Hereby my comments. But first I want to declare that I did not read the original
article. I do not have a subscription the Journal of Pediatrics online, so I only
have access to the abstract. I'm also not working in any medical or research
institution, so obtaining an issue isn't easy. I can order it, but it may take a
while before I have it on my desk.
Therefor, the following comments are only based on the abstract of the Journal of
Pediatrics and on the abstract of Dr Hirsh wrote.
I'm also not a docter, so I may make some remarks that show my ignorance.
---------
First I do note that great rise on rickets in 1998 and 1999. I wonder why this is.
Their research populations starts at 1990. What happened in the year 1998? Is this
because vit D supplementation was given before that half 1998, and afterwards not
anymore? May it be related to the AAP statement, Breastfeeding and the Use of
Human Milk (RE9729), that came out in december 1997?
I find the explanation that the bf rates are increasing among black women not
satisfying. If that is the reason, the bf rates among dark-skinned women should
have risen as fast as the rickets. Are there any numbers known about the
fluctuations in bf rates in this area? (North Carolina).
The same counts for the other explanations. If the exposure to sunligth has
decreased so much, why has this happened so fastly in 1998? As far as I know these
trends are happening gradually. So that should have given a gradual rise in the
90ies instead of such a sudden rise.
So, I would like to know more about what happened during that time in North
Carlina. Bf rates, WIC policy in vit D supplementation, but also in their overall
food programma. General poverty programs (eg. if the poverty progams have changed
and more people were kicked out the program, this could lead to increases in
several health problems, including rickets).
Since vit D levels in human milk is also dependent on the mothers vit D status I
also would like to know what the recommendation for (pregnant and lactating) women
in North Carolina are. Have there been any changes in this?
Since the rise is so sudden, something must have happened, IMO.
Another thing is that the length of the breastfeeding period is much longer than
average, espmin the population. I wonder what this means. Where these children
refusing other foods, or is this caused by their rickets? Are they having low
appetite?
I would like to know more about this. What caused what?
Also in the Journal of Pediatics, there was an article in september:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=109
69262&dopt=Abstract
"J Pediatr 2000 Sep;137(3):367-373
Case-control study of factors associated with nutritional rickets in Nigerian
children.
Thacher TD, Fischer PR, Pettifor JM, Lawson JO, Isichei CO, Chan GM"
CONCLUSIONS: Vitamin D deficiency appears unlikely
to be the primary etiologic factor of rickets in African children. Moreover, low
dietary calcium intake alone does not account for rickets. Insufficient dietary
calcium probably interacts with genetic, hormonal, and other nutritional factors
to cause rickets in susceptible children."
Since African baby's and mothers probably do not have a shortage in sunlight
exposure (though the islam is on the rise in africa, so this may lead to more
overly dressed women), the results cannot be applied to the baby's in North
Carolina. But this results does give rise to many questions, one that is: what do
we know about the causes of rickets?
I think this research indicaties there is a lot we do not know. We know that vit D
supplementation is a cure. But is a shortage in Vit D also allways the cause? The
above article says it's not. We should look further into it.
Now, the recommendations for mothers...
As a Dutch women I firstly didn't understand the problem with supplemenation vit
D. It is common here to give all baby's and children vit D, especially during the
winter (except formulafed babies). As someome said before: since this nasty
disease could be prevented with such an easy measure, why bother?
OTOH I see this fact is used heavily by the formula producers to show the
'superiority' of their product. But the main problem I see is that the ideal of
exclusive breatsfeeding is undermined. If I remember how I handled this, as a
ignorant mther with my first child, the vit D drops were the first step in early
introduction of solids. For me giving the drups with a spoon made no big
difference with giving solids at 3 months. My son loved the drops, as he loved the
solids at that early age.
Next to that I'm worried about the danger of sensitivization. Some vit D drops are
soluted in peanut oil (like the vit K drops, here given until the baby is 3 months
old ). It is medically purified peanut oil, so one says this cannot give problems.
But still I meet some mothers who say their babies vomit after getting the drops.
My second son was very colic every time he got the vit K drops.
We do give something that may act on the intestinal flora and so undermine the
protective effect of breastfeeding.
Still I think the current cases do give enough reason to recommend vit D to
certain baby's. If it can be prevented, then it should. But I think the
recommendations for mothers should include exposure to sunshine either.
Recommending them to go out for a walk every day will not harm. If they do, it
will not only be good for their Vit D status.
It's allways easier to recommend drugs above lifestyle changes. But I think in
this case it should be tried to receommend people to go out for a walk.
When women ask me about it, I first point to the official recommendations. But if
they persist and say the actually do not want to give the drops I tell them they
can take care fo good vit D intake themselves, hence improving the vit D level in
their milk , and explain about the esposure to the sun will help either.
I hope this comments are what could have been expected in this journal lcub.
regards, Annelies Bon
Lay counsellor of the Dutch bf organization "Borstvoeding Natuurlijk"
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