Severe nutritional deficiencies common in developing countries crop up from time to time in Europe and North America, where babies and toddlers so afflicted draw much attention among doctors and nurses keen to observe examples of afflictions they have only read about. The victims in rich countries may come from homes with poor parents or be malnourished because their parents practise restrictive dietary regimes or cannot cope with offspring with severe intolerances to staple foods. Kwashiorkor and rickets occur in these conditions. Hospitals write up the dietary deficiencies and intolerances and abstentions for other reasons such as macrobiotic, Rastafarian, and vegetarian persuasions; some of the victims are described as vegan.

People with a strong intolerance to animal milks may resort to non-dairy products but be betrayed by a recurrence of their allergies, usually because the alternatives have become contaminated, being manufactured in factories and on machinery also making animal-derived foods that have been inadequately cleansed between runs. We describe in detail below one of 2 cases reported recently (from Atlanta, Georgia, USA) of “severe nutritional deficiencies in toddlers resulting from health-food milk alternatives” (Pediatrics, April 2001). The report states that the families involved “do not fit the stereotypical profile in which malnutrition would be anticipated. The parents were well-educated, seemed knowledgeable and responsible and had at least average family incomes. Both families made the mistaken assumption that foods labelled as natural are always a healthy and appropriate nutritional choice.”

Both of the non-dairy alternatives, which were purchased in supermarkets, carried a warning on the container that they were not intended for use as infant formulas; however, they did not carry a caution on their use for toddlers.

We describe in case 2 a veterinary example in which the problem was of too much rather than too little and, what’s more, of an excess due to consumption of a plant source of vitamin D activity.

Case 1. Human

One of the human cases was a 17-month-old black male diagnosed with severe rickets. He had been born at term and was initially breast-fed. Vegetable infant foods were introduced when he was 4 months old; at 10 months of age he was weaned from the breast and was begun on “a soy beverage which his parents drank in place of milk, because of their taste preferences. The patient consumed a vegan diet, without intake of any animal products. Foods regularly eaten included tofu, sweet potatoes, potatoes, spaghetti, fig bars, infant cereal, bananas, strawberries, and other fruits, and vegetables. On an average day he drank 900 ml of the soy beverage, which was not fortified with vitamin D or calcium. Total daily caloric intake was estimated at 1530 kcals, which is 114% of the recommended daily allowance (RDA). The diet was also adequate in fat and carbohydrate content (108% and 117% RDA, respectively) and was high in protein (355% RDA).” Vitamin D was “essentially absent” from this diet; the only significant source of calcium came from the infant cereal, which provided about 450 mg daily (57% RDA). (VEGA notes that such alternative “dairy” products are on sale in the UK in supermarkets and health-food stores. Cow-milk in North America is fortified with vitamin D).

“The parents were well-educated and the home environment was stable. The mother worked long hours at her home business and spent very little time outdoors. As a result, opportunities for sun exposure for her child were limited. The child was seen on a regular basis by his pediatrician and was growing normally until his 9-month check-up. Thereafter he developed an almost complete arrest in growth (both height and weight),” reported the clinicians when the child at 17 months old came to their attention.

“These findings are diagnostic of advanced rickets” and they “supported a nutritional cause,” reported the clinicians, describing a text-book range of symptoms typical of florid rickets and all its corollaries in skeletal development and involvement of collagen.

The patient was started on ergocalciferol (vitamin D2) and a diet “rich in calcium and vitamin D.” Subsequently he began a course of calcium supplements. Within 1 week of initiation of the treatment “he began rolling over, began crawling within 2 months of therapy, and was walking after 6 months of therapy.” (VEGA notes that the British and American pharmacopias describe standard preparations of ergocalciferol and calcium that may be obtainable over-the-counter, but better according to a doctor’s advice and prescription. Cholecalciferol (vitamin D3) may be substituted and noted in some of these preparations, and strict veggies may have to swallow some uncertainties over the excipients, formulations, and sources of the calcium component).

This case and another (in which kwashiorkor developed as a result of protein deficiency in the baby in a family with a sensitivity to cow-milk who had resorted to a “health-food” rice “milk” that contained only 1.7g/litre protein but was actually fortified with vitamins A and D and calcium) prompt the clinicians to opine generally on the dietary and environment care needed for babies and the responsibilities of parents, food manufacturers and retailers, and authorities and regulators, as well as NGOs, to disseminate information, enforce traceability, and monitor claims and labelling.

“In industrialized countries children diagnosed with kwashiorkor are frequently thought by their families to be allergic to milk. In this setting it is usually the intentional exclusion of milk from the diet that causes kwashiorkor. In most instances the milk sensitivity is not subsequently confirmed, as was the case in this report. Cow’s milk feeds are the mainstay of dietary therapy for kwashiorkor in developing countries. No benefit has been achieved by reducing lactose intake. If milk sensitivity cannot be reasonably excluded, then initial refeeding with a protein hydrolysate formula would be the safest approach,” comment the researchers, who also observe that “a high prevalence of rickets has been reported in infants who consume macrobiotic diets (organic, whole-grain foods that are not chemically processed).”

