The Vitamin D Newsletter Mid-June 2009
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Child Abuse? Or Vitamin D Deficiency Rickets?
"By the streams of Babylon we sat down and wept when we remembered Zion." (Psalms 137:1)
Dr. Cannell: I am writing to ask your help because I think my problem has something to do with Vitamin D. Six months ago, Marissa, who is now one-year-old, developed a painless bump on her arm. I watch her closely; I know she did not fall; she was only six months at the time. In the emergency room they found a broken bone in her arm and then x-rayed her entire body and found two more broken bones, but these other two places were not swollen and Marissa did not cry when the doctor pushed on the area.
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. 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.
We had another radiologist look at the original x-rays and compare them to her current ones. He said it looked like rickets and he said her bones look much better now at the growth areas. However, when he found out it was a child abuse case he said he would not get involved.
From your website, I learned breast-feeding mothers have to take 6,000 IU a day to get enough Vitamin D in breast milk. Marissa never went in the sun; our pediatrician said babies should never go in the sun. I don't know what to do. I know you used to testify in child abuse cases, will you help us? We can pay. Kathryn, Boston, MA
The American Legal System and Child Abuse Allegations
No, I won't testify. The American legal system, when it comes to child abuse allegations, is no Zion. My years testifying in child abuse allegations involved the "memory wars," and those wars are over, won by plaintiff attorneys suing psychiatrists, often with the help of my testimony. However, I will put you in touch with a pediatric radiologist who may be able to help.
My interest in child abuse cases started with the McMartin preschool case. (I immediately thought the McMartins and Buckeys all totally innocent as I recognized the most fatal of the psychiatric disorders, hysteria, in those prosecuting them. I still remember Ray Buckey looking into the camera, with panic-stricken media all around him, saying, "This could happen to you.") My involvement in such cases ended with the Archdiocese of Boston case. (I thought the priest I was hired to defend guilty.)
My cases centered on recovered memory therapy, especially multiple personality disorder (MPD), a now discarded and discredited psychiatric diagnosis that destroyed thousands of innocent American families. Of note, during my 15 years of work in the field, every MPD patient I saw had excellent mental health insurance coverage. That is, the absence of mental health insurance apparently protects one from contracting multiple personality disorder. Cannell J, Hudson JI, Pope HG Jr. Standards for informed consent in recovered memory therapy. Review. J Am Acad Psychiatry Law. 2001;29(2):138–47.
Vitamin D Deficiency Commonly Misdiagnosed As Physical Child Abuse
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. Yorifuji J, Yorifuji T, Tachibana K, Nagai S, Kawai M, Momoi T, Nagasaka H, Hatayama H, Nakahata T. Craniotabes in normal newborns: the earliest sign of subclinical vitamin D deficiency. J Clin Endocrinol Metab. 2008 May;93(5):1784–8.
Newborn vitamin D levels not routinely measured
Unfortunately, as 25(OH)D levels are not routinely measured on American newborns, we do not recognize the multitude of afflicted infants, and the infants seldom get Vitamin D, unless they are on formula. Even if they are on formula, 12 months later they are weaned on the empty calories of "natural fruit juice," instead of "evil cow's milk," so the deficiency is just delayed by the Vitamin D formula, not prevented. That is why so many cases of autism present around 12–18 months; it is not the presence of vaccinations but the disappearance of Vitamin D; the two just happen to co-occur.
The sun-scare of the American Academy of Pediatrics
Kathryn, as far as your pediatrician telling you babies should never go in the sun, he is just following the guidelines of the American Academy of Pediatrics (AAP). In 1999, the AAP advised mothers to always keep infants out of direct sunlight, use sun-protective clothes and sunblock, and make sure children's activities in general minimize sunlight exposure. Furthermore, quite inexplicably, the AAP scientists claimed there was "no evidence" such an unprecedented and radical bit of advice would affect vitamin D levels (p. 330). Ultraviolet light: a hazard to children. American Academy of Pediatrics. Committee on Environmental Health. Pediatrics. 1999 Aug;104(2 Pt 1):328–33.
