Re: Nutritional rickets in African American breast-fed infants.
This study reports the characteristics of infants and children diagnosed
with nutritional rickets at two medical centres in North Carolina in the
1990s.They were referred thirty patients, and over half occurred in 1998 and
the first half of 1999. So, this indicates a large increase in the rate of
referrals of infants/ children with nutritional rickets seen in these two
centres.
The question is: can we infer that "the truth found in this study" is "the
truth in the universe"?
It would have been helpful to know the referral situation in this region (or
State). Are all cases of suspected nutritional rickets referred to one of
these two clinics? This is what it sounds like. But, on the other hand,
there could have been a third medical centre that was receiving referrals
from the same population, which closed down at the end of 1997 (unlikely).
Or, referrals had been made to medical centres outside North Carolina prior
to 1998 (also unlikely). But these are problems with studies that only
report cases that are referred to them.
Other references cited seem to be case studies or series as well.  It would
be helpful to know if any population-based studies have been reported. If
not, hopefully some are underway.
The other comment I have is that the authors have not attempted to define
breastfeeding at all. They state that the infants/children have a range of
"months of breastfeeding" from 5 to 24 (see Table). Because this is a
retrospective study, they are unable to say how long the infants were
exclusively breastfed for, if other milks were given, when solids were
introduced, etc. The Figure shows "incidence of breast-feeding in African
American women in North Carolina 1988 to 1998". They say this is for women
seen for the "maternal postpartum WIC visit" - but don't tell us when this
is. Does it always occur at a certain time, eg 6 weeks, or is does it cover
a range, eg in the first month postpartum? Presumably they are referring to
"any breastfeeding", but this is not stated.

I find the comment in the editorial interesting: "It is difficult to
understand the origin of the apparent objection to vitamin D supplementation
of nursing infants." (p144). Between the lines, this seems to imply  the
authors' easy acceptance of supplementation and lack of trust in women's
bodies to supply their infant with adequate nutrition.

The authors of the study recommend that "all dark-skinned breast-fed infants
and children receive vitamin D supplementation." While the authors of the
editorial say "Basing supplementation advice on the complexion of the mother
or her infant would be impossible to incorporate into a usable practice
guideline." - do they mean all infants should be supplemented?

Neither article say that the recommendations apply to infants in the USA.
Are they implying that all infants need supplementation? (in an African
village?) I think they are referring to infants in the US, but why not state
this?

Living in Australia, where we have too much sunshine, makes it hard to just
accept these recommendations. Perhaps, the authors are right. But it would
seem prudent to me to suggest population-based studies before
"recommendations" are brought in.

Lisa Amir
MBBS, MMed, IBCLC in Melbourne, Australia

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