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The regulation of vitamin-D dosage by means of twenty-four-hour urinary calcium values is relatively simple and requires no unusual laboratory procedures. If carefully applied, partial roentgenographic healing can occur and this status can be maintained permitting a nearly normal rate of growth and avoidance of hypervitaminosis D. The importance of avoiding hypervitaminosis D is stressed. Repeated swings from hypovitaminosis to hypervitaminosis D merely alternates one disturbance of bone metabolism for another; both deplete the skeleton. Adequate therapy must maintain the child as nearly normal as possible, despite the chronic hypophosphatemia. Under adequate vitamin-D therapy the leg deformities may improve but in our cases did not correct completely. Surgical correction is usually necessary. However, this is indicated only after regulation with adequate vitamin-D therapy. The deformities often recur if the therapy is interrupted or is grossly inadequate. The parents are always warned that this is a chronic metabolic disease which must be followed throughout life and is especially hazardous during growth for the prevention of deformities and the maintenance of a normal rate of growth, but may recur in later years. The general practitioner should also be informed that children whose rickets does not heal promptly with customary doses of vitamin D are not suffering from simple rickets and should be referred to clinics where their disease can be treated and followed adequately.

Summary Four types of diets were used in a study of weight gain in undernourishedchildren, viz., the customary diet used in this hospital, designated the “normal” diet, a diet richer in fat called the “fat” diet, and a diet low in both fat and complex carbohydrates, containing its calories as protein and dextrose, the “dextrose” diet. In the fourth diet ripe bananas were substituted for an equivalent amount of dextrose. Weight gains were more rapid with the dextrose and banana dietsthan with either of the other two. Consistent weight gains were obtained with the dextrose and banana diets at lower caloric intake than with the other diets. The fat diet necessitated largest caloric intake in order to maintain consistent weight gain. The rapid early gains in weight observed with banana and dextrosediets, presumably due in large part to water retention, were not subsequently lost, but were apparently replaced by tissue gains without an intervening period of slow or no gain. The psychologic effect of such gains is apparent. The studies of retention of calcium, phosphorus, and nitrogen confirmthe results of the studies of the weight gain and show that diets made up of protein and simple carbohydrates provide intake levels of these substances such that good body tissue can be built rapidly. These studies provide proof that the spectacular weight gains observed are due primarily to sound tissue growth, and that the resulting normal weight is an indication of normal body composition and not due to inordinate amounts of fat or water.

Clinical and biochemical studies of 40 children with lipoid nephrosis are evaluated. Twenty-six (65 %) are alive; 19 have been entirely well for 1 to 16 years, including three who had minimal hematuria on various occasions. Three have been well for less than a year, one still has proteinuria only, and three still have active disease. Of 22 children who had received sulfonamides for infections, only three have died. Necropsy was done on 10 of the 14 children who died. Minor glomerular changes were seen in the kidneys of four children not known to have had hematuria. Pronounced glomerular changes occurred in two children who had minimal hematuria. Of the four children who did not show any glomerular changes, two had minimal hematuria on several occasions. Pathologic changes in the liver were minimal unless acacia had been given. Laboratory determinations revealed no significant alteration of the prothrombin time. Most of the increase in the plasma fats was in the cholesterol fraction. The precentage of cholesterol esters was not decreased. In case of recovery, the cholesterol seemed to return to normal values at a slower rate than the serum albumin. Plasma fat reached values exceeding 5 gm./100 ml. in some instances. No "critical edema level" for albumin was found. The erythrocyte sedimentation test was a reliable guide in determining the course of the disease. Choline citrate (0.8 gm. each day), given to seven children for prolonged periods, failed to produce essential changes in the plasma fats or definite clinical improvement. Periods of sudden change in edema were found to be critical times for the nephrotic child. Two children developed cardiac failure after injection of large volumes of sucrose. Early diagnosis is important, for treatment is most effective in the early stage. The prognosis is good since the advent of chemo- and antibiotic therapy, and is not impaired by prolonged duration of the disease. Growth of the children who recover is good.

