Breast Milk Calcium Research Articles

Breastmilk calcium concentrations in Palestinian lactating women.

Breastmilk calcium concentrations can vary between lactating women and over the lactation period. This study assessed breastmilk calcium concentrations among Palestinian lactating women. The demographic and dietary variables of the lactating women were collected using a questionnaire. The women provided a sample of about 5 mL of breastmilk using hand expression. Breastmilk calcium concentrations were quantified using an inductively coupled plasma-mass spectrometric method. Breastmilk samples were taken from 240 lactating women. The mean breastmilk calcium concentration was 285.4 ± 115.1 mg/L. Lower breastmilk calcium concentrations were associated with age, lactating period, unemployment, dissatisfaction with income and insufficient consumption of vitamins and minerals. Breastmilk calcium concentrations were affected by demographic variables of the lactating women and insufficient consumption of vitamins and minerals. The findings reported in this study are informative to healthcare providers and decision makers who might be interested in improving the health of lactating women and their infants.

Biochemical Markers of Calcium and Bone Metabolism during and after Lactation in Ugandan Women with HIV on Universal Maternal Antiretroviral Therapy.

We reported accentuated lactational decreases in areal bone mineral density and only partial skeletal recovery after lactation in Ugandan women with HIV (WWH) initiated on tenofovir disoproxil fumarate-based antiretroviral therapy (TDF-based ART) during pregnancy compared to women without HIV (REF). WWH also had higher breast milk calcium in the first months of lactation. To investigate the mechanisms, we measured bone turnover markers (bone resorption: C-terminal telopeptide [CTX]; bone formation: procollagen type 1 N-terminal propeptide [P1NP], bone-specific and total alkaline phosphatase [BALP, TALP]), hormones (parathyroid hormone [PTH], intact fibroblast growth factor 23 [FGF23], 1,25-dihydroxyvitamin D [1,25(OH)2 D]), vitamin D status (25-hydroxyvitamin D [25OHD]), and indices of mineral metabolism and renal function. Blood and urine samples collected at 36 weeks of gestation, 14 and 26 weeks of lactation, and 3-6 months after lactation were analyzed. Mean 25OHD was >50 nmol/L throughout. Both groups experienced similar biochemical changes during pregnancy and lactation to women in other settings, but within these patterns, the two groups differed significantly. Notably, WWH had higher PTH (+31%) and lower 1,25(OH)2 D (-9%) and TmP/GFR (-9%) throughout, lower P1NP (-27%) and plasma phosphate (-10%) in pregnancy, higher CTX (+15%) and BALP (+19%), and lower eGFR (-4%) during and after lactation. P1NP/CTX ratio was lower in WWH than REF in pregnancy (-21%), less so in lactation (-15%), and similar after lactation. Additionally, WWH had lower plasma calcium (-5%), lower FGF23 (-16%) and fasting urinary calcium (-34%) at one or both lactation timepoints, and higher fasting urinary phosphate (+22%) at 26 weeks of lactation and after lactation. These differences resemble reported TDF effects, especially raised PTH, increased bone resorption, decreased bone formation, and decreased renal function, and may explain the observed differences in bone mineral density and breast milk calcium. Further studies are needed to determine whether HIV and TDF-based ART have long-term consequences for maternal bone health and offspring growth. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Maternal Epidermal Growth Factor Promotes Neonatal Claudin-2 Dependent Increases in Small Intestinal Calcium Permeability.

