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Prosecution of parents over baby’s death raises controversy over diagnosing child abuse

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2932 (Published 23 April 2012) Cite this as: BMJ 2012;344:e2932

Re: Prosecution of parents over baby’s death raises controversy over diagnosing child abuse

We read the Judgement in this case with sadness and interest:

It is accepted that Jayden suffered from congenital rickets. Congenital refers to timing; he was born with it. It is very likely his mother was vitamin D deficient during pregnancy; he was born with vitamin D deficiency. He was entirely breastfed by his mother, one of the sad facts of this case is, unbeknown to his mother or those advising her, that further contributed to his vitamin D deficiency. (para 5 1Approved Judgement, Justice Theis DBE)

This, despite the fact his mother had attended all antenatal appointments, received regular visits as part of a Family Nurse Partnership Programme (FNP) before and after Jayden’s birth, Jayden himself had been taken to all scheduled appointments, was fully immunised and had seen the GP 3 times. Since Chana Al-Alas was a high risk group at the time of her pregnancy (being under 18), the Government’s Healthy Start scheme should have guaranteed that she was able to access vitamin supplements for free. There were multiple occasions during which this family should have been encouraged to take vitamin supplements including vitamin D, which would have helped prevent rickets.

Dietary sources of Vitamin D are rare, and the main source of Vitamin D is skin synthesis during exposure to sunlight. Sunlight is a rare commodity in Northern Europe for at least half of the year and those who cover up (with sun cream or clothing), who rarely go outside, and those with pigmented skin are very unlikely to have sufficient exposure to the sun. For these reasons Vitamin D deficiency is common in the United Kingdom; half of adults have insufficient levels of vitamin D, and 1 in 6 adults are severely deficient during winter and spring2. Where a mother is herself Vitamin D deficient during pregnancy and breastfeeding (as Chana was), her baby will also be deficient. Usual advice to eat well and breastfeed exclusively for 6 months will not address this deficiency, and for this reason NICE recommends that all women who are eligible or likely to be eligible for Healthy Start should be offered the maternal Healthy Start vitamin supplement which contains folic acid, vitamins C and D.

Following a clinical review of Vitamin D deficiency published in this journal2, of 47 rapid responses recorded just 4 make mention of the Healthy Start scheme4-7. Three of these highlight low awareness of this scheme: just 8/50 of mothers in a maternity unit in Manchester had been informed about vitamin D or Healthy Start vitamin supplements4 and although 10 out of 20 were taking supplements in Glasgow, none were using Healthy Start vitamins5. A GP in Tower Hamlets6 points to the poor access to Healthy Start Vitamins as one reason for poor uptake of these vitamins. These data suggest that awareness and uptake among women of this scheme is low. What they also suggest is that awareness and use of Healthy Start among General Practitioners might also be low. Whilst most mothers will now be recommended to take Folic Acid during pregnancy, we believe that many health professionals are not giving the same advice for Vitamin D.

To this we would add we would note that pregnant women must wait until they are 10 weeks pregnant to apply for Healthy Start. Thus, the crucial first trimester is always missed. The clinical review recommended that health visitors and midwives should be distributing children’s vitamin drops2 and seemed to recommend universal provision for young children. Jayden’s case illustrates the need for vitamin D supplementation to begin during pregnancy, and for all health professionals delivering care to pregnant women and young children to be aware not only of the symptoms of vitamin D deficiency but, more importantly, to take the simple preventive action of ensuring Healthy Start vitamins are reaching families.

1 London Borough of Islington v. Chana Al-Alas, Rohan Wray, Jayda Faith Al-Alas Wray. Neutral Citation Number: [2012] EWHC 865 (Fam) http://www.judiciary.gov.uk/media/judgments/2012/lb-islington-al-alas-wr....

2 Pearce, S H, Cheetham, T D Diagnosis and management of vitamin D deficiency. BMJ 2010;340:b5664 doi: 10.1136/bmj.b5664 www.bmj.com/content/340/bmj.b5664.full

3 NICE (2008) NICE public health guidance 11. Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households www.nice.org.uk/PH011 http://www.nice.org.uk/PH011

4 Zipitis, El Azabi and Samanta. Vitamin D supplementation, guidelines,
and awareness of midwives and new mothers. Rapid Response BMJ 29 January

5 Crawford & Burge 2010 rapid response). Knowledge and use of vitamin D supplementation in pregnancy, and vitamin D preparations
Rapid Response BMJ 1 July 2010 http://www.bmj.com/rapid-response/2011/11/02/knowledge-and-use-vitamin-d...

6 Livingstone 2010 rapid response) Making supplementation appropriate and accessible with vitamin D
Rapid Response BMJ 19 January 2010 http://www.bmj.com/rapid-response/2011/11/02/making-supplementation-appr...

7 Nagaraj & Howe Why universal vitamin d supplementation or fortification is not the best Public health strategy for vitamin D deficiency in the UK
Rapid Response BMJ 21 January 2010 http://www.bmj.com/rapid-response/2011/11/02/why-universal-vitamin-d-sup...

Competing interests: No competing interests

30 April 2012
Patricia J Lucas
Senior Lecturer
Ailsa Cameron, Tricia Jessiman
School for Policy Studies, University of Bristol
8 Priory Rd, Bristol, BS7 8LJ