Summary The rate of growth in length of infants given one teaspoonful of high grade cod liver oil (340 to 400 U.S.P. units of vitamin D daily) has been compared with the rate of linear growth of infants given the same type of diet, but with the source of vitamin D from irradiated milk (60 to 135 U.S.P. units of vitamin D daily) or its vitamin D equivalent as cod liver oil or cod liver oil concentrate milk, and with standard growth rates reported in the literature. A review of the growth standards shows that the rate of linear growthin infancy is increasing. Standards reported in 1929 and 1933 show rates of growth definitely increased over those of older standards. Infants given 340 to 400 U.S.P. units of vitamin D daily grow at rates definitely more rapid than those of even the recent standards. Infants ingesting from 60 to 135 U.S.P. units of vitamin D daily grow at the same rate as the recent standards. Exposure to sunlight increased the rate of growth in the few infants in whom this measure was tried and who were receiving the lower of the two stated amounts of vitamin D. The increased rate of linear growth is ascribed chiefly to the increased intake of vitamin D and its resultant effect on skeletal growth. Although the influence of vitamin A has not been entirely excluded, certain of the observations recorded indicate that vitamin A was not the limiting factor in the growth of the infants studied.

Metabolic studies of calcium, phosphorus, and nitrogen in children with moderate to severe idiopathic scoliosis have been carried out. The findings demonstrated no clear-cut abnormality in mineral metabolism, but did show a serious disturbance in catabolism of protein with excessive wastage of nitrogen through the urine. The metabolic error also appears to involve derivatives of sulphur-containing amino acids. The scoliotic children tended to excrete a larger number of essential amino acids than did normal children of the same age range.

Summary The rate of linear growth of nine infants given from 1,800 to 4,600 units of vitamin D daily has been compared with standard rates of growth, and with the growth of infants given the same dietary regimen but amounts of vitamin D varying from 135 to 340 units daily. The rates of growth with the very high vitamin D intake were similar to or less than those of infants given 135 units daily, and definitely lower than the growth rates of infants given 340 units of vitamin D daily. It is concluded that the effect of vitamin D on increasing linear growth reaches a maximum when the vitamin D intake is greater than 135 and less than 1,800 units, probably in the neighborhood of 340 to 600 units daily. Vitamin A in amounts exceeding those of the food (milk, vegetable, and fruit purees) apparently does not affect linear growth of infants. Factors affecting growth rates of individual infants are discussed. It is concluded that in order to determine the effect of the dietary regimen, growth should be studied well past 6 months of age, preferably during the greater part of infancy. Growth during the first 8 weeks of life may be affected by factors other than the dietary regimen of the infant.

Summary The ages at eruption of the first deciduous lower central incisor of groups of healthy infants with carefully controlled diets having relatively low, intermediate, and high amounts of supplementary vitamin D were compared. The incisors of twenty-two infants given the intermediate vitamin D intake, from 300 to 400 units daily, showed the earliest mean age at eruption, 24.68 weeks. The incisors of seventeen infants with a low vitamin D intake, from 135 to 270 units daily, were delayed in their eruption, appearing at a mean age of 28.29 weeks. Incisors of six infants with a high vitamin D intake, over 1,800 units daily, also seemed delayed in their eruption, appearing at a mean age of 27.16 weeks; however, this is less conclusive because of the small number of infants in this group. In an effort to determine whether early or late eruption is more nearly normal, the dental eruption data of six infants who had the 300- to 400-unit intake but who were subject to illnesses were presented. Although the group is small, the mean age of incisor eruption, 29.0 weeks, seemed to indicate that illness delays tooth eruption and that the earlier eruption age is more nearly normal. The response of dental eruption to variation in vitamin D intake tends to parallel the responses of linear growth and mineral retention to the same influence during infancy.

The results of a fifteen year follow-up of a family with idiopathic Fanconi syndrome without cystinosis have been reviewed and compared with those of similar cases recorded in the literature. The disease in our patients is considered to be of autosomal dominant transmission. The mother and her oldest child, a son, were severely affected with stunting, hypophosphatemia, hypokalemia, acidosis, gross aminoaciduria (including increased excretion of cystine), proteinuria and glycosuria. The son showed hypercalciuria, but the mother's urinary excretion of calcium was within the normal range. The two younger children were small for their ages and showed some increase in aminoaciduria; each finally achieved low normal height and in neither has the disease developed as yet. Of four grandchildren, one is somewhat stunted at one year of age, but otherwise, up to the present, all seem to be normal. Control of the disease in the two affected members became increasingly difficult after each lapse in therapy. Similar findings have been reported by others.

