Rickets, once thought vanquished, is reappearing. In some less developed countries it hardly went away. This seminar reviews the effects of genes, stage of development, and environment on clinical expression of the disease. Rickets can be secondary to disorders of the gut, pancreas, liver, kidney, or metabolism; however, it is mostly due to nutrient deficiency and we concentrate on this form. Although calcium deficiency contributes in communities where little cows' milk is consumed, deficiency of vitamin D is the main cause. There are three major problems: the promotion of exclusive breastfeeding for long periods without vitamin D supplementation, particularly for babies whose mothers are vitamin D deficient; reduced opportunities for production of the vitamin in the skin because of female modesty and fear of skin cancer; and the high prevalence of rickets in immigrant groups in more temperate regions. A safety net of extra dietary vitamin D should be re-emphasised, not only for children but also for pregnant women. The reason why many immigrant children in temperate zones have vitamin D deficiency is unclear. We speculate that in addition to differences in genetic factors, sun exposure, and skin pigmentation, iron deficiency may affect vitamin D handling in the skin or gut or its intermediary metabolism.

SUMMARY Previous work at this hospital and elsewhere has shown that anaemia in toddlers is common and is associated with psychomotor delay. It seemed unclear, however, whether this association was cause and effect or merely due to the same underprivileged environment. A double blind randomised intervention study was, therefore, performed. After an initial assessment 97 children with anaemia (haemoglobin 8-11 g/dl) aged 17-19 months received either iron and vitamin C or vitamin C only (control group) for two months and were then reassessed. The children who received the iron had an increased rate of weight gain and more of them achieved the expected rate of development. While iron deficiency anaemia is unlikely to be the only factor in the slower development of children living in underprivileged circumstances, it can at least be easily identified and treated. Routine child health surveillance in such areas should include a haemoglobin determination.

SUMMARY This study examined the faecal flora on days 4, 14, and 28 of 17 breast fed babies and 26 bottle fed babies receiving a modern infant formula based on demineralised whey. Generally among breast fed babies bifidobacteria and staphylococci were the predominant organisms, whereas in the formula fed babies the predominant organisms were enterococci, coliforms, and clostridia. Despite the extensive modification of cows' milk to make an infant formula resemble human breast milk, the results are very similar to those previously reported with unmodified cows' milk baby feeds. The exact dietary factor responsible for these microbiological differences is unclear and in succeeding papers we have looked at the effects of protein quality, in particular the content of whey proteins, casein, and lactoferrin.

No abstract

SUMMARY One hundred and forty five Asian children born at Sorrento Maternity Hospital, Birmingham, were reviewed at the age of 22 months. A significant association of iron deficiency and poor vitamin D state was found. Two fifths of the children were anaemic, two fifths had a low plasma concentration of vitamin D, and one fifth had both features. This was more than simple overlap of the two deficiencies; the children with low plasma vitamin D concentrations had significantly lower concentrations of haemoglobin and serum iron. On the other hand, the deficiencies were not merely individual features of generally poor nutrition; growth and other measures of protein energy nutrition were slightly better in these children, and their plasma zinc concentration was no lower than in the children without deficiencies. It seems, therefore, that child health surveillance as currently practised-for example, growth monitoring, clinical signs, etc-will not detect these problems unless a haemoglobin determination is included. In view of the association of poor iron and vitamin D state combined prophylaxis is desirable. At present, strategies for preventing rickets in this country are not combined with attempts to detect or prevent iron deficiency. In our opinion they should be and the options are discussed.

1. Metabolic changes associated with Ramadan fasting were studied in eleven Asian pregnant mothers. This was compared with a group of control mothers undergoing a normal physiological fast.2. At the end of the Ramadan fast day there was a significant fall in glucose, insulin, lactate and carnitine, and a rise in triglyceride, non-esterified fatty acid and 3-hydroxybutyrate. When compared with the control group, none of the Ramadan mothers had a completely normal set of biochemical values at the end of the fast day.3. Pregnancy outcome in the two groups was comparable. 4. We are wary of the metabolic departures from normal observed in the Ramadan fasting mothers. If asked we advise mothers to take up the dispensation from fasting during pregnancy which is allowed.An important aspect of the Muslim religion is the fast of Rosa during Ramadan. During Ramadan all healthy adults are obliged to fast from sunrise to sunset. The length of the fast therefore depends on the exact time of sunrise and sunset in the country where the person lives. The duration of the fast in temperate climates such as Britain averages about 18 h/d when Ramadan occurs during the spring and summer. This is dependent on the exact time of sunrise and sunset, but is approximately observed between 02.30 and 19.30 hours here. Pregnant women are allowed to postpone their fast until after delivery, but about three quarters of mothers attending this hospital continue to observe it for various reasons (Eaton & Wharton, 1982), for example, convenience when eating as a family, and social pressures. However, they often ask about the possible harmful effects of fasting both to themselves and their babies.Although there is some evidence of metabolic stress in Ramadan (Prentice et al. 1983), the work was carried out in the deprived conditions of the tropics where the prevalence of endemic malnutrition, tropical infection and drought may have compounded the effect of fasting during pregnancy. The better environmental conditions of the Muslim population in Britain provides an opportunity to study the metabolic effect of Ramadan fasting without these complicating factors. Moreover, a previous study in Birmingham of nonpregnant Muslim diabetics (Barber et al. 1979) concluded that fasting was safe. This study was designed to determine the metabolic effects of Ramadan fasting during pregnancy in healthy mothers living in Britain. M E T H 0 D S PatientsAs part of a larger study of glucose metabolism in pregnancy all mothers booking at this hospital in time were invited to attend a clinic at 17 weeks and again at 28 weeks for a more detailed assessment than is usually possible in a routine antenatal clinic. Some of these mothers were selected to take part in this Ramadan study as follows.

The intestinal flora of breast-fed infants differs from that of formula-fed infants. It is thought that this difference in flora may be one important reason why breast-fed babies suffer less from gastrointestinal disease. Differences in intestinal flora are reflected in the profile of faecal short chain fatty acids (SCFA). Very little is known about faecal concentrations of SCFA in babies fed breast milk or infant formula. In this study, faecal SCFA were measured in babies at two and four weeks of age who had been either exclusively breast fed or bottle fed from birth. There was no significant difference in total faecal SCFA concentrations between breast-fed and formula-fed babies when lactate was included. The formula-fed group, however, had less lactic acid and higher concentrations of propionic and n-butyric acids than breast-fed babies. Very few babies had significant levels of n-butyric acid, although this SCFA is believed to be important for the health of the colonic mucosa of adults.

No abstract