A higher concentration of calcium in breast milk than blood favors paracellular calcium absorption enabling growth during postnatal development. We aimed to determine whether suckling animals have greater intestinal calcium permeability to maximize absorption and to identify the underlying molecular mechanism. We examined intestinal claudin expression at different ages in mice and in human intestinal epithelial (Caco-2) cells in response to hormones or human milk. We also measured intestinal calcium permeability in wildtype, Cldn2 and Cldn12 KO mice and Caco-2 cells in response to hormones or human milk. Bone mineralization in mice was assessed by μCT. Calcium permeability across the jejunum and ileum of mice were 2-fold greater at 2 wk than 2 mo postnatal age. At 2 wk, Cldn2 and Cldn12 expression were greater, but only Cldn2 KO mice had decreased calcium permeability compared to wildtype. This translated to decreased bone volume, cross-sectional thickness, and tissue mineral density of femurs. Weaning from breast milk led to a 50% decrease in Cldn2 expression in the jejunum and ileum. Epidermal growth factor (EGF) in breast milk specifically increased only CLDN2 expression and calcium permeability in Caco-2 cells. These data support intestinal permeability to calcium, conferred by claudin-2, being greater in suckling mice and being driven by EGF in breast milk. Loss of the CLDN2 pathway leads to suboptimal bone mineralization at 2 wk of life. Overall, EGF-mediated control of intestinal claudin-2 expression contributes to maximal intestinal calcium absorption in suckling animals.

Formulation of Snack Bar from Torbangun Leaf as Food Source for Iron and Calcium

Indonesia has local unutilized food and it contains mineral, it is torbangun leaf. Consumption of torbangun leaf can increase level of several mineral such as iron, calcium, zink, and magnesium in breast milk. Torbangun leaf powder contains 70.77 mg iron; 1258.29 mg calcium; dan 97.42 mg Phosphor. Torbangun leaf also contains lactogogum which can stimulate breast milk gland on mother by proliferating secretion cell of mamari. Therefore the quality and quantity of breast milk could increase. Torbangun leaves can be developed into emergency food items such as snack bars. The aim of this study was to develop snack bar with substitution torbangun leaves. From trial error, torbangun leaf was substitution until 10 g, 15 g, and 20 g. The best formula was substituted 10 g torbangun leaf which 9.6% protein; 10.43% fat; 66.3% carbohydrate; 1006.54 mg calcium; and 44.76 mg iron, with total an energy was 397.47 kcal/100 g.

Investigation of amino acids and minerals in Chinese breast milk.

The nutrients in human milk, particularly amino acids and minerals, are important for infant growth and development. Since there are few reports of amino acids and minerals in Chinese breast milk, we conducted this study to establish a representative preliminary database of breast milk nutrients in Chinese breast milk. In this study, we collected breast milk from healthy mothers in seven cities in western, southern and central China. The composition, content and proportion of total amino acids and ten elements (potassium, sodium, calcium, magnesium, iron, zinc, manganese, copper, selenium and phosphorus) in human milk in different lactation stages were investigated. In this study, it was found that the content of total essential amino acids (671.47 mg 100 mL-1 ) in Chinese breast milk was higher compared with the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) (574 mg 100 mL-1 ), but the content of leucine (LEU) (129.01 mg 100 mL-1 ) and cysteine (CYS) (20.31 mg 100 mL-1 ) was much lower than that recommended by ESPGHAN. Moreover, it was found that the content of most of these ten elements decreased during lactation, and the content of calcium in Chinese breast milk was lower compared with ESPGHAN. In addition, the content of selenium (7.23-20.55 mg 1000 mL-1 ) in breast milk from the three cities Nanchang, Shanghai and Guangzhou in China was much higher than that recommended by ESPGHAN. In a word, amino acids and minerals in Chinese human milk showed a significant difference from other countries. Human milk meal or infant food should be regulated to meet the requirements of the infant and to maintain the balance of the amino acids and minerals. © 2020 Society of Chemical Industry.

Retinol, α-tocopherol, and selected minerals in breast milk of lactating women with full-term infants in South Korea.

