Which of the following is the earliest sign of rickets?

NVS Staff Nurse - 2019

Child Health Nursing (Pediatrics)

Easy

Appeared in: NVS Staff Nurse - 2019

Explanation

Craniotabes is the earliest clinical sign of rickets, typically appearing in early infancy (around 3-6 months).
It is characterized by a softening of the skull bones, particularly the occipital and parietal bones, which indent easily under pressure, similar to a ping-pong ball.
This sign manifests before the more widely known deformities of the chest (like rachitic rosary) and limbs (like bowlegs) develop.

Option A: Harrison groove is a later sign of rickets. It is a horizontal depression on the lower part of the chest caused by the pull of the diaphragm on the softened rib cage.
Option B: Bowlegs (genu varum) is a deformity that appears much later. It is caused by the stress of weight-bearing on softened leg bones and only becomes evident after a child starts to stand and walk.
Option D: Rachitic rosary refers to the palpable and sometimes visible enlargement of the costochondral junctions of the ribs. This is a sign of changes in the thoracic skeleton and appears later than craniotabes.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Chronological order of clinical signs in Rickets as background academic context rather than a clinical decision trigger.
Early recognition of craniotabes by a nurse during routine infant assessment is critical for timely intervention with vitamin D and calcium, which can prevent severe, irreversible skeletal deformities.
Nurses play a key role in health education, particularly in advising mothers who exclusively breastfeed about the importance of Vitamin D supplementation (400 IU/day) for the infant to prevent nutritional rickets.
What if? If an infant presents with seizures (hypocalcemic tetany) but no obvious skeletal deformities, rickets should still be a strong differential diagnosis. Severe hypocalcemia can manifest before the classic bone changes are prominent, and craniotabes may be the only subtle physical sign.

How to Approach the Question

First, identify the core concept of the question, which is the chronological appearance of signs in the disease process of rickets.
Recall the pathophysiology: rickets affects growing bones due to poor mineralization. The skull bones grow rapidly in early infancy, making them susceptible to early changes.
Consider the options in the context of an infant's physical development. Craniotabes affects the skull and can be assessed from birth.
Signs like rachitic rosary and Harrison groove involve the chest wall, which shows changes after the deficiency has been present for some time.
Bowlegs is a weight-bearing deformity, so it logically cannot appear until after the child starts standing or walking.
By this process of elimination and understanding of developmental milestones, conclude that the sign affecting the skull (Craniotabes) is the earliest to manifest.

Concept Tested & Keywords

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E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 103-105

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 517-519