Let There Be Light

You’ve done everything right. You always remembered to take your prenatal vitamins. You breastfed your child. You found a natural sunscreen and adorned your child with a brim hat to fight those UV rays. Perhaps you even recognized that cow’s milk is unfit for human consumption and weaned your child onto an alternative (hopefully not soy—hard to keep up, isn’t it?). But you have done everything right—you even played Brahms in utero.

Your child is growing from an immobile bobble-head to a full-fledged being. He begins to pull himself up and take those first few tentative steps that quickly turn into an endless run. When he starts walking like an overworked cowboy, you don’t take much notice—after all, most toddlers are slightly bowlegged. But then he stops running as much, and his energy seems low. One day he suddenly has trouble standing up. When your pediatrician informs you your child has rickets, you feel as if you’ve been slammed over the head. Rickets, in the 21st century, in the Bay Area: this is the experience of some parents who did everything right.

According to information released by the Children’s Hospital & Research Center in Oakland, 56 children suffering from rickets have been treated over the past five years. The study, led by Dr. Suruchi Bhatia, Medical Director of Endocrinology, is one of the few tracking what had been thought to be a virtually eradicated condition.

Rickets, or childhood osteomalacia, rose out of the smoke of the Industrial Revolution, hitting epidemic proportions early in the 20th century. Caused primarily by a vitamin D deficiency, rickets is a softening and weakening of the bones that leads to bone pain, skeletal deformities, increased risk of bone fracture, weakening of the muscles, muscle cramps, dental deformities, and delayed growth. In its most severe form, rickets can cause spasms of the feet, hands, and larynx, difficulty breathing, and convulsions.

It was noted as early as the late 18th century that sunbathing cured rickets. But when mass populations moved to the cities to work in factories, the discovery did little to curb the disease. Smog and high-rises blocked the sun, and children often worked long hours alongside their parents in artificially lit factories. It is estimated that 80 percent of children living in Boston in 1900 had rickets.

In the 1920s, a series of experiments tracking the effects of ultraviolet light on foods fed to rats concluded that irradiated food could produce the same safeguard against rickets as sun exposure. The food irradiation process (later to be replaced by vitamin D synthesis) was patented in 1924 and allowed children to meet their vitamin D needs through fortified milk and bread. “Seemingly overnight, the imminent threat of epidemic disease dwindled to a half-forgotten historical event,” reads a National Academy of Sciences article.

Half-forgotten but not gone. The 56 cases reported by Children’s Hospital & Research Center in Oakland are not out of the ordinary; over a similar period, Children’s Hospital of the Central Coast treated 47 children with rickets, and Lucile Packard Children’s Hospital at Stanford saw 117 children with a primary diagnosis of rickets and another 647 with a secondary diagnosis. While these numbers are alarming, they represent just a small fraction of rickets incidences. According to Kelley Scanlon of the Centers for Disease Control and Prevention, hospital discharge data show only the most severe cases of rickets, probably about 20 percent of the total cases that occur, while 80 percent of children with rickets are treated by their physicians.

Because many children with rickets are treated locally and it is not a communicable disease (and therefore not tracked by Public Health Offices), it is extremely difficult to gauge its prevalence. Says Scanlon, “There has been a lot of stuff in the literature about ‘the rise of rickets,’ but we’ve never been able to confirm an actual rise. We do know there has been an increase in reports, and that was a concern to us.” The reports were worrisome enough that in 2003 the American Academy of Pediatrics began recommending vitamin D supplementation for all breast-fed infants.

Whether or not an official study proves an upward trend, many believe that the escalation of rickets reports represents a deeper, more ubiquitous problem. Dr. Laura Bachrach, Professor of Pediatrics at Stanford University School of Medicine, who has seen several severe rickets cases over the years, believes that the figures are just “the tip of the iceberg because we haven’t been routinely screening children to see how many kids in the Bay Area are vitamin D deficient.”

Why now? If rickets all but disappeared in the 1920s, why the upsurge?

One reason is that vitamin D is not naturally present in most foods, including breast milk, and people are increasingly cutting dairy and milk—the most commonly fortified products—from their diets. According to Scanlon, “We have talked to parents of children with rickets in the past, and these were highly educated parents doing the best they could, breastfeeding their child, and some of these children were weaned onto a soy beverage. These parents were very upset that no clinician, no healthcare provider, ever told them that that soy beverage didn’t have vitamin D and that there really weren’t very many other vitamin D sources in the diet, and that the child was at risk of vitamin D deficiency.”

