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Lack of vitamin D in infants can result in broken bones and shaken baby syndrome - March 2010

The Vitamin D Council Newsletter, March 5, 2010 Another Shattered Family

Dear Dr. Cannell:

I am writing to you today to see if there is any information or help you can give to me. On October 25th of 2009, I gave birth to our wonderful son & we were overjoyed. Four days later we noticed that our son had a swollen right thigh so we took him back to the hospital & there an x-ray was done & he had a fractured femur!
Then on the 2nd of Nov. the hospital carried out further scans & we were told that he had fractures to the fibula, tibia & 3 fractures of the ribs. You can now only imagine the situation we are now in but we remain strong & are fighting this all the way knowing that we have not shaken our baby or abused our son or caused these fractures. It was only after our repeated requests that the hospital carried out blood tests on our son for calcium, Vitamin D etc. this was after him been in the hospital & after we had been accused of Shaken Baby Syndrome.” These tests came back as normal.
However I have been tested & have low levels of vitamin D and I have been for a bone density scan which is below average for a woman of my age.

Do you think that there is the possibility that my vitamin D deficiency in pregnancy caused the fractures during the birth of my son?

I would really appreciate any information you could give me with this matter.....I am not concerned about my deficiency; I just want this nightmare to be over.

Jane, Chicago

Dear Jane:
I am so sorry for your nightmare; perhaps it is consoling to you to know you are not alone. Please read my newsletter of June 2009:
Child Abuse Or Vitamin D Deficiency Rickets?
Since I wrote that article last June, two additional papers have come out, including a frightening paper from England, which I will discuss last.
The diagnosis of “shaken baby syndrome” rests on three findings, multiple broken bones, retinal hemorrhages, and intracranial bleeding. Pretty clear diagnosis, right? Proof of abuse, right?

If cases like yours were due to parental child abuse, then fractures would not occur while the infant was still in the hospital, only after the infant was taken home. What happens when fractures are found before the infant leaves the hospital? Child abuse by the doctors and nurses? Not a chance, the fractures are said to be due to “temporary brittle bone disease,” not “shaken baby syndrome.”

Below is a case series of five infants where the fractures occurred while the children were still in the hospital, and thus the authors could not diagnose shaken baby syndrome because doctors and nurses know that doctors and nurses do not beat infants, parents do that. So the doctors diagnosed “temporary brittle bone disease,” which just means the infant’s bones break for no apparent reason in the first few months of life. Vitamin D levels were not obtained on any of these five infants. In each case, the parents were lucky not to have spent time with their infant at home, or the diagnosis of temporary brittle bone disease would have been shaken baby syndrome, and tragedies like yours may have ensued.

Paterson CR. Temporary brittle bone disease: fractures in medical care. Acta Paediatr. 2009 Dec;98(12):1935-8.

Here is a description of one of the infants. “On the day of delivery, a male infant was admitted to a neonatal unit for 4 hours before being returned home with the mother. Mother noticed a ’crackle or pop noise every now and then and he would flinch.’ When he was held, she could feel a ‘popping sensation’ in his back . . . after she had again drawn it to the attention of the staff an x-ray was taken which demonstrated a recent posterior fracture of the sixth right rib with slight displacement. There was also a probable undisplaced fracture of the right seventh rib posteriorly. It was asserted that such posterior rib fractures do not occur at birth and were characteristic of a non-accidental injury. The police and social services were summoned, but because it was clear that the fractures had occurred in hospital, it was accepted that a non-accidental cause was very improbable.”

What would have happened to the mother if she had said nothing and taken the infant home? Even more interesting is a paper by Dr. Pamela Mahon and her colleagues at the University of Southampton. Using intrauterine ultrasound, they looked for evidence of rickets before the infants were even born, studying 424 pregnant women with high resolution ultrasound and also checking maternal vitamin D levels. You should be able to get the full text of the article and a commentary with these two links:

Mahon P, et al. Low Maternal Vitamin D Status and Fetal Bone Development: Cohort Study. J Bone Miner Res. 2009 Jul 6.

Hewison M, Adams JS. Vitamin D insufficiency and skeletal development in utero. J Bone Miner Res. 2010 Jan 15;25(1):11-13.

About one-third of the fetuses in England have evidence of intrauterine rickets, as evidenced by the classic finding of splaying or flaring at the end of the femur. They found splaying was common in fetuses whose mothers had vitamin D levels less than 20 ng/ml, and even saw a suggestion of splaying with levels less than 30 ng/ml. Only about 1/3 of the pregnant women in the USA have levels above 30 ng/ml.

The implications of Dr. Mahon’s above paper are hard to overstate. It implies that if a biopsy of the end of the femur was taken at birth, one-third of all newborns, perhaps more, would show pathological evidence of rickets. If x-rays of these same infants were taken at birth, some would certainly be found to have multiple asymptomatic fractures caused from the battle to traverse the birth canal. Again, if these fractures are diagnosed before the infant leaves the hospital the diagnosis is temporary brittle bone disease; if the infant is taken home and then readmitted the diagnosis is “shaken baby syndrome” and the parents charged with felony child abuse.