"Third Wave" of Rickets Currently Underway
Getting back to the papers in Pediatric Radiology, 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. Chesney RW. Rickets or abuse, or both? Pediatr Radiol. 2008 Nov;38(11):1217–8.
Authorities fail to see, or acknowledge, the connection
Next, Dr. Carole Jenny, head of the American Academy of Pediatrics Section on Child Abuse, implies such tragic miscarriages of justice simply don't happen. She then claims, "We have been checking every child with multiple fractures for metabolic bone diseases for several years and have not identified a single child with Vitamin D deficiency." How can that statement be true if every other researcher is reporting infantile and early childhood Vitamin D deficiency to be rampant in normal children? Furthermore, how can an infant beaten severely enough to cause multiple fractures not be bruised or in distress? Dr. Jenny cleverly avoids the question. Jenny C. Rickets or abuse? Pediatr Radiol. 2008 Nov;38(11):1219–20.
Finally, we have commentary by two additional pediatric radiologists, Drs. Thomas Slovis and Stephen Chapman, who make it clear they do not believe in the Vitamin D deficiency pandemic. They found an illustrated medical dictionary to support their claim that one cannot have rickets unless one has x-ray evidence of rickets. If they had found a dictionary with more words and fewer pictures they would discover rickets is defined pathologically, not radiologically.
In fact, in the largest cases series of rickets in Canada, Dr. Leanne Ward and her colleagues at the University of Ottawa found 7% of the rachitic children did not have evidence of rickets on their x-rays, the diagnosis was made by low 25(OH)D levels (mean in the 104 cases was 6 ng/mL) and by elevated alkaline phosphatase levels (mean 1237 U/L). So Canadian physicians wisely feel they can diagnose rickets even when x-rays are "normal." Ward LM, Gaboury I, Ladhani M, Zlotkin S. Vitamin D-deficiency rickets among children in Canada. CMAJ. 2007 Jul 17;177(2):161–6.
However, Drs. Slovis and Chapman correctly point out how subjective the diagnosis of bone demineralization is on plain film x-rays. Then, they go on to dispute the rickets diagnosis made by Drs. Keller and Barnes in the four case reports, proving the x-ray diagnosis of rickets is also subjective—at least in these four cases, as two pediatric radiologists diagnosed rickets and two did not, looking at the same four sets of x-rays in four separate cases!
Kathryn, like your baby, the 25(OH)D levels in these cases were not taken at the time abuse was alleged, but apparently months later after the baby had been on Vitamin D formula. However, the mothers, like you, who were apparently breast feeding their baby without Vitamin D supplementation, had low 25(OH)D levels; one was 4 ng/mL and another 8 ng/mL. Slovis TL, Chapman S. Evaluating the data concerning vitamin D insufficiency/deficiency and child abuse. Pediatr Radiol. 2008 Nov;38(11):1221–4.
Microscopic bone abnormalities
A remarkable Australian paper is in press, looking at bone specimens and blood samples from people killed in accidents. (Apparently, ladies, some of the men staring at you are not admiring your figure, but are waiting for you to get run over by a car so they can take your blood and x-ray you.) These researchers found that unless one has 25(OH)D levels above 36 ng/mL, one has microscopic bony abnormalities. Thus, perhaps as many as 50% of American children have microscopic bone abnormalities that radiologists cannot see, as >50% of American children have levels below 36 ng/mL. Drs. Slovis and Chapman, like many radiologists, have been looking at abnormal x-rays of children's bones so long they don't know what normal is.
Subclinical rickets a "normal variant"
However, Drs. Slovis and Chapman have discovered something without knowing it. They point out that rachitic changes in the elbow are a "normal variant." I'll bet you the house that this "normal variant," like craniotabes, is present much more often in severely Vitamin D-deficient children. That is, subclinical rickets is so common it is routinely missed by radiologists because its first radiological signs are in the ulna and those rachitic changes are interpreted as a "normal variant."