With the common knowledge that more darkly pigmented children require more sunlight to synthesize vitamin D in the skin, increasing a risk of deficiency (nearly 75 percent of rickets cases at Children’s Hospital in Oakland were African-American children), and considering that as many as 80 percent of African-Americans are lactose-intolerant, one has to wonder at the logic of fortifying milk to combat vitamin D deficiency.

African-American children aren’t the only ones lacking Vitamin D. Unless you are drinking four glasses of milk a day, or eating fish liver oils, you’re probably not getting enough vitamin D in your diet. With the American Academy of Dermatology, the American Academy of Pediatrics, and the Skin Cancer Foundation leading an effective campaign against the sun, you are likely not getting enough Vitamin D from the body’s natural ability to produce it, either. Even an SPF 8 sunscreen will prevent the absorption of UV light that triggers your body’s vitamin D production. “People believe that as little as 30 minutes exposing the face, arms, and hands without sunscreen on is sufficient to make enough of your own vitamin D, but parents are being very conservative about keeping babies out of the light. Oftentimes they don’t get that requisite sunlight,” says Dr. Bachrach.

This conservative approach to sun exposure is nurtured by a constant bombardment of well-funded messages that sun equals skin cancer. Consider this imperative from the Skin Cancer Foundation: “Babies under six months should never be exposed to the sun.”ÊTheir response to healthcare professionals and vitamin D experts who suggest a mere five to ten minutes of sun exposure is unequivocal: “Most dermatologists and cancer groups including the Skin Cancer Foundation have argued strongly against this ‘solution,’ since all unprotected UV exposure contributes to cumulative skin damage, accelerating aging, and increasing our lifetime risk of skin cancer.” While the Skin Cancer Foundation’s annual report is not available on its web site, the list of corporate sponsorships (including a Corporate Leadership Council, Cosmetic Industry Board, Corporate Council, and International Corporate Council) is a virtual who’s who of the sunscreen industry.

Powerful messages have a powerful impact. “For 30 years the dermatology community has been unchallenged in terms of telling people they should never be exposed to direct sunlight,” says Michael Holick, a leading vitamin D expert and professor of medicine, physiology, and biophysics at Boston University School of Medicine. “It’s had a devastating consequence, which is to cause severe vitamin D deficiency throughout the entire population of the world, including the United States. This has been a major issue for pregnant women because a prenatal vitamin contains 400 units of vitamin D, which is 40 percent of what they need. Most humans depend on the sun for their vitamin D requirement—90 to 95 percent was typically coming from sunlight. If they’re getting 40 percent of what they need and they’re not getting any sunlight, they’re likely to be vitamin D deficient.” In fact, in a recent study of 40 mother/infant pairs at Boston University Medical Center, Dr. Holick and his colleagues found that 80 percent of mothers and 76 percent of infants (at birth) were vitamin D deficient.

Dr. Holick, who was fired from his secondary position as professor of dermatology at Boston University for advocating “sensible sun exposure,” estimates that from 30 to 50 percent of all children and adults in the United States are at risk of vitamin D deficiency. The consequences of this deficiency go far beyond rickets. According to Dr. Holick, adequate vitamin D decreases risk of type I diabetes, multiple sclerosis, colon cancer, prostate cancer, and breast cancer. It also lowers insulin resistance, a major contributor to heart disease and regulates calcium levels which, in turn, help to regulate blood pressure. It is even a risk reduction factor for malignant melanoma. In fact, research indicates that vitamin D might help prevent 30 deaths for each one caused by skin cancer.

Of course, no one is suggesting baking in the sun in the name of vitamin D production. And sun exposure has its limitations: skin tone, latitude, season, cloud cover, and pollution all affect UV absorption. In the Bay Area, for example, our northern latitude means little vitamin D synthesis three to six months out of the year. However, a combination of sensible sun exposure when possible, and fortified foods or supplements when UV light is scarce or during the winter, can go a long way in preventing vitamin D deficiency.

Rickets and vitamin D deficiency are easily preventable. The rise of rickets in the Bay Area could be quickly eradicated by information disseminated with half the intensity of the sunscreen campaign. Says Scanlon, “I don’t know what different organizations are doing to encourage that all parents are getting that message, but we’re not doing it at Centers for Disease Control. Part of that is just funding issues and what we can do outreach on.” If sunlight could be bottled, sold at $9.99, and “slip, slop, slapped” on every two hours, creating a $455 million industry, we could probably find corporate funding to spread the message.

Alas, the sun is free, and a year’s supply of supplements can be purchased for $30. For now, parents who are trying to do “everything right” for their children will have to rely on the trickle of information that creeps into the media every time vitamin D is linked to the prevention of yet another disease.

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