Also, one-third of newborn infants in the USA who come through the birth canal also have retinal hemorrhages, or bleeding in the back of the eye.

Hughes LA, May K, Talbot JF, Parsons MA. Incidence, distribution, and duration of birth-related retinal hemorrhages: a prospective study. J AAPOS. 2006 Apr;10(2):102-6.

Of course, you may say, broken bones and bleeding eyes could happen during a vaginal delivery, but what about brain hemorrhage, certainly that is proof of abuse? Well, it has been proof – proof positive of parental child abuse – for decades, sending thousands of parents to prison for “Shaken Baby Syndrome.” Guess what, it turns out that 26% of newborn infants have brain hemorrhages after a normal, natural, vaginal delivery.

Looney CB, et al. Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology. 2007 Feb;242(2):535-41.

I suspect, but cannot prove, that the same infants who have the bleeding eyes and the hemorrhagic brains are more likely to have broken bones and I suspect the etiology is of all three conditions is somehow associated with maternal vitamin D deficiency. While I understand that Vitamin K deficiency is involved in bleeding of the newborn, that does not explain why hemorrhagic disease of the newborn is seasonal, peaking in January and February and the lowest in July and August.

Douglas AS. Seasonality of hip fracture and haemorrhagic disease of the newborn. Scott Med J. 1993 Apr;38(2):37-40.
Furthermore, two studies found that various blood clotting factors are associated with vitamin D levels, although the associations are confusing.

Jorde R, et al. Serum levels of vitamin D and haemostatic factors in healthy subjects: the Tromsø study. Acta Haematol. 2007;117(2):91-7.

Jorde R, et al Parameters of the thrombogram are associated with serum 25-hydroxyvitamin D levels at baseline, but not affected during supplementation with vitamin D. Thromb Res. 2010 Jan 11.

However, no one has tried to connect the dots and ask if fragile bones, bleeding eyes, and hemorrhagic brains are associated with maternal vitamin D deficiency. If a scientist would just conduct a study of newborns, looking for splaying of the femur, retinal hemorrhages and intracranial bleeding at birth, seeing if those findings are associated with maternal and infantile vitamin D levels, the mystery may be solved and countless families spared the nightmare you are going through.

Jane, families unlucky enough to have x-rays taken of their infants after they return to the hospital, like your family, are in a world of trouble. Without knowing you and your family, I am as certain as I can be that all your son’s fractures may have been caused from vitamin D deficiency during your pregnancy leading to brittle bones that broke during the trauma of his birth.

I have no magic words to salve your tragedy. Show the above studies to your attorney. I also know a kind and honest attorney who is knowledgeable about these things, his name is Zachary Bravos. Zack has recently published a critical article on Shaken Baby Syndrome in the Journal of the Illinois Bar Association.

John Cannell, MD, Executive Director, Vitamin D Council
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Temporary brittle bone disease versus suspected non-accidental skeletal injury - Oct 2010

Arch Dis Child doi:10.1136/adc.2009.180463
Alan Sprigg : Correspondence, Radiology Department, Sheffield Children's Hospital, Western Bank, Sheffield S10 2TH, UK; alan.sprigg at sch.nhs.uk

Temporary brittle bone disease has been proposed again as an alternative explanation for suspected non-accidental injury. This is still not considered a real entity by mainstream opinion. The recent publications remind us to look carefully for alternative explanations and to investigate for predisposing bone disorders thoroughly.

Introduction

When a child presents with unexplained skeletal injury, the age, history of presentation and level of mobility of the child is important. The absence of a clear history to explain an injury raises the issue of non-accidental skeletal injury (NASI). It is also important to consider any underlying bone disorder that might predispose a bone fracturing with normal handling force.

NASI has medicolegal implications for children and parents. In the UK, experts must provide balanced and impartial evidence to assist the court. Lawyers are instructed by the various parties but the expert is independent. Against this background the judge balances contrary medical expert evidence and opinion. Many alternative explanations have to be considered. Courts are faced with issues of scientific hypothesis, leading edge research and epidemiological data but court is not the best arena for scientific discussion.

Paterson first proposed the concept of temporary brittle bone disease (TBBD) in 1993.1 He described a personal series of 39 children who had unexplained fractures in the first year of life. He proposed TBBD as a transient predisposition to fracture with normal handling force, without any bruising, proven medical diagnosis or biochemical abnormality. They suggested this was due to temporary immaturity or fragility of collagen related to trace element deficiency (eg, copper) or transient osteogenesis imperfecta (OI). They provided no specific test to confirm TBBD. There was no complete data table on their 39 cases and there was a lack of comprehensive bone biochemistry results. TBBD presented a theoretical and attractively benign explanation for suspected NASI …


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