My name is Ian GreyBull and I am a junior in the nursing program at the
University of North Dakota.  I am writing in regards to the
journal article by Shelly R. Kreiter, MD on Nutritional rickets in
African American breast-fed infants in the Journal of Pediatrics
>>August 2000;137 issue.  Before I read this article I was not aware of the
>>issue's that surrounded nutritional rickets, especially in the
>>African-American population.  The aim of this study was to analyze the
>>characteristics of infants and children diagnosed with nutritional rickets
>>at two medical centers in North Carolina in the 1990's.  The study design
>>involved physical and radiographic findings, calcium, phosphorus, alkaline
>>phosphatase, and 25-hydroxyvitamin D levels of the thirty infants and
>>children diagnosed with nutritional rickets at the two medical centers
>>were reviewed.  Also included was the breast-feeding data that was
>>obtained from the North Carolina Women, Infant, and Children Program
>>(WIC).  The steps or methods the study followed was to review all of the
>>patients records between the years 1990 and 1999. And to obtain
>>information of all the patients which included age at diagnosis, infant
>>feeding, history of vitamin D supplementation, biochemical findings,
>>radiographic findings, race/ethnic background, sex, weight and height at
>>the time of diagnosis, and results of follow-up studies.  The results of
>>the study showed that in 1998 and the first half of 1999 57% of the
>>patients were diagnosed with nutritional rickets.  All were
>>African-American, all were breast fed, and those over the age of one had a
>>history of poor intake of fortified cow's milk or other diary products.
>>Eleven of the children or 37% were diagnosed between November and March,
>>the coldest months in North Carolina.  Some of the signs and symptoms of
>>the patients included skeletal abnormalities and failure to thrive.
>>Height and weight measurements were available for some of the patients.
>>This reflected <5th percentile in lenght for 65% of the patients and <5th
>>percentile in weight for 43% of the patients.  For the rest of the
>>patients it was even a lower percentile for both length and weight, with
>>only two patients with the lenght of >50th percentile..  The results also
>>showed decreased levels of 25-hydroxyvitamin D in 19 of 23 patients (83%)
>>in whom it was measured.  The conclusion indicated the factors that may
>>have contributed to the increase in diagnosed nutritional rickets was that
>>more African American women were breast feeding, fewer infants were
>>receiving vitamin D supplements, and children that were exposed to less
>>sunlight.  The authors of this study recommend that all dark-skinned
>>breast-fed infants and children receive vitamin D supplementation.
>>     This study was done in a very thorough manner. The study design and
>>methods used really strengthen this study.  It really showed the reader
>>strong evidence on how the researchers came to their conclusions.
>>However, this study does have a couple of weaknesses.  One of the
>>weaknesses is the limited geographical area in which the study was done.
>>Only researching North Carolina gives this study a one dimensional view of
>>the pattern of nutritional rickets among African American infants and
>>children.  Another weakness is that some information was not present on
>>the mothers of the infants and children in the study.  The  vitamin D
>>status of the mothers and the amount of sunlight exposure of the patients
>>(both mother and infants) is the information that should have been
>>included in this study.  This can impact one's clinical practice because
>>of the increase in the number of breast-fed baby's.  Whether or not to
>>encourage breast feeding in dark skinned infants at risk is a concern.
>>And if the mother decides to breast feed you might have to provide
>>information on giving the infant adequate amounts of vitamin D supplements
>>and sun exposure to help prevent nutritional rickets.  A future in-depth
>>study should be done throughout the United States involving dark skinned
>>infants diagnosed with nutritional rickets.  This would give this topic of
>>concern more fire power to fight with, concerning the authors current
>>recommendations.


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