Rickets returns: Whatever happened to cod liver oil?

Rickets, a disease caused by a lack of calcium and vitamin D that leads to softening of the bones and bone deformities is reportedly on the rise in the United States and elsewhere. Once the most common nutritional disease of children, Rickets caused bowlegs and other problems such as deformed pelvises. It was first vanquished by teaching mothers to give their infants and children cod liver oil and sunbaths, and subsequently with the vitamin D fortification of milk beginning in the 1930s. So, why has it come back and who is at risk?

People with dark skin have a higher risk, because they need more sunlight to get enough vitamin D. Also at risk are breastfed babies that to do not get vitamin D supplementation, young people who do not consume vitamin D fortified milk, people living in northern latitudes who miss effective sun exposure for parts of the year and others who get neither sun exposure nor vitamin D supplementation and calcium in their diets. Do you spend your time inside playing video games and drinking soda?  You aren't helping your bones.

Cod liver oil and sunshine both provide vitamin D and both were recommended for preventing and treating rickets beginning in the 1920s.  The United States Children's Bureau as well as state and local health agencies began promoting both measures in the childcare advice pamphlets. The Children's Bureau distributed the pamphlet "Sunlight for Babies" as well as "Baby's Daily Time Card" meant to be hung near the crib. It listed times for sunbathing and when to administer the cod liver oil in orange juice.  The Metropolitan Life Insurance Company gave advice booklets to its policyholders including one entitled, "Sunlight the Health Giver."  In winter, families were instructed to keep the baby inside in front of an open window, while manufacturers encouraged the purchase of windows with special glass that let in the sun's helpful rays or the use of indoor sunlamps. For those without yards or time to watch babies take sunbaths, window cages were designed to hold babies safely out in the open air.

Health experts, government agencies, and manufacturers also promoted giving infants and children cod liver oil.  Like sunbathing, it had long been touted as having numerous health benefits, such as preventing anemia, colds, and even tuberculosis.  Yet, babies and children hated the taste. The Children's Bureau tacitly acknowledged this in the second edition of its booklet, "Infant Care," when it advised: "The mother must not let him know by her facial expression that she does not like the smell of the oil because that will teach the baby not to like it. She must take it for granted that he will like it even if she does not."  Fat chance. As one mother wrote in her son's baby book about teaching him to take barley water "at least we do not have to force it down as we do the cod liver oil, which he hates. Until his bath he has a strong fish odor for he spits the oil out usually and it gets in his sleeper."

Ironically, the success of the campaign to get mothers to give infants and children cod liver oil meant that generations of youngsters continued to be dosed with the foul-tasting and foul-smelling stuff even when they no longer needed it for preventing rickets thanks to the widespread availability of vitamin D fortified milk.  That doesn't mean cod liver oil (now thankfully available in pill form) doesn't have its uses.  It is now used for high blood pressure, heart disease, and diabetes, among other conditions. Vegetarian alternatives are available.

Likewise, sunbaths are back; albeit in strictly limited amounts. The American Academy of Pediatrics recommends no direct sunlight for babies under six months of age and limited exposure after that and opposes altogether the use of tanning beds.  According to the government, ten to fifteen minutes in the sunshine, three times a week, is sufficient to produce the body's requirement of vitamin D.

The message is simple: rickets was vanquished once; it shouldn't be back again. Now, the solutions are easy, and don't require a spoonful of cod liver oil.

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