RICKETS (Hansard, 11 February 1946)

§ Dr. Stephen Taylor (Barnet)
The subject I wish to raise this evening is one with which hon. Members on this side of the House in particular, are unfortunately only too well acquainted. Rickets is known to our Continental colleagues as "the English disease." It was first described by two English doctors in the 17th century. It was christened by an Englishman, Dr. Francis Glisson, in 1650. Its cause and method of prevention were elucidated in Sheffield by Sir Edward Mellanby, and our island had, in peacetime, the unenviable distinction of being a first-rate field laboratory for the study of rickets. Rickets is a disease of infants. Active rickets is rarely seen in children over two years of age. Its main feature is faulty formation of bone, a matter of particular importance as in the first two 144 years of life bone growth is most rapid and the skeleton for the future is being formed. It may, therefore, be lifelong. Rickets is not in itself fatal, but its presence increases the liability to infection, particularly infection of the lungs. Pneumonia is one of the main causes of death in infancy. Rickets differs from most other human ailments in that medical knowledge of it is practically complete.
We know what causes rickets, and we know how to prevent it. We have the material necessary to prevent it, yet it is not prevented. It is still with us. The latest and most reliable statistics that I have been able to obtain are those contained in the Ministry of Health Survey on Rickets published in March, 1944. This survey covers the whole country, and was made for the Ministry of Health by the British Paedriatric Association. What they found was briefly this. By X-ray tests, by examining wrists and the bones of the skull, it was found that about four per cent. of children under 18 months had or had had rickets. By ordinary direct medical examination— that is, by examining the wrists, the bones of the chest and of the legs—the figure was about 12 per cent., varying from nought per cent. in such places as St. Albans to the staggering figure of 60 per cent. in Sheffield Taking the more cautious X-ray figure, we must conclude that about 24,000 children in this country still suffer from rickets every year, which is entirely unnecessary. These figures may have changed a little lately, because since January, 1944, the whole cream dried milk issued by the Ministry of Food has had vitamin D added to it, sufficient to give 800 units per pint. But the problem remains a big one, because only children up to nine months of age are liable to get this dried milk and, of course, most children do not receive it at all. The cause of rickets is lack of vitamin D or calciferol. One-fiftieth of a milligram—that is, about one-fiftieth of a pin's head—of this calciferol each day is all that is needed to prevent rickets. During the war it has been the policy of the Ministry of Food—and a good policy too—to make available vitamin D2 along with the other vitamins cheap or free in the country. Orange juice containing vitamin C, and cod liver oil containing vitamins A and D2, have been the media chosen, but they have not been entirely 145 successful, as the Ministry of Health figures which I have just quoted show.
In April, 1944, the wartime social survey made an inquiry for the Ministry of Food, the results of which are available to hon. Members of this House. About 900 mothers with young children were studied, and they were selected at random. It was found that about 70 per cent. of these were collecting their orange juice and only 40 per cent. were collecting their cod liver oil. Why is it that 30 per cent. were failing altogether to get their vitamin supplements? I think there were two main reasons. First there was the failure to appreciate the importance from the health point of view of collecting these vitamin supplements, and, secondly, physical difficulties in the collection—for instance, the distance from the distributing centres, awkward times of opening or difficulties in connection with minding other children in the family. The answer to the first reason is simple—more health education. The answer to the second is more improvement and imagination in the distributing machine. But even when we have got these right, there remains the relative unpopularity of cod liver oil, and anyone who has tasted it realises why. It is not surprising that in children over one year of age the consumption of cod liver oil rapidly falls off, but not that of orange juice. The persevering mother may stick to it and win the battle, but it is among the unpersevering and less conscientious ones that the danger of the lack of vitamin D is most serious. There is another factor. These babies are very liable to spit out the cod liver oil, and cod liver oil stains on the clothes are almost impossible to remove, as anyone who has tried to do it knows. This is another factor which discourages mothers from giving it to the children.
I will now say a few words about the alternatives. Cod liver oil and malt is much more popular with children than is cod liver oil, but it will not prevent rickets unless it has extra Vitamin D added to it. One of the commonest causes of rickets is relying on cod liver oil and malt to prevent it. There is, however, one real alternative, and I want to urge the Government to give this a fair trial in one or two of our Northern towns. One-tenth milligram of calciferol—that is, enough Vitamin D for one week—can be dissolved quite easily in about 15 milligrams—that 146 is, 15 pins heads in volume—of bland arachis oil. That mixes perfectly and tastelessly with cocoa-butter and can be used for making chocolates which cannot be distinguished in taste from ordinary chocolate. A small penny bar of chocolate, taken once a week, thus contains everything that is needed to prevent rickets. I am quite certain such a food supplement would be quite as popular, if not more popular, with the mothers and the children than the orange juice is at present.
There are two possible objections to this proposal. The first, the more serious one, is that such chocolate would not contain the Vitamin A which cod liver oil contains. It might be possible to add to the chocolate 'pro-vitamin A (carotene) which, inside the body, changes into Vitamin A. In any case, unlike Vitamin D, there are many natural sources of Vitamin A available, for example milk and vegetables, and it is almost certain that children would in fact get the Vitamin A they need from existing natural sources of Vitamin A, particularly from their extra priority milk. The second objection is that the chocolate might not be used for the proper purpose, and that it might find itself in the wrong place or in the stomach of the wrong child This danger, of course, already exists with the orange juice, which is sometimes shared out with a whole family and goes where it is not intended to go. But even the feckless mothers almost always want to do what is right for their babies, provided it is not too difficult. I believe the enormous majority would in fact put the chocolate where it ought to go, that is, into the mouth of the child. In any case, the only way to find this out is to try a small experiment. It might prove a failure, but that is what experiments are for, to find out if they work before we make a mistake on a large scale. However, it might prove a success, and, if so, surely the target of getting rid of 24,000 cases of rickets per year in childhood is something which is worth while aiming at.
Rickets has really ceased to be a medical disease and become a political one. Its prevention is in the hands of this Government and of the House. I suggest it is our job to see that rickets in Britain is made as rare as the bubonic plague. I believe we can do it inside the life of a Parliament if we really want to.

