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Excerpted from Martha May Eliot MD. The control of rickets: preliminary discussion of the demonstration in New Haven. Journal of the American Medical Association. 1925;85:656–663.
THAT ANIMALS CAN BE protected against rickets by the use of cod liver oil and ultraviolet rays is an established fact. It has also been clearly shown that cod liver oil and sunlight exert a great influence in the cure of rickets. Whether these measures are sufficient to prevent rickets in infants in a community is the problem on which we are working in the demonstration in New Haven. It is my purpose to set forth briefly the plan of the study and to offer a preliminary discussion of the results.
The demonstration was started in October, 1923, for a three year period by the United States Children’s Bureau in conjunction with the Pediatric Department of the Yale School of Medicine and with the active cooperation of the local health organizations. A district of the city was selected having a population of approximately 13 500, one third of which were negroes, and two thirds a mixed population composed of Italians, Irish, Polish, and Americans. The office of the demonstration is known in New Haven as the "Children’s Bureau." The staff consists of three physicians, three public health nurses, two social investigators, a roentgen-ray technician and a secretary. The staff is necessarily large in order that the records may be complete and accurate.
The main problem of the investigation was to show whether rickets could be prevented in a community by the intensive use of cod liver oil and sunlight. The infants born within the selected district during the first two years of the study are examined and started on cod liver oil and sunbaths, if possible, before the end of the first month of life. They are brought to the Children’s Bureau once a month for physical and roentgen-ray examinations in order that rickets may be discovered as early as possible and intensive treatment instituted if necessary. The nurses visit the homes frequently to see whether the instructions are being carried out. In order to provide control material for the investigation, it was necessary to take for examination the children under 5 years of age living in the district at the time when the demonstration started. Later, however, it became clear that it was even more important to have for comparison a group of infants who were born during the period of the demonstration, but who had received no cod liver oil and concerning whom no instructions regarding sunlight had been given. Examination of such a control group was begun at the end of the first year of the demonstration and has continued throughout the past winter. The infants of this group correspond in age to those in the district who are being given antirachitic treatment.
The daily routine in the demonstration is comparatively simple. The birth certificates of babies born in the district are sent to the Children’s Bureau office by the board of health. If the certificate is signed by a local physician, a call is made by one of the Children’s Bureau physicians, to explain to him the purpose of the demonstration and to ask his cooperation. If the physician has already been seen, a letter is written telling him that the birth certificate has been sent to the Children’s Bureau, and that the mother will be urged to bring the baby for examination. No new baby is brought to be examined without the knowledge and consent of the family physician. When the nurse takes the birth certificate to the mother, she has an opportunity to tell the mother about the Children’s Bureau, and to make an appointment for the baby to be examined as soon as the mother is able. At the first visit the baby is weighed, measured and examined thoroughly. At this visit, also, a roentgenogram is taken of the bones of both forearms. A uniform technic [sic] in taking the roentgenograms is used for all babies, so that the films may be compared satisfactorily with one another. Before leaving, the mother is given general advice by the physician with regard to routine feeding and care of the baby. She is instructed to give both cod liver oil and sunbaths to the baby, and is asked to bring him back once a month for physical and roentgen-ray examinations.
The importance of teaching the mother how to give the cod liver oil to the baby cannot be overemphasized. Success in the administration of cod liver oil to babies depends on two things: the method used, and the ability of the physician or nurse to convince the mother of the value of the cod liver oil. An actual demonstration of the best method of administration is given to each mother by one of the nurses. With the baby lying across her lap, the nurse pours out the proper dose in a spoon held in her right hand. With her left hand she opens the baby’s mouth by pressing the cheeks together between her thumb and fingers. The oil may then be poured little by little into the baby’s mouth. If the mouth is not held open until the oil entirely disappears, the baby will spit out what is left. When this happens, the mother very frequently reports that the baby has vomited the oil. It is frequent for infants to spit out oil not yet swallowed, but in only a few instances have we found that the infant actually vomits it.