The comments continue: “The absence of vitamin D-fortified milk in a vegan diet results in inadequate vitamin D and calcium intake. In addition, the high fibre content in a vegetarian/vegan diet also reduces the absorption of calcium and, thus, further disposes one to rickets....Breast milk does not provide enough vitamin D to meet the requirements of an infant in the absence of sufficient sun exposure.”

Dark-skinned patients increase the risks of deficiency even at the latitude of Atlanta, Georgia, at 34ºN, with an average of 217 days of sunshine annually. “Secular lifestyle changes may also decrease the amount of time infants and children are outdoors during sunlight hours. These include factors such as both parents working long hours, increased sedentary indoor lifestyle (e.g. computer games), poor outdoor air quality (smog), lack of sidewalks, and outdoor heat and humidity with available indoor air conditioning,” write the clinicians. In short, “perhaps because of these lifestyle changes, physicians need to be even more attentive to high-risk groups of children (i.e. darkly pigmented, breast-feeding, or vegetarian/vegan infants and children).”

The doctors warn colleagues: “Although most pediatricians are familiar with the skeletal manifestations of rickets, many may be unaware of the neuromuscular clinical features, because these are generally not emphasized in standard pediatric texts. Rickets should be in the differential diagnosis of infants and children with motor delay.”

VEGA observes sadly that in countries with so many advantages and where shoppers pay over the odds and rely on health-foods for nutritional benefit, parents can be so busy buying and selling that they can’t spare the time to enjoy the open air adequately with their babies. And will the babies, when grown up, have the time to ensure that their parents, probably now grandparents and possibly “institutionalized” and of limited mobility, can also enjoy the benison of the sun’s rays on skin thinned, wrinkled, and less responsive maybe, but still adequate to generate their requirements of D for free.

For VEGA's comment on the recent death of a baby fed a "fruitarian" diet see Lethal Fanaticism in Bringing up Babies.

Case 2. Animal

Calcinosis caused by golden oat grass (Trisetum flavescens) has been described in detail in cattle, but there is less recorded in the incidence in other herbivores and horses. An investigation on a herd of goats in Switzerland was reported last year (Veterinary Record, 5 February 2000), in which an outbreak of enzootic calcinosis was traced to ingestion of haylage containing oat grass. (Haylage in a preserved feedstuff halfway between hay and silage. The grass is cut green, chopped small, wilted and stored in an airtight tower silo).

The goats were from a herd that included 47 lactating does, 24 kids, and 2 bucks, most of them belonging to a mountain breed. The farm was located 1650 metres above sea level in southeast Switzerland (Unterengadin). The animals were stabled from November to early April and fed hay and baled haylage; the haylage was made from second-cut hay from a 2-hectare field with more than 50% golden oat grass. From June to September the goats grazed a nearby alpine pasture. In June six goats 31/2 to 61/2 years old were seen by a veterinarian because they were frequently recumbent, showed difficulty in rising and moving, and intermittently carried a leg.

*Margarine, like butter, describes a yellow fat comprising at least 80% fat, the rest being almost entirely water. Unlike butter, margarine is required by law to be fortified with vitamins A and D. Spreading fats with a lower fat : water ratio are so fortified by voluntary agreements in the trade. “Vegetarian” margarine used in the baking trade and disclosed among the ingredients listed on labels on products such as cakes and biscuits, with claims of suitability for vegetarians/vegans, is likely to contain whey, a by-product of cheese-making. Additives and enhancements such as omega-3 or DHA sources introduce specific fatty acids derived from microalgae by processes of biotechnology.

Clinicians counted further signs of distress in the goats: kneeling after rising and, when eating, stilted gait, arched back, shifting weight from leg to leg, swinging of a limb, and reluctance to remain standing after arousal; the heart rate in 3 goats was significantly elevated. Milk production in all the goats was much reduced and they were infested with intestinal parasites.

Radiography and post-mortem examinations found extensive calcification of tissues and organs. The results were similar to those for cattle intoxicated by the excessive activity of 1,25(OH)2D3, which is the extraordinary result of heightened vitamin D potency in a plant.

Enzootic calcinosis occurs predominantly in sub-alpine regions at altitudes between 70 to 1500m above sea-level. Presumably it occurs less at lower altitudes “because of competition from other plants that are less suited to sub-alpine climates.” Why had enzootic calcinosis not been reported previously in the area of the described outbreak? The land had not been tilled for generations, therefore preventing excessive proliferation of golden oat grass; or grass to be harvested as dry hay rather than haylage contains less of the 1,25(OH)2D3, which declines in content as the cut is dried. Nutritional and farming factors abound in these observations and show that picturesque meadows may be blighted with plants as toxic as ragwort – or more so.

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