Introduction

Kashyapa says, in a normal child, one year of age is the maximum time to attain milestone of walking enabling the child to walk few independent steps. Child failing to attain the same, with delayed motor developmental milestones by one year due to various causes should be considered as victim of Phakka. Phakka disease is classified under Kuposhanajanya Vyadhi.^[3] A lack of adequate mineralization of growing bones results in rickets.^[4] The term Rickets is derived from English word wrick (twist) and Greek word rachitis means excess of osteoid tissue. It causes the bones to become soft and weak which can lead to bone deformities. Rickets can cause bone pain, poor growth and deformity of the skeleton such as bow legs, curvature of the spine and thickening of the ankles, wrists and knees.

According to Acharya Kashyapa, Phakka Roga mainly classify into three groups on the basis of their causes as follows.

• Kshiraja Phakka
• Garbhaja Phakka
• Vyadhija Phakka.

1. Kshiraja Phakka^[5] - It occurs due to Kaphajstanya sevan by the child (Balak) and child (Balak) become Krusha. Phakka-Dugdha which is vitiated with Kapha dosha causes obstruction in Rasavaha Srotasa and cause nutritional deficiency in a child resulting in to Kshiraja Phakka Roga.

2. Garbhaja Phakka^[6] - When a nourishing Mother / Dhatri conceives during breast feeding period, causes deficient milk secretion. There is less nutritional content in milk which is required for growth and development of child. There by the Balak gets emaciated due to malnourishment. This condition gives rise to Garbhaja Phakka.

3. Vyadhija Phakka^[7] - In Vyadhija Phakka child suffers from Ksheenata of Mansa, Bal becomes emaciated due to Nij and Aagantujadi Roga (disease). Different Nija Rogas which arise due to Dosha vitiation, i.e., systemic disorders like different types of virulent infectious disorders causing fever, when occurs repeatedly are the causes of failure to thrive (Jwaradhibhi). Similarly, different Agantuja Rogas which arise due to environmental hazards like air, water, pollution, food poisoning, adulteration,

2) Vitamin D increases calcium and phosphorus absorption in intestine.
3) For reabsorption of phosphate by renal tubular cells and raise the level of phosphate in the blood.
4) In normal growth of bones, the bone forming cells appears as cartilage cells which degenerate and disappear (apoptosis) and calcium and phosphorus are deposited in vitamin D deficiency cartilage cell do not degenerate but continue the grow.
5) For regulation of immune system.
6) Stimulation of cell differentiation.

Metabolic Changes in Rickets^[10]

1) Vit D Deficiency leads to decreased calcium and phosphate absorption from intestine which leads to decreased level of calcium and phosphate.
2) Compensatory mechanism by parathyroid hormone (PTH) causes a) Reduced calcium excretion by kidney b) Calcium released from bones c) Decreased Renal tubular reabsorption of phosphate.
3) Sr calcium returns to normal but phosphate level falls.
4) There is Prolonged vit D deficiency. Even PTH cannot sustained its action.
5) Sr calcium and phosphate both levels decrease and there is Increased osteoblastic activity.

Important changes in Rickets^[11]

• General

1) Failure to thrive
2) Protruded abdomen
3) Increase risk of respiratory infection
4) Increase risk of fracture
5) Pot -belly due to hypotonia of abdominal muscle

• Craniofacial changes

1) Craniotabes
2) Frontal and parietal bossing
3) Large anterior fontanel and delayed closure of anterior fontanel.
4) Delayed dentition and dental caries

Thoracic changes

1) Rachitic rosary: Beading of costochondral junctions.
2) Harrison sulcus: A groove / depression along the lower costal margins.
3) Sternal Deformities like pectus excavatum i.e., depression of sternum.
4) Pigeon - Chest deformity.

1. Sarvang Snehan: By Bala tail/ Chandanbalalakshadi Tail/ Raj Tail/ Narayan Tail
2. Sarvang Swedan a) Bashpa Swedan with Dashmulbharad Churna. b) Nadi Sweda with Vataghna Dravya c) Swedan with Shalishastik Pindasweda.
3. Physiotherapy and use of Phakka Ratha For prevention of Phakka Roga Ayurveda has suggested Nashya, Dhuma, Gandush, Pradeha, Parisheka and Kaphashamaka Dhara.^[16]

Treatment of Rickets (According to Modern science)^[17,18]

A) Neonate and infant - Administration of vitamin D 2000 IU/Day and 1 to 18 years Administration of vitamin D 3000 to 6000 IU/Day minimum for 3 months along with oral calcium supplement 30 -75 mg/kg/day for 2 months OR
B) Stoss method - Infants more than 3 months- 60,000 IU weekly for 6 weeks along with calcium supplement (By 4 weeks shows radiological line of healing) OR
C) Vit D is administered orally either in a single dose of 600,000 IU or over 10 days (60,000IU daily for 10 days) followed by a maintenance dose of 400-800IU/day and oral calcium supplement 30 -75 mg/kg/day for 2 months.
D) Expose the child to the sunrays in morning hours for about 15-20 minutes. Human skin contains provitamin which gets activated and synthesized on exposure to sun. This promotes the absorption of calcium and phosphorus by the body which makes the bone grow stronger.
E) Include whole grains and beans like oats, Barley, Rice, Black beans, Lentils, etc. in the diet regularly
F) Consume more of green leafy vegetables like Spinach, Methi, etc.
G) Consume dry fruits like Almond, Walnuts, Cashews, Raisins in diet
H) Include fresh fruits like Oranges, Figs, Bananas, etc. in daily diet

Conclusion

According to modern science Rickets is a condition where the bones in the children become soft and weakened due vitamin D deficiency. In Ayurveda symptoms of rickets are similar to Phakka Vyadhi and it is said to be a nutritional disorder but Phakka which is mentioned by Kashyapa is definitely not limited to a single disease.