Abnormal levels of serum phosphorus are found in association with various metabolic disturbances, such as renal insufficiency, hyper and hypo-parathyroidism, rickets and osteomalacia. In this study, we have attempted to determine the effect of experimental hyperphosphatemia upon some of the other constituents of the serum, and upon the urinary constituents. The work was planned to supply values which could be used as standards of comparison for future studies, using animals that will be subjected to various procedures which might be expected to alter their mineral metabolism.Sodium glycerophosphate injections were used to raise the serum phosphate level. The glycerophosphate was chosen because it was thought that it would be tolerated in larger amounts than the inorganic salt, and because of the growing opinion that phosphate esters may play an important role in the metabolism of calcium and phosphorus.Dogs were given intravenous injections of 50% solution of sodium glycerophosphate, in amounts equivalent...

This report concerns the quantities of calcium retained and the growth in length and weight of 5 white infants fed evaporated milk containing the unsaponifiable fraction of cod liver oil (Zucker concentrate) in an amount which allowed 400 U.S.P. units of vitamin D to the reconstituted quart. When the experiment was started one infant was 11 weeks, one 6 weeks, and the remaining 3 infants 10 to 20 days of age. The vitamin D intake of the youngest infants was 245 units daily; the maximum intake was 400 units a day. The intakes and retentions of calcium per kilogram of body weight are plotted on the chart. For comparison are shown average values from former observations. The solid line shows the average calcium retentions of infants given 340 U.S.P. units of vitamin D daily as cod liver oil and represents 200 periods of study of 24 infants; the dotted line shows the average retentions from 135 U.S.P. unit milk (60 to 135 units daily) as determined from 40 periods of study of 7 infants. The quantities of calc...

This report concerns the preliminary findings regarding the utilization by the human infant of vitamin D from different sources. The criterion chosen was the quantity of calcium retained by well infants given the same amount of milk and the same rat unitage of vitamin D. Irradiated evaporated milk containing 50 units,∗ and evaporated milk containing the unsaponifiable fraction of cod liver oil (Zucker concentrate) allowing 150 units per quart of reconstituted milk respectively, were compared with evaporated milk plus vitamin D given separately as a cod liver oil containing 40 units of D per gram. The Zucker concentrate milk was mixed with plain evaporated milk, and the quantities of cod liver oil were so chosen that the vitamin D unitage of each diet was constant for any given intake of milk, and was regulated by the amount present in the irradiated milk. The youngest infants received only 22 units daily, but by 16 weeks of age, all the infants were ingesting approximately 50 units of D daily. The plan of...

Children 4-12 years of age have been given calcium salts in amounts such that the calcium content was equivalent to that in a pint or quart of milk. The retentions of calcium and phosphorus have been determined and compared with the retentions from the equivalent quantities of milk. The calcium and phosphorus retentions of children from 1 to 4 years of age have been determined when a quart of milk was given as the chief source of calcium, and when a calcium salt was substituted for one pint of the milk. A few studies were made wherein the salt was substituted for all of the milk. The protein intake of each diet was kept approximately constant during the salt and milk periods. The salts used were calcium lactate, carbonate, gluconate, and the di- and tri-phosphates. The latter was given either as the salt or in the form of a purified bone meal. No difference was observed in the relative retentions from the two sources. The results are summarized in Table I.In general, the calcium and phosphorus retentions ...

Summary1. Male rats injected subcutaneously with β-aminopropionitrile and aminoacetonitrile developed the same skeletal lesions of lathyrism as did those fed these compounds. 2. Methyleneaminoacetonitrile fed to rats produced very severe skeletal lesions and is probably more active than the aminoacetonitrile. 3. Diets high in casein, gelatin, vit. E. and other antioxidants did not protect the rats fed Lathyrus odoratus seeds from developing skeletal lesions. 4. Radio-autographs of the skeleton after injection of S35 and studies on sulfur excretion of rats fed Lathyrus odoratus peas and rats fed a control diet showed that the metabolism of sulfur is probably not altered in lathyrism.

