Rickets was believed to have been consigned to the Victorian era, when the bone disease was a sign of poverty and malnutrition in children. However, a resurgence of this and other conditions caused by a deficiency in vitamin D in recent years has led to a renewed emphasis on the role of midwives in tackling the problem.
Earlier this year, the chief medical officers from the four UK departments of health wrote to some healthcare professionals, although not midwives, to remind them of the recommendations for vitamin D supplementation (Davies et al, 2012). The letter said that evidence suggested that up to a quarter of the UK population could be at risk of vitamin D deficiency.
It told NHS staff that all pregnant and breastfeeding women and children aged between six months and five years should take a daily supplement of the vitamin.
The exception to this is infants who are fed formula milk, who will not need vitamin drops until they are receiving less than 500ml a day, as these products are fortified with vitamin D. This echoes recommendations from NICE, which stress the importance of midwives discussing vitamin D supplementation with pregnant women at the booking appointment (NICE, 2008).
Low levels of vitamin D have long been known to contribute to bone problems such as rickets. The vitamin is essential for the growth and development of a baby’s bones, by regulating the absorption of calcium and phosphate (NICE, 2012). According to NICE (2008), women should be told that the supplements will increase the vitamin D stores of both mother and baby and reduce the risk of the baby developing rickets. This guidance tells healthcare professionals to take particular care advising those at greatest risk of vitamin D deficiency. These include women from South Asian, African, Caribbean or Middle Eastern descent, as darker skin does not produce as much vitamin D and who for cultural reasons, may wear clothing that covers them completely. Those who have little exposure to the sun are also at extra risk, as are obese women, because the vitamin is fat soluble and can be stored in fat cells.
A growing body of evidence in recent years has also suggested a link between shortages of the vitamin and a higher risk of other conditions, including heart disease, multiple sclerosis, type 1 diabetes, bowel cancer and breast cancer (Holick, 2004). The vitamin is mainly produced by ultraviolet B (UVB) sunlight rays falling on the skin, but some is also absorbed from food such as oily fish, cod liver oil and egg yolks.
RCM professional policy advisor Janet Fyle says it is important that all midwives are up to date on the latest recommendations regarding vitamin D. ‘Advising on vitamin D is an important part of the public health role of midwives,’ she says. ‘Midwives come into contact with women from early on in their pregnancy and are involved with them throughout their antenatal care and birth. This makes them key people to talk to women about vitamin supplementation and dietary issues in pregnancy.’
She continues: ‘The recommendation that bottle-fed babies need not be given vitamin D supplements could impact on the woman’s infant-feeding decision, as she may wrongly believe that formula milk is superior to breastmilk because of the added vitamin D.
‘This is why it is important for midwives to update their knowledge around vitamin D supplementation and breastfeeding and be able to provide parents with simple advice that improves their health, but also support their informed choices and decisions.’
Research has suggested that midwives are not giving sufficient advice to pregnant women on vitamin D. A study published in Archives of Disease in Childhood last year found that only a quarter of 34 midwives in South London who completed a questionnaire said they gave routine vitamin D advice to their clients during pregnancy (Jain et al, 2011). A survey of 73 community midwives and health visitors published in Community Practitioner found that only half were aware of the Department of Health’s recommendations around vitamin D (Lockyer at al, 2011).
Jill Demilew, consultant midwife for public health at King’s College NHS Foundation Trust, says that all midwives should advise pregnant women to take vitamin D supplements in the information they send out before meeting them, and discuss it again when they meet them for the first time. ‘Midwives are shocked that rickets is increasing and it is shocking that a disease of malnutrition is here today,’ she says. ‘Talking about vitamin D should be a routine part of antenatal care. As all women should be taking supplements, the message is very simple. Education of all healthcare professionals who come into contact with pregnant women and children about the importance of vitamin D and the government’s recommendations is also important.’
Women on low incomes can qualify for the government’s Healthy Start programme, which offers free vitamin supplements, including vitamin D. However, the chief medical officers said in their letter that uptake of vitamin D through this is very low. Jill says that midwives need to make sure it is straightforward for women to access these free vitamins locally. When she looked into the availability of the supplements in her area, she found that there was confusion over collection points for the Healthy Start programme. All midwives in the area now have lists of collection points to make it easier for pregnant women to get the vitamins. Midwives should also be giving all women information about the programme to ensure that those who are eligible, which includes all pregnant women under the age of 18, can benefit, according to Ms Demilew.
Colin Michie, a consultant paediatrician at Ealing Hospital in London, has seen increasing cases of bone problems, delays in reaching milestones, such as walking, and seizures among children caused by a shortage of vitamin D. He stresses that healthcare staff need to remember that rickets and vitamin D deficiency are not limited to people from low-income backgrounds. Concerns about skin cancer have led to some children being covered in high factor sunscreen and rarely being exposed to enough sunlight to generate vitamin D.
Colin points out that another consequence of increasing vitamin D deficiency is a number of cases where parents may have been wrongly accused of harming their children because vitamin D deficiency has left them with weak bones. This has led to small children being admitted to hospital with suspicious bone breaks.
‘Vitamin D is very cheap to make and those not receiving it will increase costs for the NHS in the future with complications,’ he says. ‘We are not going to know the outcomes of the deficiency for the children of women who are pregnant now for perhaps 50 years. Midwives have a crucial role in talking to pregnant women about supplementation.’
For more information about the Healthy Start programme, please visit: healthystart.nhs.uk
The UK departments of health recommend (Davies et al, 2012):
All pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D, to ensure the mother’s requirements for vitamin D are met and to build adequate fetal stores for early infancy.
All infants and young children aged six months to five years should take a daily supplement containing vitamin D in the form of vitamin drops, to help them meet the requirement set for this age group of 7-8.5µg of vitamin D per day. However, those infants who are fed infant formula will not need vitamin drops until they are receiving less than 500ml of formula a day, as these products are fortified with vitamin D. Breastfed infants may need to receive drops containing vitamin D from one month of age if their mother has not taken vitamin D supplements throughout pregnancy. References
Davies SC, Jewell T, McBride M, Burns H. (2012) Vitamin D – Advice on supplements for at risk groups, Department of Health. See: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132508.pdf (accessed 5 October 2012).
Holick MF. (2004) Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. The American Journal of Clinical Nutrition 79(3): 362-71. See: intl-ajcn.nutrition.org/content/79/3/362.full (accessed 5 October 2012).
Jain V, Raychaudhuri R, Barry W. (2011) A survey of healthcare professionals' awareness of vitamin D supplementation in pregnancy, infancy and childhood- midwives, GPs and health visitors have their say. Archives of Disease in Childhood 96: A16-8. See: adc.bmj.com/content/96/Suppl_1/A16.2.abstract (accessed 5 October 2012).
Lockyer V, Porcellato L, Gee I. (2011) Vitamin D deficiency and supplementation: are we failing to prevent the preventable? Community Practitioner 84(3): 23-6. See: www.ingentaconnect.com/content/cp/cp/2011/00000084/00000003/art00007 (accessed 5 October 2012).
NICE. (2008) Maternal and child nutrition. See: publications.nice.org.uk/maternal-and-child-nutrition-ph11/recommendations#vitamin-d-2 (accessed 5 October 2012).
NICE. (2012) Making sure pregnant and breastfeeding women receive vitamin D. See: www.nice.org.uk/newsroom/features/MakingSurePregnantAndBreastfeedingWomenReceiveVitaminD.jsp (accessed 5 October 2012).