BACKGROUND/OBJECTIVESThis study was performed to measure fat-soluble vitamins and minerals in breast milk of Korean lactating mothers who exclusively breastfed their babies.SUBJECTS/METHODSBreast milk samples were collected from 334 mothers. Concentrations of retinol and α-tocopherol were analyzed by high performance liquid chromatography ultraviolet spectrometry while concentrations of minerals were measured by inductively coupled plasma optical emission spectrometry.RESULTSRetinol and α-tocopherol contents of breast milk were 39.58 ± 19.64 µg/dL and 0.23 ± 0.13 mg/dL, respectively. Average sodium, potassium, calcium, phosphorus, and magnesium levels in breast milk were 11.11 ± 5.16, 38.56 ± 9.01, 27.87 ± 6.10, 13.56 ± 3.30, and 3.05 ± 0.65 mg/dL, respectively. Contents of trace elements such as iron, zinc, copper, and manganese were 40.26 ± 46.21, 98.40 ± 62.47, 24.09 ± 9.03, and 0.90 ± 1.63 µg/dL, respectively. Fat-soluble vitamin concentration was positively correlated with total fat in milk samples, but no significant differences were observed in levels of retinol, α-tocopherol, or minerals based on whether or not lactating women were taking dietary supplements.CONCLUSIONSMicronutrient contents of breast milk samples from Korean lactating women were comparable to those of other nations. Retinol and α-tocopherol levels were correlated and also with total fat in breast milk.

Calcium intake of rural Gambian infants: a quantitative study of the relative contributions of breast milk and complementary foods at 3 and 12 months of age.

BACKGROUND/OBJECTIVES:There is a paucity of information from developing countries on total calcium intake during infancy, and potential consequences for growth and bone development.DESIGN:Observational longitudinal study of rural Gambian infants (13 males and 17 females) at 3 and 12 months of age.SUBJECTS/METHODS:Breast-milk intake and calcium concentration, weighed dietary intake, anthropometry, midshaft radius bone mineral content (BMC) and bone width (BW).RESULTS:At 3 and 12 months (mean±s.d.) calcium intake from breast milk was 179±53 and 117±38, and from other foods 12±38 and 73±105 mg/day. There was no difference in total calcium intake; 94% and 62% of calcium came from breast milk. At 3 and 12 months, weight s.d.-scores were −0.441±1.07 and −1.967±1.06; length s.d.-scores were −0.511±1.04 and −1.469±1.13. Breast-milk calcium intake positively predicted weight (P=0.0002, P⩽0.0001) and length (P=0.056, P=0.001). These relationships were not independent of breast-milk intake, which positively predicted weight (P⩽0.002) and length (P=0.06, P=0.004). At 3, but not 12 months, weight and length correlated with total calcium intake. There were no relationships between total calcium intake and breast-milk intake with BW or BMC.CONCLUSION:The combination of low calcium intake from breast milk and complementary foods resulted in a low total calcium intake close to the estimated biological requirement for bone mineral accretion. Relationships between calcium intake and growth were largely accounted for by breast-milk intake, suggesting that low calcium intake per se was not the limiting factor in the poor growth. These findings have potential implications for deriving calcium requirements in developing countries.

Early life low-level cadmium exposure is positively associated with increased oxidative stress

Environmental exposure to cadmium (Cd) is known to induce oxidative stress, a state of imbalance between the production of reactive oxygen species (ROS) and the ability to detoxify them, in adults. However, data are lacking on potential effects in early-life. We evaluated urinary concentrations of 8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG), a recognized marker of oxidative DNA damage, in relation to Cd exposure in 96 predominantly breast-fed infants (11–17 weeks of age) in rural Bangladesh. Urinary 8-oxodG was measured using liquid chromatography tandem mass spectrometry and Cd in urine and breast milk by inductively coupled plasma mass spectrometry. Median concentration of 8-oxodG was 3.9nmol/L, urinary Cd 0.30μg/L, and breast-milk Cd 0.13μg/L. In linear regression analyses, urinary 8-oxodG was positively associated with Cd in both urine (p=0.00067) and breast milk (p=0.0021), and negatively associated with body weight (kg; p=0.0041). Adjustment for age, body weight, socio-economic status, urinary arsenic, as well as magnesium, calcium, and copper in breast milk did not change the association between Cd exposure and urinary 8-oxodG. These findings suggest that early-life low-level exposure to Cd via breast milk induces oxidative stress. Further studies are warranted to elucidate whether this oxidative stress is associated with impaired child health and development.