The regulation of vitamin-D dosage in resistant rickets (familial or essential hypophosphatemia) is best accomplished by measuring the twenty-four-hour urinary calcium output against the curve of normal excretion. For such comparison the subject's weight and a fairly close estimate of calcium intake are also necessary. Qualitative tests for urine calcium are of no real value in determining the child's status with respect to vitamin-D therapy. Urinary calcium values before treatment are usually three standard deviations or more below the normal mean excretion value. With high doses of vitamin D, urinary calcium rises toward the mean, the rate of rise paralleling the size of the dose. Maintenance of urine calcium at values approximating the normal mean will promote healing of clinical rickets and avoid hypervitaminosis D. A rise of urinary calcium to approximately three standard deviations above the mean, or higher, means hypervitaminosis, and the dosage should be decreased sharply. The abnormal rise in urinary calcium from overtreatment precedes a rise in serum calcium by days or weeks, except after operative treatment when the child will be thrown into acute hypervitaminosis D unless the vitamin is discontinued for a time starting before operation.

The best provision for well-being in any period of life is to arrive at that point in good nutritional and physical status. The well-born infant is sturdier throughout infancy than the baby poorly born; the sturdy infant has stores to give impetus to growth in the preschool years. The child who is in excellent nutrition will have stores to be drawn upon during the rapid growth at puberty. The well-nourished mother can nourish her fetus well; therefore, the best insurance for a healthy infant is a mother who is healthy and well nourished throughout her entire life, as well as during the period of pregnancy itself. Present mortality statistics show that, though we have made impressive progress in lowering the death rate of children under one year of age, the neonatal death rate is still declining too slowly. The fetal and neonatal death rates, plus the number of incurably damaged

In addition to rickets arising from diets deficient in vitamin D or salts of calcium or phosphorus, bone dystrophy has been noted in various disturbances of mineral metabolism which lead to imperfect deposition of the mineral constituents of bone, or to their excessive mobilization. Because of the similarity of clinical picture and the mechanics of production, the term rickets may justifiably be applied to the whole of this diverse group of bone dystrophies. Those cases arising from deficient absorption of inorganic bone constituents should be considered of exogenous origin, whether the deficient absorption be due to inadequate intake of minerals or of vitamin D, to inadequate ultraviolet irradiation, or to other cause. Those instances in which the metabolic disturbance is not dependent upon inadequate absorption are secondary to some endogenous disturbance of metabolism.Several patients with endogenous rickets have been studied intensively in this clinic, and while their bone lesions were very similar, t...

It has been observed that children with malnutrition and an accompanying diarrhea usually have a markedly impaired ability to digest fats and complex carbohydrates, even though these children may not exhibit all the symptoms characteristic of celiac disease. In view of these findings it seemed possible that the ability to utilize fats and starches might be impaired in malnutrition of less severe degree.To test this hypothesis, 5 children from 8-13 years old and from 10-20% underweight were used as subjects. These children were underweight presumably because of lack of proper food. Four of the 5 had hypertrophied tonsils; no other abnormality was observed. Three types of diet were used: a normal diet, similar to the customary hospital diet; a fat diet containing increased amounts of butter and cream, and with a F.A:G ratio of 1.5:1, supposedly below the ketogenic level. The third or dextrose diet was the diet used in the treatment of celiac disease in this clinic; rich in protein, minerals and vitamins, ve...

Few reports are available on urinary excretion of thiamine and riboflavin by children, in relation to different food sources in the diet. An opportunity for such study presented itself in connection with a study of utilization of various foodstuffs. Each child in the original study was given in succession a basal diet, which was planned as a diet adequate in all known nutrients, and two experimental diets, wherein one food was substituted at two levels for the given percentage of each food in the basal diet. Thiamine intake varied from 0.47 to 2.83 mg. daily; riboflavin intake, from 0.79 to 3.23 mg. a day. In addition, six children were given diets containing 0.35 mg. or less of thiamine daily until urinary excretion of this vitamin had apparently reached a minimum level or until it was deemed medically desirable to increase the thiamine intake. Materials and Methods The data comprise 84

RHEUMATIC fever has long been recognized as a disease occurring most frequently in children receiving poor environmental care. In the past two decades, the nutritional background of children with rheumatic fever has attracted growing interest.* At the present time, however, it is still not clear whether or how suboptimal nutrition, acting in conjunction with other adverse living conditions, such as poor housing, overcrowding, repeated exposures to infections, and less protection from physical and emotional stresses, increases the susceptibility and modifies the response of the hosts to the disease. Jackson and others 4 found that the recurrence rate of rheumatic fever was lowered in children who had special attention devoted to improvement in their environments, including nutrition. Of the various factors possibly involved, the most significant association was observed between the dietary ratings and the recurrence rate of the disease. They found a significant correlation (inverse) between the adequacy of the

