I have been No-Mail for many months as I work to complete my thesis, but came back to lurk among my Lactnet friends recently. So making up for lost time, I have the urge to wax rhapsodic about Things Rickety.  :-)

There are a couple of issues at play with this rickets report, and this is a great opportunity to tease out the confluence of an issue in the news, which is public health, as well as (public) policy (through Healthy People BF goals), marketing, and (gasp) common sense. What a bonanza!

One stated concern was that "Once again, the formula company has developed a way to get products into the hands of new mothers, planting a seed of doubt that breastmilk is not "good" enough and associating their name with "good products".  This, believe it or not, doesn't bother me, because I tend to think of the vitamins coming from their pharmaceutical division (they do require an Rx) and not their formula side. I don't know which came first - their Rxs or their formula - but both have been around for a very long time. They also happen to make OTC antipyretic medicines, but are we going to tell mothers not to treat a fever because the stuff comes from a company that also makes formula or gets their name into the house - I don't think so. Maybe that's me though. But the point is - can we improve the Vit D in her milk? Sure, but that requires some common sense. Keep reading...

Another concern was "who wrote the press releases for this since the local TV stations headlined it by saying " Breastfeeding may put your baby at risk for developing rickets"." Like most press, they're going for the ratings. Although technically true, this is a qualified statement, though I doubt many readers/viewers (let alone newswriters) will have the patience to tease out the important parts.

As you probably know, the press reads all the major medical journals (they actually get them a week early, but the articles are "embargoed" until the release date - this gives them a chance to line up people to interview, etc.) and in this case, got the lead from the August issue of The Journal of Pediatrics, release date August 18 I believe. Not only is this the main article but it garnered the editorial attention as well. You can read both (for a $25 fee, but I'll bet your local pediatrician subscribes to JPeds and will let you read it for free)  from the publisher's website here: 
 http://www1.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=current&id=pd 
or a summary from MedScape here: http://pediatrics.medscape.com/MedscapeWire/2000/0800/medwire.0818.Rickets.html

Because I receive the email alert service (through MedScape) for things pediatric, I headed immediately to their article to get the Rest of the Story. It is not simply a handful of casual reports - (but an example of evidenced-based practice if there ever was one - very timely reposting of the description, Kathleen) and is very well written by a premiere pediatric journal. I encourage everyone to read it. There is good data (but not having accessed the original yet, I don't know if they calculated rate or incidence), and the solution, vitamin supplementation, is understandable, given the cheapness and nearly iron-clad guarantee to resolve the problem. That all pediatric problems could be so easily solved.

Caution - "supplementation" here is NOT what we usually think of (the formula kind) - we're talking 1/4 cc, for vitamins! (Hardly damaging to milk supply, or anything else really, even mom's opinion about the quality of her milk).

I digress. So, from MedScape, "The researchers, ..., suggested that the lack of vitamin D in the diet, combined with deficient production of the vitamin because of their heavily pigmented skin, predisposed these infants to rickets.

Using data from physician surveys and the North Carolina Women, Infants and Children (WIC) program, the researchers noticed that the new cases of rickets occurred as the incidence of breast-feeding in the area increased. They also noted that local pediatricians frequently neglected to recommend vitamin D supplements for breast-fed babies.

But the increase in nutritional rickets is not confined geographically. In the accompanying editorial, the authors point out that cases of rickets are increasing throughout the United States."

Folks, this is not a new or unknown association, BF and rickets, for our world today. It is new to the USA perhaps. When I was studying with the Jelliffes at UCLA, we discussed in one international health class the high rate of rickets (in both mothers and BF babies) in equatorial middle-east nations (a known ongoing problem even today). I remember the discussion focused on how odd that an *equatorial* nation, with maximum sunshine, should experience *any* rates of rickets. We learned that, for infants and adults, exposing face and forearms for 30 minutes is more than sufficient to make the RDA, even in winter (Land of the Midnight Sun has some exceptions). But culturally, these middle-east women (who also had rickets remember) are completely covered and generally don't go out with their *young* babies (read: the ones at risk) in the daytime. Also, I recall Dr. Jeliffe saying that the amount of Vit D in BM is dependent, naturally, on the mother's own stores (and ability to manufacture enough). Sun-bathe baby alone, and the problem is solved through Plan A, or sun-bathe both and the baby gets Plan B through mom's milk. What a deal! Our assignment was to develop a Public Health campaign to change this situation without altering the cultural demands. (Can you guess the solution? I'll put it at the end of this posting.) 

The wonderful thing about this "problem" for us here in the USA today is that it does have an extermely cheap effective solution that will practically guarantee no rickets: supplemental Vit D (and there are products available which are only A,D,C combination without iron or flouride). The amounts are usually Vitamin A 1500 IU, Vitamin C 35 mg, and Vitamin D 400 IU (100% recommended amount for infants). (An aside: I remember my mother giving us liquid Vitamin D in 1950s in Washington, DC area - it had a gnarly taste but I happened to like it - she called it our "Liquid Sunshine" and never had any problems getting us to take it.)
 
But first, may I summarize some factors as I see them (from my Public Health perspective):
1. We (at all ages) can manufacture adequate amounts of Vit D through sun-exposed skin - face and forearms are sufficient.
2. We need 30 minutes of sunlight per day to do so.
3. Rickets seems to be on the rise in breast-fed dark-pigmented infants, who are *pre-disposed* to rickets (pigment blocks the rays that are required by the skin to manufacture the Vit D). I would hazard a guess that their mothers don't get out much either.
4. Protection against sun exposure is getting alot of press lately (because of McCain), so we might expect to see an increase in light-pigmented BF infants also, as mothers become more cautious.
5.The reason formula-fed infants are not affected and don't need supplemental vitamins is that formula, like our regualr boxed milk, is Vitamin A & D enriched already. 
6. It took 10 years to identify 30 cases in N.Carolina (This is not an epidemic. However, 30 is significant enough to sit up and take notice...not one baby should have rickets in today's entire world - IMHO)

There is another solution as well, which is not mentioned in the Medscape article and probably not in the original.You probably know where I'm headed.   
  
==> The other, even cheaper, solution is some simple education (like we have done so many times for so many things BF), to teach some common sense, about how we make our own Vitamin D, and to encourage our moms to enjoy 30 minutes of indirect sun every day with her baby (does not need to be direct sun, but it should NOT be through a window). 

==> And if the mother elects not to do this for whatever reason, or wants a nearly iron-clad guarantee, then we are obliged IMNSHO to also teach about appropriate vitamin supplements. Especially, we should alert our dark-complexion clients...

So. The solution for the equatorial moms? Our class came up with a campaign "Take it to the Roof" - mom takes her lunch on the roof of her house every day with the baby - flat roofs are where the breezes are and much life takes place in that part of the world - because only on her roof, out of the view of the neighborhood, can she in all propriety uncover both her face and her arms and sit with her baby. Real Life Story, Problem, and Solution. (The Third World can teach the Industrialized World a thing or two...)

And now you know why my thesis is getting ever longer...I'll return to lurking now.

Katharine West, RN, BSN, MPH  (on the home stretch to an MSN)
Sherman Oaks, CA
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