P2-388 Calcium in breast milk is associated with the underweight of infant at around 6 months age in a cohort of Bangladesh

IntroductionAppropriate growth of infants is important for their health and further life. In Bangladesh, there are still many infants below the growth standards. Calcium (Ca) is a major component of...

Effect of Domperidone on the Composition of Preterm Human Breast Milk

Domperidone is increasingly prescribed to improve breast milk volume despite a lack of evidence regarding its effects on breast milk composition. We examined the effect of domperidone on the nutrient composition of breast milk. Forty-six mothers who had delivered infants at <31 weeks' gestation, who experienced lactation failure, were randomly assigned to receive domperidone or placebo for 14 days. Protein, energy, fat, carbohydrate, sodium, calcium, and phosphate levels in breast milk were measured on days 0, 4, 7, and 14, serum prolactin levels were measured on days 0, 4, and 14, and total milk volume was recorded daily. Mean within-subject changes in nutrients and milk volumes were examined. Maternal and infant characteristics, serum prolactin level, and breast milk volume and composition were not significantly different between domperidone and placebo groups on day 0. By day 14, breast milk volumes increased by 267% in the domperidone-treated group and by 18.5% in the placebo group (P = .005). Serum prolactin increased by 97% in the domperidone group and by 17% in the placebo group (P = .07). Mean breast milk protein declined by 9.6% in the domperidone group and increased by 3.6% in the placebo group (P = .16). Changes in energy, fat, carbohydrate, sodium, and phosphate content were also not significantly different between groups. Significant increases were observed in breast milk carbohydrate (2.7% vs -2.7%; P = .05) and calcium (61.8% vs -4.4%; P = .001) in the domperidone versus placebo groups. No significant adverse events were observed among mothers or infants. Domperidone increases the volume of breast milk of preterm mothers experiencing lactation failure, without substantially altering the nutrient composition.

Bone Mass and Breast Milk Calcium Concentration Are Associated with Vitamin D Receptor Gene Polymorphisms in Adolescent Mothers1,

Lactation-associated bone loss has been reported in adolescent mothers. Polymorphisms in the vitamin D receptor (VDR) gene may contribute to differences in the physiologic skeletal response to lactation in these mothers. We evaluated the influence of VDR gene polymorphisms ApaI, BsmI, and TaqI on bone mass, bone and calcium-related hormones, and breast milk calcium of lactating adolescents with habitually low calcium intake. Total body bone mineral content (TBMC), total body bone mineral density (TBMD), lumbar spine BMD (LSBMD), serum hormones [intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, insulin-like growth factor-I (IGF1), prolactin, and estradiol), and breast milk calcium were measured in 40 lactating Brazilian adolescents (15–18 y), and compared by VDR genotype subgroups after adjustment for calcium intake and postmenarcheal and lactational periods. TBMD and LSBMD Z scores were −0.55 ± 1.01 and −1.15 ± 1.48, respectively. LSBMD was higher (21%; P < 0.05) in adolescents with the aa genotype (n = 5) compared with those with the AA genotype (n = 7). TBMC and IGF1 were higher (23 and 50%, respectively; P < 0.05) in adolescents with tt (n = 4) than those with TT (n = 29) and Tt (n = 7) genotypes. Breast milk calcium and serum iPTH were higher (24 and 80%, respectively; P < 0.05) in adolescents with bb (n = 8) compared with those with BB (n = 21) genotype. These results indicate that bone mass and breast milk calcium are significantly associated with VDR genotypes in lactating Brazilian adolescents. Those with aa and tt genotypes had a better bone status and those with bb genotype had greater breast milk calcium.