Demonstrations of the sunbaths are given by the nurses at their visits to the homes. If the baby is fortunate enough to have been born between the first of March and the first of September, sunbaths are started outdoors before the end of the first month of life. If the baby is born in the winter months, the sunbaths frequently must be given indoors inside an open sunny window. At whatever season the baby is born, however, the mother is impressed with the importance of direct sunbaths. She is taught that the full value of the sun’s rays is obtained only when they reach the skin without the intervention of clothing or window glass.
When outdoor sunbaths are given, the hands and face are exposed first for ten or fifteen minutes only. After the first few days other parts of the body, at first the arms and a little later the legs, are in turn exposed to the sun. The period of exposure is increased two or three minutes daily. The increase for infants with dark skins may be more rapid than for infants with fair skins. As the weather gets warmer, the arms and legs and in time the whole body may be exposed together. As the baby becomes accustomed to the sunbath, the period is lengthened to one hour twice daily. Care must be taken to increase the length of the sunbath gradually, so as not to burn the skin. Sufficient exposure daily to produce slight reddening will gradually tan the skin. Pigmentation is the outward evidence that the ultraviolet rays of the sunlight are effective. It is important, too, in the intense heat of July and August, that the sunbaths should be given before 10 o’clock in the morning and after 3 o’clock in the afternoon. The baby’s head at this season should be protected from the sun between these hours. Graduated outdoor sunbaths, such as are here described, may be given to any baby 3 or 4 weeks old who is born in the spring and summer.
In our northern climate it is possible to give outdoor sunbaths to healthy infants even in the winter. Feeble and premature infants cannot, of course, be exposed outdoors in winter. It is well known that the temperature on a cold day may be 40 or 50 degrees higher in the direct sunlight than it is in the shade. The heat of the sunlight, which we would so gladly dispense with in July and August, must be utilized in winter to its greatest extent. The baby born in the fall or winter may be given outdoor sunbaths except on days when the temperature is below freezing. . . . Increase in the amount of skin surface exposed and the length of exposure should be gradual; but, in time, the face, arms and legs may be slightly tanned, even in winter. It may not be possible to expose the whole body. Babies who are given indoor sunbaths in winter may begin outdoor sunbaths early in the spring, so that they will be well tanned by the end of April. . . .
A preliminary report may be given at this time of the group of babies born in the first year of the demonstration, from Aug. 15, 1923, to Aug. 15, 1924. It has been possible to follow a series of 216 babies with more or less regularity. These babies range in age at the present time from 8 to 18 months. . . . [Our study found] an extremely early incidence of rickets by roentgen-ray examination. . . . Twenty-three, or 11 per cent of the 216 infants, showed no rickets at any time by roentgen-ray examination. One hundred and seventy-nine, or 83 per cent, showed evidence of mild rickets by roentgen-ray examination before eight months of age. The remaining fourteen, or 6 per cent, showed rickets by roentgen-ray examination after eight months. . . .
None of the infants of the demonstration developed marked rickets, and only 4.3 per cent developed moderate rickets shown by roentgen ray, whereas 23 per cent of the first and 34 per cent of the second control groups showed both moderate and marked rickets. The antirachitic treatment given to the infants in the series of the demonstration has been successful in keeping them from developing advanced rickets. . . .
The extraordinary chronicity of rickets has been striking in our series of roentgenograms. The evidences of rickets first seen in the second or third months of life may be followed month after month even to the end of the first year or later. If the infant is under treatment, evidence of lime salt deposit as well as the evidence of active rickets may be seen; the process finally becomes low grade and sluggish and, though constantly present, is controlled. If the infant is not under treatment, the roentgen ray shows increasing and accumulating evidence of disease month after month, until the well known picture of marked rickets is seen. . . .
The importance of the fact that definite clinical signs of rickets do not appear until after the roentgen-ray evidence cannot be overemphasized when considering the problem of prevention. It is well known that the curative effect of cod liver oil and light are not marked until from the third to the sixth week of treatment. It may be supposed, therefore, that the preventive effect of these measures will not be well established for at least a month. If 65 per cent of infants with rickets show the roentgen-ray evidences before the end of the fourth month, prophylactic treatment should certainly be begun by the end of the first month, if not sooner. Our figures indicate that even larger doses of cod liver oil than we have given and longer exposure to direct sunlight should be recommended, if the disease is to be entirely prevented. . . .
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