The results of routine prophylaxis and treatment of rickets in war-time nurseries.

In an earlier paper (Krestin, 1944) it was shown that rickets, although generally of a mild nature, still presented a problem in infant entrants to the wartime nurseries of Preston, since 36 per cent. of those under two years were found to have evidence of past or active disease, and in some of the poorer districts the incidence was considerably higher. Moreover, it was further noted that even when mothers had previously availed themselves of the free distribution of the Ministry of Food cod-liver oil for their babies, the results were still disappointing. Similarly, in a recent widespread survey throughout Great Britain and Ireland published by the Ministry of Health (1944) 73 per cent. of infants with x-ray evidence of rickets were said to have previously received codliver oil or other vitamin D preparation. Since the efficacy of cod-liver oil both in the prophylaxis and the treatment of this disease is now beyond doubt, it is clear that such results could be due only to inadequate dosage or to carelessness and irregularity of administration. It seemed, therefore, of interest to assess the results of the prophylactic use of cod-liver oil and of the therapeutic use both of this and of a more concentrated preparation of vitamin D for active rickets, as used in the routine of the Preston war-time nurseries where the doses and regularity of administration could be assured. The subjects of this investigation were all unselected infants and children admitted to three residential and ten day nurseries. All were full-term babies. The conditions and diets were fairly uniform and constant in all the nurseries. Infants under six months were fed on a dried or fresh cow's milk. All were examined clinically soon after admission, whilst all under three years and some older children had x-ray films taken of the distal ulna epiphyses. Thereafter, regular clinical examinations were carried out at monthly or shorter intervals. All were again x-rayed at the end of six months, and the 'controls' with a small number of the others were x-rayed at shorter intervals during this period. More frequent x-ray examinations were not possible owing to the distance of the nurseries from the x-ray centre. Chemical investigations of the blood were not practicable. Three groups were studied, a ' control,' a ' prophylactic' and a ' therapeutic.' The first two were free from all obvious disease or defect on admission, and the third from all disease other than active rickets as determined radiologically. The cod-liver oil used was that supplied by the Ministry of Food and was ' fortified ' by the addition of calciferol (Di) so that one drachm contained 700800 I.U. of vitamin D. It was given in the pure form in a teaspoon in two divided doses after meals. In the case of infants under six months the initial dose was half a drachm twice daily and this was increased within a week to the full dose stated in table I. In about 2 or 3 per cent. the oil could not be given owing to refusal on the part of the child, the appearance of skin rashes, or gastro-intestinal upsets. These were then given a more concentrated preparation of vitamin D, but are not included in this paper. Those in day nurseries received the doses on six days, and the residents on seven days a week. The concentrated preparation used in some of the ' therapeutic ' group was given in a single daily dose and contained 2000 I.U. of vitamin D per c.c. The observations of the ' control ' group were made during a six-months' period from the autumn of 1943 to the early spring of 1944. Those of the other two groups were made during this period as well as the same period of the previous year. The diets and conditions in the nurseries during these two periods were similar and the climatic conditions much the same. Further, no other method of treatment, such as ultra-violet radiation, was used in these children.