Fractures common in rickets
As far as fractures in rickets, they are not uncommon. In fact, I could not find a large case series of rickets without some of the children having fractures. One case series from the University of Pennsylvania Medical School in 1979 found about 20% of the rachitic children had fractures. I like this case series as it may contain the first case report of an autistic child being cured with Vitamin D. Bachrach S, Fisher J, Parks JS. An outbreak of vitamin D deficiency rickets in a susceptible population. Pediatrics. 1979 Dec;64(6):871–7.
Autism, Rickets, and Vitamin D
The paper reports a rachitic, 16-month-old child who was breast-fed without maternal or child Vitamin D supplementation, presented with generalized demineralization, a fractured tibia, and severe rickets. Her parents were Muslim and both mother and child wore black robes, indoors and out. After weaning, the child's diet consisted entirely of fruits, vegetables, and grains. Her early development was normal; she began talking at age 13 months, but lost all her speech at 15 months. On exam she was hypotonic, she did not speak during her 6-day hospital stay, and her developmental milestones were delayed. No psychiatric exam was done as autism was exceptionally rare in 1979; the authors did not comment on her social interactions. She was treated with 100,000 IU Vitamin D as a single Stoss dose, and then 2,000 IU per day. She was lost to follow up for 18 months but continued the 2,000 IU per day. When seen, her hypotonia had disappeared (hypotonia is present in 50% of autistic children), her developmental milestones were normal, and her speech had returned. If an earlier case report of Vitamin D curing autism exists, I cannot locate it.
As a medical student at UNC I studied rickets one summer in Iran, long before Vitamin D testing was available. I was amazed at how "normal" appearing bones in children with greatly elevated alkaline phosphatase levels became so much more normal after 250,000 IU of Vitamin D a week for ten weeks. The Vitamin D dramatically lowered alkaline phosphatase (often into the normal adult range (20–140 U/L), indicating the "normal" alkaline phosphatase upper limit for children (500 U/L) is but another indication of pandemic childhood Vitamin D deficiency. I remember these children as shy, withdrawn loners but I never asked mothers about their child's speech. When I looked at the x-rays of the growth plates of the bones of autistic children recently published by Dr. Mary Hediger and colleagues at the NIH, I thought how much more normal those growth plates would look after Vitamin D treatment, and if their autism would improve. Hediger ML, England LJ, Molloy CA, Yu KF, Manning-Courtney P, Mills JL. Reduced bone cortical thickness in boys with autism or autism spectrum disorder. J Autism Dev Disord. 2008 May;38(5):848–56.
"Beyond a Reasonable Doubt" Rule Does Not Apply
Kathryn, you, your husband, your child, and your family are in a world of trouble. Unlike murder, the "beyond a reasonable doubt" rule does not extend to child abuse allegations. I know that it is supposed to, but it seldom does and is one of the reasons I stopped testifying. Judges and juries treat child abuse allegations on the basis that "if there is smoke, then there is fire." Time and time again I have seen the most idiotic testimony be accepted by agape judges and naïve juries who are afraid they might let a child abuser go free. "Better jail ten innocents than let one child abuser go free," is their motto.
Three hundred and sixteen years ago, the Reverend Increase Mather, Cotton Mather's father, gave the opposite advice in Salem, Massachusetts. He paraphrased Blackstone when he said that it was better to let ten witches go free than to shed the blood of one innocent woman, and Reverend Increase Mather earnestly believed in witches. His and Blackstone's earlier advice (better that ten guilty go free than one innocent be convicted) does not apply to child abuse in 21st Century America. That said, we all know child abuse is all too real and witches are not. However, I dare anyone to look at the American Satanic Ritual Abuse cases of the 1980s and early 1990s and say that that was not witchcraft allegations under another name. Nor did that fact help any of the hundreds of innocents jailed during the day-care child abuse hysteria of the same era. Day care sex abuse hysteria. Wikipedia.
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.
However, it happens.
Few people know that all of the 20 people hung in Salem 316 years ago denied they were witches. (As Dr. Jenny would say, they were "in denial.") Not one confessed witch was hung (they were jailed instead and eventually freed) and many confessed to being witches. That is, the Salem DA offered accused witches the same deal you are getting: confess and I won't destroy you. Twenty brave souls in Salem Massachusetts chose death over a lie.
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