Rapid Responses to:

CLINICAL REVIEW: M Z Mughal, H Salama, T Greenaway, I Laing, and E B Mawer Lesson of the week: Florid rickets associated with prolonged breast feeding without vitamin D supplementation BMJ 1999; 318: 39-40 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Questioning terminology: "prolonged" breastfeeding

Leslie Ayre-Jaschke   (4 January 1999)

Considering factors in vitamin deficiency

Audrey Trenholme   (6 January 1999)

Vitamin D deficiency presenting acutely in an infant

Edmund Lamb   (30 January 1999)

Vitamin D and Iron deficiency in Asian children

Indra Ariyawansa   (16 July 1999)

Prevention of Rickets, is the message getting through?

Scott Williamson, Stephen Greene, Consultant Paediatrician   (12 June 2007)

Questioning terminology: "prolonged" breastfeeding 4 January 1999
Leslie Ayre-Jaschke, Lactation consultant Peace River Breastfeeding Clinic Send response to journal: Re: Questioning terminology: "prolonged" breastfeeding	The authors do not define "prolonged" breastfeeding. Since the World Health Organization recommends exclusive breastfeeding for four to six months, with appropriate introduction of solid foods, and the continuation of breastfeeding for at least two years, the term "prolonged" sounds out of date. There are accepted definitions for breastfeeding research (see Labbok), which do not appear to have been used in this study.
Considering factors in vitamin deficiency 6 January 1999
Audrey Trenholme, Lactation Consultant self-employed Send response to journal: Re: Considering factors in vitamin deficiency	Firstly it would be helpful to clarify the definition of breastfeeding used and then what is 'prolonged'. Also it would be important to know when solids were introduced and what other foods the children have been eating. That the mothers also had very limited exposure to sunlight during and after pregnancy seems important. How do you measure the influence of this? How can you measure or explain the effects of other factors? Are you implying that breastmilk is deficient in vitamin D? It seems to be an easy target for "blame". If it is, how did we survive as a species till now? If the vitamin D levels are different now than 100 or 1000 years ago, why. So, in light of this article, what, if any are the authors' recommendations?
Vitamin D deficiency presenting acutely in an infant 30 January 1999
Edmund Lamb Send response to journal: Re: Vitamin D deficiency presenting acutely in an infant	Vitamin D deficiency in non-Caucasian populations in the UK is a problem which clearly has not gone away (1, 2). Readers should be reminded that manifestations of vitamin D deficiency may also present acutely. A four-month old male infant was admitted with respiratory arrest and fitting: he had a blue face, tongue and lips and blood gases confirmed a respiratory acidosis (pH 6.932; pCO2 12.4 kPa). He was immediately intubated on 100% oxygen. His mother gave a 2 day history of rapid breathing and coughing and on the morning of admission had noted jerking movements of the limbs. His previous medical history was unremarkable: he had been born at full term by normal vaginal delivery to non- consanguineous Turkish Muslim parents and had been exclusively breast fed. Initial investigations revealed hypocalcaemia (1.17 mmol/L, phosphate 2.47 mmol/L, albumin 37 g/L) and increased alkaline phosphatase (510 U/L, age- related reference range 65-265 U/L). There was no clinical or radiological evidence of rickets but a chest X-ray showed right upper lobe consolidation; influenza B virus was later isolated. Subsequently, the child was shown to have vitamin D deficiency (25-hydroxy vitamin D 6 nmol/L, reference range 15-100 nmol/L) and appropriate secondary hyperparathyroidism (PTH 135 ng/L, reference range 10-65 ng/L). Magnesium was normal (0.63 mmol/L). He was treated with Amoxil, calcium supplements (i.v. calcium gluconate at first, followed by Sandocal 3 mg qds) and alfacalcidol (400 ng od) and his calcium returned to normal after 18 days. Hypocalcaemia can cause laryngeal spasm and stridor in children, which may precipitate respiratory arrest: in this case it may have been exacerbated by bronchiolitis. (Indeed, there is some evidence that vitamin D deficiency may increase susceptibility to infection (3)). There are sporadic reports of hypocalcaemia presenting in this manner (4, 5); the former of these cases also occurred in non-Caucasian infants. Paediatricians should be aware of this unusual presentation of vitamin D deficiency, particularly in susceptible populations. Edmund Lamb, Consultant Clinical Biochemist, Kent and Canterbury Hospitals NHS Trust, Canterbury, Kent CT1 3NG References 1 Mughal MZ, Salama H, Greenaway T, Laing I, Mawer EB. Florid rickets associated with prolonged breast feeding without vitamin D supplementation. BMJ 1999; 318: 39-40. 2 Lawson M, Thomas M. Vitamin D concentrations in Asian children aged 2 years living in England: population survey. BMJ 1999; 318: 28. 3 Bikle DD. A bright future for the sunshine hormone. Scientific American March/April 1995: 59-67. 4 Train JJA, Yates RW, Sury MRJ. Hypocalcaemic stridor and infantile nutritional rickets. BMJ 1995; 310: 48-9. 5 Halterman JS, Smith SA. Hypocalcemia and stridor: an unusual presentation of vitamin D-deficient rickets. J Emerg Med 1998; 16: 41-3.
Vitamin D and Iron deficiency in Asian children 16 July 1999