§ Colonel Stoddart-Scott (Pudsey and Otley)
May I just ask the hon. Member for Barnet (Dr. Taylor) this question? I know it is not his intention to mislead the House, but he has indicated that the cause of this disease is one of food deficiency. Is it not true the Sheffield school discovery was, that it was not only deficiency of food but also a deficiency of sunlight? You could give a child-all the vitamins and all the foodstuffs that he has already told us about, but at the same time it would be possible to have rickets unless the child had either sunlight or artificial sunlight.

§ Dr. Taylor
I cannot quite agree with what the hon. Member has just said. Sunshine is an alternative for Vitamin D and not a supplement to Vitamin D. Sunshine in fact forms Vitamin D in the skin, but it can be taken just as satisfactorily by mouth and got into circulation in that way. It is perfectly possible to bring children up in cellars, and provided they get enough Vitamin D they do not get rickets.

§ The Parliamentary Secretary to the Ministry of Health (Mr. Key)
I am certain the House will not expect me to talk with the same learned assurance with regard to this matter as the speech of my hon. Friend indicated he has the capacity to do. I have got, as far as I can, to speak on behalf of my Department in this matter. With regard to the investigation carried out in 1944 by the British Paedriatric Association, I want to draw attention to the fact that, in that investigation, when the same group of children was examined by several clinical observers and radiologists, the findings differed widely. However, making allowances for those differences, it is true that evidence of the existence of rickets in a mild form was found in two and a half per cent. of children under the age of six months, and about four per cent. of children under the age of 12 months, with a negligible number above that age. The first important conclusion to be drawn from that is, that despite our difficulties of feeding and so on, there had been no increase of rickets during the war.
The report of that inquiry was considered by the Medical Sub-committee of the Minister's Advisory Committee on Mothers and Young Children, and various recommendations arising out of the report were made. Those recommendations have 148 been accepted by the Minister and have been acted upon. The Committee found that national cod liver oil, at its present potency of some 700 or 800 international units of vitamin D per teaspoonful, really did contain an adequate concentration of that particular vitamin. They suggested that increased publicity should be given to the necessity for mothers to obtain a supply of the national compound, and that great attention should be given to instructing them on the importance of vitamin D. Through whatever organisations we could use—the B.B.C., the maternity and child welfare centres, and so on—such advice and publicity has been given. They also made recommendations that vitamin D should be added, as my hon. Friend has said, to national dried milk, and that is being done.
The uptake of cod liver oil is a matter of concern to the Ministry, and has been for some time, and it would seem that, in spite of the publicity and attempts which have been made at education, there has not been a very substantial improvement in consumption. The actual consumption at present is about 25 per cent. of the potential—that is, some 25 per cent. of mothers with children under the age of five are taking their amount of cod liver oil. It is not a definite proportion; the figure varies considerably, but the irregularities seem to indicate a smaller consumption in summer than in winter. I might add that the figure of 25 per cent. pays no regard to the possible consumption of various proprietary brands which may be available. To explain this lack of take-up of cod liver oil, the usual reason has been that which my hon. Friend has given, namely, the factor of palatability. Consideration has been given to the possibilities of improving the palatability of the cod liver oil. There have been difficulties, because even if you take the simple process of cold-clearing during production, it is found that there is an increase of anything between 15 per cent. to 20 per cent. in the cost of production and a loss of something like 10 per cent. of the availability. As a result, therefore, we felt that, perhaps, other methods ought to be adopted. Our investigations have shown that the palatability element is really one that, perhaps, is largely due to the way in which the cod liver oil is given to the child. In the nurseries where it is given under proper supervision palatability or lack of 149 palatability does not seem to be a factor that, interferes with consumption.
With regard to vitamised chocolate, as the hon. Member said, whilst it is possible under existing conditions to add vitamins A and D, and it is actually being done—vitarnised chocolate is being produced—there is a lack of vitamin A concentrate. This would be lost as a result of changing over from the use of cod liver oil. It is this difficulty of getting the necessary quantities of vitamin A which prevents the use of that method. It would not be possible, although we can get a good deal of cod liver oil, to use cod liver oil for the purpose of fortifying the chocolate. It is amongst the infants of the lower age that the need is for this addition, and we are advised that children of that age would not be properly treated if this chocolate were used for that purpose. We are doing everything we can in the way of investigating and carrying out experiments in co-operation with the Ministry of Food to find a practical means 150 of solving the problem. Orange juice has been suggested as one way. It is not at all certain we should not get the same difficulty with regard to palatability. We have adopted measures and increased measures for the fortification of margarine; and so far as expectant mothers are concerned the A and D vitamin tablets given to them in the centres and so on are a contribution towards this.
I am sure my Ministry are glad that this matter has been put forward for public consideration here, and perhaps, the discussion will help towards giving this matter publicity. I do want to emphasise that all our experience has shown that if cod liver oil is given as a routine matter from the age of one month onwards the factor of palatability does not prevent its consumption in the way the hon. Gentleman suggested