i think this is a tremendously important article in terms of its conclusions
and its possible impact on breastfeeding. needless to say, i think there are
some serious problems with the conclusion reached by the authors, which is to
advise supplementing of dark-skinned infants with vit. d by the age of two
months.

this was a retrospective study, which makes it difficult to get some of the
information that might be crucial to a clear understanding of what is
happening. the article seems to be about an alarming increase in rickets.
however, what they state is that since the NUMBERS of breastfed dark-skinned
babies have increased, so have the numbers of cases of rickets. i am not
clear from this whether the proportion of rickets in the population has
increased. the study does mention that in the early 60s (the time of lowest
bf rates) rickets was almost unheard of. its my interpretation that the rate
remains the same and the numbers have increased because breastfeeding has
increased.

so first i have to wonder, if this is not an epidemic, and the rates have
"always" been the same in relation to numbers of babies breastfed, then what
is really the cause?

in this study, it states that the level of vit. d in breastmilk is
insufficient to prevent rickets i am not sure that i like having breastmilk
compared to the "daily recommended amount" that one needs in cow's milk, but
what we really need to focus on is the amount needed to prevent rickets.
obviously nature never intended mothers to stay home in the cave and not go
outside, since sunlight is the way to prevent rickets.

but it also states that if vit. d. levels in the mother are low, then levels
in the milk will be low. no mention was made of the mothers' health or
supplementing the diet of the mother, instead of the baby.

i think the crucial point is sunlight. the study states "we do not have
information on sunlight exposure of our patients, but we have no reason to
suspect a change over the past decade." i think this is a serious flaw.
questions were raised at our journal club here about this specific remark.
one is, with the increase in numbers of welfare programs that require mothers
to return to work or study, are more babies in daycare? we know that many
babies are in daycare for long enough during the day to never be outdoors in
sunlight.

also, the thought that a baby or child is not out in sunlight enough to
prevent rickets bespeaks a dreary existence. shouldn''t counseling mothers on
the need for sufficient sunlight be the FIRST step in preventing rickets?

another thought mentioned was that there was some talk of other diagnoses -
FTT etc. were these children screened for the presence of other health
problems that might not have been caused by the rickets but might have
predisposed them to it? or caused it? malnutrition/malabsorption problems
came to mind.

also, no mention is made in the study of recognition of the lactose tolerance
difficulties that might be related to race, when mention was made of
inadequate intake of dairy products by these children. nutritional counseling
should be another step  - for its own sake as well as preventing rickets.

i thought annelies' comments were very good. the importance of exclusive
breastfeeding and the danger of disrupting what is going on in a baby's gut
are completely ignored by the acceptance of this solution to the problem. we
see this information but it seems very few people "believe" it, that is, that
even one dose of something else besides breastmilk can cause harm.

at our journal club the very first comment was "well, this doesn't cause any
harm and it could do some good, so isn't it a good idea?" i think this is not
true first of all - we don't know if it could do harm, and as someone else
pointed out, the usual supplement used is not vit. d alone but in a mix of
other things. annelies pointed out that peanut oil is in some preparations of
this vitamin. do we really know if this is safe in otherwise exclusively
breastfed babies?

the ways in which this sort of recommendation could do harm are medical and
politcal. and before someone makes another veiled plea for me to not play the
race card, i am going to say i feel that it is necessary. ignoring it won't
make it any less relevant. "medical science" and other forms of "science"
have long been used to prove that variousgroups are inferior. women are
inferior because their uterus causes them to be hysterical. blacks can run
faster than whites but aren't as smart. etc. etc.

and then there are physical differences that seem to be well-supported by
science. higher rates of lactose intolerance in various groups. higher
incidence of some diseases. the authors of this study seem to believe that it
is merely the darkness of the skin that causes this problem, but i don't
think they have proven this well enough to draw the conclusions stated.

when babies have jaundice that needs treating (ignoring the usual truth that
it doesn't need treating), it used to be that they were given transfusions.
wow! what a process. now, babies are treated with phototherapy. they are sent
home with equipment and the parents are responsible for making sure they get
their treatment. no one says "oh, we can't waste time counseling them on the
need for more light, and we can't trust them to carry through with it, so we
will just give the baby a transfusion and be done with it."

is this study falling back on "oh, just give them vit. d and be done with it"
because of the unspoken belief that there won't be enough compliance in this
population to prevent the problem? really, isn't there at least a hint of
predetermined belief about this population based on race and class?
institutional racism is no less offensive than the overt kind.

of course, there is also the persistent belief that supplementation is NOT
bad. also, the lack of belief in the true sufficiency of breastfeeding is
shown by this statement -

"we support breast-feeding (sic) as the ideal nutrition for babies and
children

BUT (my emphasis)

recommend supplementation of all dark-skinned, breast-fed (sic) infants and
children with 400 IU of vitamin D per day, starting at least by 2 months of
age."

it's my contention that a lack of belief in the primacy of complete
breastfeeding leads to conclusions such as these, that it is "okay" to tamper
with exclusive breastfeeding instead of seeking the true cause of the
disease.

there is also the cynical aspect of my nature that reminds me that a
pediatrician here told me that she must see 40 patients per day. that breaks
down to about 10 minutes per patient, perhaps enough to see if the child is
dead or alive but nothing more. of course the ped couldn't do "lifestyle
counseling" or "nutritional counseling" - better to just hand over a sample
of a vitamin with a handout from the manufacturer and tell oneself "oh well,
she's probably supplementing anyway, or is going to wean anyway," or even "if
i tell her to not give the baby anything at all except breastmilk - and the
vitamin - she'll do it." i doubt it. since the influence of formula reps is
apparent to us all, its no surprise that the vitamin reps will have the same
influence. i wonder if that is what this study is about? if one doesn't
believe in breastfeeding enough to feel this is a serious problem, then the
solution of the vitamin is an easy choice. if you operate, however, from the
belief that exclusive breastfeeding is the standard and anything else is a
deviation from the norm, then you look for ways to fix the factors impairing
normal breastfeeding, not supplant it. i don't feel that this is the case
with this recommendation.

carol brussel IBCLC

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