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This year I have raised the standard of the suboptimal haemoglobin level by including those
children who had a haemoglobin of 85 per cent. I have done this because I feel that any haemoglobin
level below 90 per cent, in a child is unsatisfactory, and that these suboptimal levels are so often
found in undernourished children, particularly associated with repeated septic lesions and chronic
bronchial catarrh.
It is remarkable to find a much larger percentage of both anaemic children and those with
a suboptimal haemoglobin level attending the Starcross Street than the Hoxton centre where
the families are of a lower social status, but each year it is the same, and also is associated with a
higher incidence of old rachitic manifestations.
Seven of these children with suboptimal haemoglobin levels from Starcross Street and three
children from the Hoxton centre have been sent to Dr. Lucy Wills, in the biochemical department
of the Royal Free Hospital for investigation. Their blood investigations and those of twelve old
cases from Starcross Street have been done by Dr. Crowley, who has given the following report
from the biochemical department of the Royal Free Hospital:—
"Of 18 children examined in detail, all were found to be suffering from iron-resistant
anaemia. Fifteen had, as well, chemical evidence of latent rickets, of these eight were investigated
in detail and treated for some months. One was found to be suffering from chorea. The
remainder all recovered from the anaemia on combined treatment with iron and massive doses
of vitamin D."
A number of these children had failed to respond to simple iron therapy and the low inorganic
phosphorus level of the blood and low calcium phosphorus ratio suggested a vitamin D as well as
an iron deficiency resulting in chemical rickets.
Excellent results were obtained with massive doses of calciferol.
Vitamin D
therapy.
Massive doses of vitamin D (calciferol) 100,000 international units weekly have been tried
at the Hoxton and Starcross Street nutrition centres on four types of case:—
(1) The cases of anaemia and suboptimal haemoglobin levels treated by vitamin D and
large doses of iron (pil. ferr. sulph. i. t.d.s. or Blaud's gr. 45 daily).
(2) Cases of chronic bronchial catarrh.
(3) Cases with repeated septic sores.
(4) Cases failing to gain weight.
Up to the present I have only treated four cases of sores, eight cases of bronchial catarrh
and 25 cases of anaemia. I think that the chest cases have definitely improved, and all the
anaemias except two have responded.
The calciferol is given in a dose of 200,000 i.u. in four tablets which are eaten at the centre
once a fortnight. This safeguards any waste of expensive drugs or refusal of the child to swallow
the tablets when given by the mother.
Of all the deficiencies in the diet of these children, that of vitamin D is probably the
greatest. In many cases it is probably completely absent as so often they dislike fish, such as
herring, the only probable dietetic source. They have not much opportunity to store up vitamin D
from sunshine in this climate, particularly in winter, and the amount of garments they wear must
result in shutting out such ultra-violet rays as might reach them.
I do not think that the vitamin A deficiency is so great a problem as the children get
considerable amounts in their milk in school and in vitaminised margarine.
Many of the children must depend for their vitamin D supply on their dose of cod-liver oil
in school, and the vitamin D content of that is small. Even a halibut-oil capsule containing
485 i.u. of vitamin D makes a weekly dosage of 2,425 i.u. only.
This is probably a satisfactory maintenance dose for a healthy child, but I think it is too
small to benefit a child with chronic bronchial catarrh or a suboptimal haemoglobin level, which
are the conditions for which so many of the children are recommended cod-liver oil or halibut oil
in school.
Only a few children can have vitamin D therapy at the nutrition centres under supervision,
and expensive vitamin preparations given to take home would often be wasted.
At the nutrition centre the cases of bronchial catarrh and sores have usually needed three
fortnightly doses of vitamin D 200,000 i.u. Many of the anaemias have only needed this, or at
the most six doses, so the expense would not in the end be greater than the prolonged dosage
with cod-liver oil and malt.