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 *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. 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