The normal variations in the components of blood phosphorus throughout the period of growth have been established in a previous study. 1 It has also been shown that both in severe rickets in rats 2 and in late rickets in children, 3 the ester (acid-soluble organic) phosphorus of the corpuscles as well as the inorganic phosphorus of the serum is much depleted and that during healing an increase in ester phosphorus is often the first alteration in the blood phosphorus with treatment. The phosphatase content is much increased during active rickets, and it decreases slowly with treatment. 3 The following report concerns alterations in the blood phosphorus in diseases of infants and children, particularly such diseases as may be associated with alterations in serum calcium or inorganic phosphorus. The analytic methods used have been discussed in detail elsewhere. 1 Calcium was determined by the Kramer and Tisdall method; 4 the

Calcium, phosphorus and magnesium are usually considered together, from a nutritional point of view, because all three occur in bone, and, with carbonate, make up the major part of the bone mineral. The metabolic paths of the three elements are by no means wholly parallel, even though the major part of the body content of each is found in the same tissue. Whereas 99 per cent of body calcium is found in the skeletal structures, bones and teeth, both phosphorus and magnesium are important constituents of soft tissue also. The small amount of calcium not in bone is a component of extracellular fluid; magnesium and phosphate, on the other hand, are components of intracellular fluids, and the phosphate radical appears to be essential in an ever increasing number of metabolic reactions. Milk and its derivatives, such as cheese and ice cream, are the chief sources of calcium in the diet

THE INCIDENCE of deficiency disease in infants has decreased concurrently with increase and dissemination of nutritional knowledge. However, hypochromic anemia continues to occur commonly in the latter half of the first year of life. It is desirable, therefore, to prevent rather than treat hypochromic anemia. This study was undertaken to determine the amount and form of iron needed for this purpose. Since the studies of Elvehjem and co-workers,1Stearns and co-workers,2Heath and Patek,3and McClean,4iron preparations have been employed more frequently during the early months of postnatal life to prevent depletion of iron stores and to insure the availability of sufficient iron to maintain optimum hemoglobin values during infancy. Various amounts and types of iron have been advised as a daily dose. McClean4recommends 50 to 60 mg. of iron daily as ferrous sulfate; Elvehjem, 25 mg. of iron daily as ferric pyrophosphate

The nitrogen retention of a group of 33 diabetic children between the ages of 3 and 15 years has been studied during a total of 42 metabolism periods of 3 to 4 days each. The diets were calorically sufficient according to Holt's standards, and the protein intake approximated 2 gm. per kilogram body weight, the average for the younger children being slightly above, and that of the older group somewhat below this value.The average retention of 4 children more than 10% under weight was greater than that of children whose weight was approximately normal, while the retention of overweight children did not differ materially from that of the normal group. The average retention for the group (omitting the 4 underweight children) was .044 gm. of nitrogen per kilogram body weight.

To the Editor:— Two international seminars on the general subject of infant metabolism were held in Leyden, The Netherlands (October 15-30), and in Stockholm, Sweden (Nov. 1-15, 1950), under the auspices of the Exchange of Scientific Information of the World Health Organization of the United Nations and at the invitation of the countries mentioned. Delegates from five neighboring countries (Belgium and France, and Denmark, Finland and Norway) together with an American group and one Australian (a staff member of the World Health Organization) were invited to these seminars. Participants in the seminars came, therefore, from nine countries and represented 21 universities. The project was the first of its kind to be undertaken by the World Health Organization. Its purpose was to effect an exchange of information on a research level between countries where medical investigation is highly developed, and it serves to supplement currently existing programs in health care in

The healing of late rickets has been observed in the pediatric clinic of the State University of Iowa coincident with the maintenance of a low level of inorganic phosphorus in the serum.1One possible explanation of this phenomenon is that sufficient ester phosphorus (acid-soluble organic phosphorus) was available at the site of the deposition of mineral so that, through the action of phosphatase, calcium phosphate could be deposited.2If this explanation is correct, an increase in the ester phosphorus of the blood without a concomitant increase in the inorganic phosphorus of the serum might result in healing of the rachitic process. This report presents the results of a study of the phosphorus partition in whole blood and in serum during healing of late rickets in two children. The serum calcium and the plasma phosphatase have also been studied. The methods used for phosphorus partition are discussed in detail