Indra Ariyawansa Send response to journal: Re: Vitamin D and Iron deficiency in Asian children	Editor With reference to the paper re. Vit D deficiency in mainly breast fed Asian children by Mughal et al, I wish to report on a case of nutritional rickets in one of twins. The patient, the first and the bigger of twin girls of non consanguinous Asian parents, who arrived in the U.K. two years previously, presented at the age of 18 months with clinical signs of rickets. She had been exclusively breast fed up to four months and accepted weaners thereafter in only very small amounts, resulting in a diet of mainly breast milk. The second twin was formula fed from the age of two months as she refused breast milk. Neither twin received any vitamin or iron supplements. The patient was slower in starting to walk, had a waddly gait and tended to fall easily, as compared to her twin, and also was the shorter of the two. On examination she had markedly bowed legs, and swelling of end of long bones with mild frontal bossing of skull. Biochemistry:- Serum Ca++ 1.73 nmol/l, PO4 - 0.72 nmol/l, Alk.Ph 3707 iu/l. Classical radiological changes of rickets with osteopenia, widening of growth plates, and cupping and fraying of metaphyses were also seen. Vitamin D deficiency was confirmed by a low level of 25-OH-D - 4.6 mgms/l, while 1-25-OH2-D level was apparently normal at 46 mgms/l, reflecting secondary hyperparathyroidism. She began to walk steadily and showed complete resolution of biochemical and radiological changes within six months of treatment with Vit.D supplements. Her twin was normal on examination, and had normal bone biochemistry with Ca++ 2.57, PO4 - 1.63, and Alk Ph 690. This interesting case with a perfectly matched control in her twin focuses on the causes of Vit.D deficiency, and the need for supplements in Asian babies fed almost exclusively on breast milk. The patient also had iron deficiency anaemia, strengthening the comments by Lawson, Thomas, and Wharton in the same journal. The Department of Health recommendations of Vit. D supplements to all children under five years seems not to be carried out as a routine practice. The need for its implementation, especially in Asian children, perhaps even with iron supplements, cannot be over emphasised. Indra Ariyawansa Consultant Paediatrician Birch Hill Hospital Rochdale 1 Mughal, Salma, Greenway, Laing, Mawer. Florid Rickets associated with prolonged breast feeding without Vit D supplementation. B.M.J. 2.Jan.99. 2 Lawson, Thomas,. Vit D concentration in Asian children aged 2 years living in England; population survey. B.M.J. 2.Jan.99. 3 Kocturk, Zetterstrom. Thoughts about rates of breast feeding. Acta Paed. 88'99. 4 Wharton. Low plasma Vit.D in Asian toddlers in Britain. BMJ 2 Jan 99 Editorial note The little patient's mother gave written consent to the publication of the above mentioned material
Prevention of Rickets, is the message getting through? 12 June 2007
Scott Williamson, Specialist Registrar Ninewells Hospital, Dundee, DD1 9SY, Stephen Greene, Consultant Paediatrician Send response to journal: Re: Prevention of Rickets, is the message getting through?	Dear Sir 10 years ago a group of 6 children were diagnosed with vitamin D deficient rickets in Manchester, and were presented in the BMJ as a ‘Lesson of The Week’ highlighting the need to implement the government’s policy on vitamin D supplementation(1). In Tayside in the last 4 months we have diagnosed 5 infants with vitamin D deficient rickets in an almost identical scenario to the Manchester report. None of these children or mothers had received vitamin D supplementation. Their families were unaware of the need for this. This is despite the UK government recommendations for the universal use of vitamin supplements to all breast feeding infants to prevent rickets which have existed for over 10 years(2). This recommendation is particularly important for those of Asian, African, Afro-Caribbean or Middle Eastern origin with reduced exposure to sunlight. Continuing concern in the medical literature highlights this (3,4,5). The public is not receiving this message so clearly. The NHS direct website is not specific and leaves an ambiguous message about the need for vitamin supplements(6). The recommendations are more clearly laid out as a component of the ‘Healthy Start Initiative’ which has replaced the welfare food scheme, but the uptake of vitamins was particularly low when this scheme was last audited(7). None of the affected families we saw are eligible for this scheme as it is mainly directed at the poor and disadvantaged, and not specifically immigrant groups(8). The scientific advisory committee on nutrition (SACN) have just published a position statement on vitamin D, with particular reference to preventing rickets, in which they highlight the need for a public health campaign on the issue, emphasising the need to supplement infants in high risk groups with vitamin D(9). This is the same message which has been re- iterated in the literature through the last decade. Evidence that it is getting through is lacking(3,5), and our own experience highlights this. Rickets remains an unusual condition to many general practitioners. The signs and symptoms were only recognised by the GP in one of the cases we saw. The SACN report is timely, but it is now imperative to disseminate the message to all health visitors and general practitioners across the UK, as they are in a position to carry it out and eradicate this epidemic. 1. Mughal MZ, Salama H, Greenaway T, Laing I, Mawer EB. Lesson of the week: Florid rickets associated with prolonged breast feeding without vitamin D supplementation. BMJ 1999; January 2;318(7175):39-40. 2. HMSO. Department of Health COMA report on Weaning and the Weaning Diet. ; 1994. Report No.: 45. 3. Allgrove J. Is nutritional rickets returning?. Arch Dis Child 2004; August 1;89(8):699-701. 4. Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new concern. Arch Dis Child 2002; March 1;86(3):147-9. 5. Callaghan AL, Moy RJD, Booth IW, Debelle G, Shaw NJ. Incidence of symptomatic vitamin D deficiency. Arch Dis Child 2006; July 1;91(7):606-7. 6. Do I need vitamin supplements? Available at: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1122. Accessed 06/05, 2007. 7. Department of Health. Scientific Review of the Welfare Food Scheme. London: TSO.; 2002. Report No.: 51. 8. Healthy Start. Available at: http://www.healthystart.nhs.uk/. Accessed 06/01, 2007. 9. Scientific Advisory committee on Nutrition. Update on Vitamin D. Position statement by the Scientific Advisory Committee on Nutrition. ; 2007 May. Competing interests: None declared