Child abuse or vitamin D deficiency?
June 14th, 2009The latest Vitamin D Council newsletter, by Dr. John Cannell, is a must-read. (No, really.) His correspondent, “Kathryn,” is an African-American mother who faces child abuse charges following of the discovery of unexplained fractures in her infant following an x-ray. She had been following medical advice by breast-feeding and keeping her daughter out of the sun. But people with dark skin are particularly susceptible to vitamin D deficiency, and breast-fed children are in particular danger, as a vitamin D deficient mother produces deficient breast milk. She writes:
Well, a child abuse expert was called in and we were accused of abuse and they took our baby away, saying we had beaten her. I can’t forget Marissa screaming when they tore her out of my arms. We were shocked. We could never do such a thing. Even though they could not find any evidence of abuse except these broken bones, the DA tells me if I don’t plead guilty and testify against my husband and say he did it, I will be prosecuted as well and never see my baby again. Our lawyer says I can be forced to testify against my husband in child abuse but he would never hurt Marissa. I don’t know what to do. My husband is ready to plead guilty to save our baby from foster care but I don’t think I can let him do that.
I have learned of other African American parents in the same situation. Neither of us would ever abuse our child, it took seven years of trying and then infertility treatment to have her. The reason I am writing is because I have read about cases of rickets where unexplained fractures are common, especially in African Americans like us, that are being called child abuse. I breast fed Marissa but I now know that breast milk doesn’t have enough Vitamin D. We should have given it to her but our pediatrician never said anything about it and La Leche league says breast milk is all infants need.
When we learned Vitamin D may be involved, I asked my doctor to test me and my level was 5 at first. [The Vit. D council recommends 50-80 ng/ml as optimal.] He prescribed Drisdol and now it is 18 after taking 50,000 IU per week for two months. When our lawyer brought up rickets and Vitamin D deficiency the DA had Marissa x-rayed for rickets and tested for Vitamin D; her x-rays were normal and her blood level is now 21, but the child abuse doctors never tested her for Vitamin D when they first took her away from us and she had been on 400 IU formula in foster care for five months when they finally tested her.
Dr. Cannell writes:
The issues you raise about Vitamin D deficiency being misdiagnosed as child physical abuse are so common they were recently the topic of four papers in Pediatric Radiology. First, Drs. Kathy Keller and Patrick Barnes, both pediatric radiologists, published four cases reports. The course of each child was similar. Concerned parents took their child to the doctor for leg bumps, well baby checks, or even the flu. X-rays showed multiple skeletal fractures that were asymptomatic. No mention of bruises, skin abrasions, retinal hemorrhages, parental drug abuse, parental sociopathy, nor evidence the child was frightened of their parents. The children had been seen previously by physicians, nurses, lactation consultants, day-care workers, audiologists, family and friends with no suspicions of abuse. Such parents often have a reputation of being the most protective and concerned parents on the block. Drs. Keller and Barnes thought all four children had rickets. Keller KA, Barnes PD. Rickets vs. abuse: a national and international epidemic. Pediatr Radiol. 2008 Nov;38(11):1210–6.
The key here is the history as much as x-rays. These are often black children, living above latitude 35 degrees, usually breastfeeding without Vitamin D supplementation, often born in the late winter or early spring. The key on exam is that the fractures are painless, unlike traumatic fractures, and there are no bruises. A common finding in the neonatal medical record is craniotabes, or softening of the skull. About 20% of “normal” newborns have soft bones as evidence by craniotabes; of course these newborns are not normal, they are simply the newest additions to the Vitamin D deficiency pandemic.
…
Professor Russell Chesney, Chairman of the University of Tennessee Health Science Center Department of Pediatrics, went next, warning readers we are currently in the “third wave” of rickets; the first caused by air pollution during the industrial revolution, the second wave occurred during the 1980s mainly due to La Leche League-type breast-feeding among heavily clothed immigrants, and the current third wave. (The current wave of rickets is the gift of the sun-scare academic dermatologists, who, in turn, are gifted multi-million dollar grants from the cosmetic and sun-screen industry.) Professor Chesney points out that asymptomatic fracture from Vitamin D deficiency is not uncommon, adding that similar fractures have been noted in young arctic foxes, alpacas, and polar bears kept in zoos, all who apparently suffer such fractures during normal play—unless arctic foxes abuse their kids. I suspect arctic fox infants will get adequate Vitamin D long before African American infants.
It doesn’t look good for Kathryn.
We have no way of knowing how many innocent African American families have been, and will be, destroyed when child abuse experts misdiagnose the fractures and pseudo-fractures (Looser’s zones) of rickets as child abuse. In a recent report of two such cases, Dr. Senniappan of Saint Mary’s Hospital in England gave some good advice that was ignored in your case: “Clinicians have the duty to exclude the possibility of an underlying medical disorder associated with skeletal fragility,” and they have to do so at the time the diagnosis of child abuse is considered, not six months later after the child has been given Vitamin D and calcium in formula. Senniappan S, Elazabi A, Doughty I, Mughal MZ. Case 2: Fractures in under-6-month-old exclusively breast-fed infants born to immigrant parents: nonaccidental injury? (case presentation). Diagnosis: Pathological fractures secondary to vitamin D deficiency rickets in under-6-months-old, exclusively breast-fed infants, born to immigrant parents. Acta Paediatr. 2008 Jul;97(7):836–7, 992–3.
In Scotland, Dr. Colin Patterson of the Ninewells Hospital in Dundee reported on a case of unexplained fractures and warned, “A mistaken diagnosis of abuse can lead to irreparable damage to both family and child.” Paterson CR. Vitamin D deficiency rickets simulating child abuse. J Pediatr Orthop. 1981;1(4):423–5.
Kathryn, as far as the deal the DA is offering (having you plead guilty, dropping abuse charges against you, having your husband plead guilty and go to prison, and giving you your child back if you enter testimony against your husband), this is usually how the DA gets a conviction of “confirmed” child abuse. It is an unusual woman who would risk both prison and her child to defend the truth—not to mention a husband.
This is pretty messed up.
