, worse at night, will keep him up and he crys wth pain and parents give paracetamol
. Waist is tiny, I was going to measure this but his father was not keen
. Pronation in feet but normal for age
. Healthy birth but accoarding to father walked at 6 months?!

Any advice on what you think this maybe, my mind is thinking Rickets or a similar malabsorption problem especially with the presentation of the knees. I just think it's something which needs to be referred on as this can't be right? I've given some paediatric arch supports today to lightly correct the pronation on the theory it will have a slight knock on effect on the knees
Please elaborate with as much information if you can as I'm always keen to learn and be prepared for seeing it next time also if I haven't included something you want to know let me know and I'll include it, there must be something I have forgotten haha
Thank you in Advance

 

If he has seen you for podiatric referral I would assume he has a pediatrician.
If he has no Primary Care provider the prudent thing to do is have the patient's parents find one and have a general exam, along with the usual labs.

Your description, although not mentioning other joints, does sound like he may be suffering the effects of malnutrition or developmental pathology.

Steve

 

Hi Steve,
Thank you for your reply.
With regards to the other joints I was keen to have a look but his father was very neglectant to let me see more than I absolutely had to, however when holding his shoulders and elbows etc to check correct alignment you can really feel that they are of the same, very large round joints with very small bones. He only gets pain in the lower limbs. His face is very sallow and pale and although he appears happy and looks healthy at first glance on closer scrutinity it is obvious to see that something is wrong.
He has recently migrated from a neighbouring trust and has never seen a paediatrician, I've referred him over to one today after seeing him yesterday expressing my concerns.
It is good to know that I am along the right lines though

 

Hi Kerrie,

I read your post first thing this morning and was going to reply that you should refer on without hesitation.

On re-reading (after the dogs had been taken out:morning your second post shows that you've done this already - so job done really.

My only other comment is that your referral should be marked urgent, and you should follow up with a polite request(s) for progression of referral until you know that the child has been seen. Oh, and document everything of course.

As pods our training mandates we have a duty of care to each patient. In real terms this means that we could be called to give evidence if the patient is at-risk and we fail to take appropriate action. Worst case scenerio is that we could be accused of clinical negligence if, hypothetically, an at-risk child was knowingly sidelined (ie put on a non-urgent referral list which may extend because of holidays or illness) by the GP or NHS Trust admin because they were not aware of the urgency of the case.

Thanks for highlighting this interesting case.

 

could be Coeliac disease, but would need bloods to ascertain this.

 

Kerrie, nothing to do with the thread but the Title

There are no such things as growing pains.

Pains in growing children occur for many reason and some can be because of growth, which has caused changes in forces acting on bone, ligament etc etc

But growing pains is not a diagnosis a fine but very important line imo

 

I've marked it as Urgent and followed up with a call to the GP surgery. I've asked the GP to inform me of the progress of the referral and have also touched base with the paediatrician and also the community paediatric dietician informing them that he will probably DNA but needs to be chased up relentlessly. Let's hope it goes the way we want.
I'm intending to review him at 3-6 monthly intervals to track his growth and hopefully weigh and measure his height etc as the parents don't seem to mind coming to theses appointments. I'm also thinking for my own benefit of doing a case study on him as I'm looking to do PGCert in Paediatrics next year