Rickets: Vitamin D and Calcium Deficiency

To the Editor In his historical perspective, Jeffrey O'Riordan accounts for the appearance of rickets in London in the early 17th century from reduced UV exposure and vitamin D deficiency, resulting from coal burning and air pollution.1 However, we propose another hypothesis to account for the appearance of rickets, which also accounts for O'Riordan's observation that rickets was reported initially in the country, where presumably there was less smoke. Rickets was evidently a popularly known disease in the early 17th century and was described in the Netherlands as early as 1614.2 The appearance of rickets was coincident with another cultural practice increasingly adopted in 17th century London: wet-nursing. Infants from wealthier parishes were sent out of London to wet-nurses in country parishes.3 Rickets was more common among affluent than working-class children. Francis Glisson observed, “this disease doth more frequently invade the cradles of the rich than afflict poor men's children.”4 Swinburne pointed out that “there was a suspicion among families and doctors that a bad wet-nurse or poor feeding provoked the condition.”2 Infants who were wet-nursed in the country were likely to have as much sun exposure as other children in the wet-nurse's family. Wet-nurses often nursed several children simultaneously. The concentration of calcium in breast milk declines as the duration of breast feeding increases.5 Consequently, the continuous lactation of the wet-nurse would have resulted in a relatively low calcium concentration of her breast milk. Cereal porridges used in weaning,2 possibly with high phytate content, would have further aggravated a marginal calcium intake. We propose that the calcium intake of many infants who were wet-nursed and weaned to cereal porridges was insufficient to permit adequate bone mineralization. The resultant hypocalcemia and secondary hyperparathyroidism are likely to have increased vitamin D catabolism and converted relative vitamin D insufficiency to vitamin D deficiency.6 The latter hypothesis emphasizes the role of low dietary calcium intakes in the pathogenesis of rickets and is analogous to the situation in developing countries today, where calcium deficiency is an important cause of nutritional rickets. Whereas vitamin D–deficient rickets typically manifests in the first year of life, Glisson described manifestations primarily in the second year,4 similar to children with inadequate calcium intake. Calcium deficiency likely contributed to the appearance of rickets in England, which was probably supplanted 200 years later by vitamin D deficiency as the principal cause of rickets during the industrial revolution.

Wet-nursing and rickets

Layinka Swinburne (JRSM August 20061) provides fascinating documentation that rickets was well-established in London by the early 17th century. However, the widespread prevalence of rickets is commonly ascribed to the industrial revolution of the 19th century, with increased pollution and closely crowded urban dwellings reducing the exposure of children to sunshine.2 The origin of rickets before the industrial revolution may relate to the widespread practice of wet-nursing alluded to in the article. Infants from wealthier parishes were sent out of London to wet-nurses in country parishes.3 Nursed children of wealthy parents apparently had the greatest risk of rickets. The wetnurse engaged in continuous breast feeding, even nursing several children simultaneously. Nursed children were included in the country family of the wet-nurse and not necessarily deprived of sunshine. As the duration of lactation increases, the concentration of calcium in breast milk declines.4 Consequently, the calcium intake of very young infants who were wet-nursed was probably considerably less than required for adequate bone mineralization. Although calcium in breast milk is more bioavailable than that of cow's milk, the concentration of calcium in breast milk is only about one quarter the concentration of calcium in cow's milk. As Swinburne points out, non-dairy weaning paps would further aggravate marginal calcium intake. The appearance of nutritional rickets in the 17th century probably resulted primarily from restricted calcium intake rather than from vitamin D deficiency, coinciding with the increased adoption of wetnursing. Nutritional rickets exists along a spectrum ranging from isolated vitamin D deficiency to isolated calcium deficiency.5 Nutritional rickets may most often result from relative calcium and vitamin D deficiencies interacting with genetic and environmental factors. Although calcium deficiency as a cause of rickets has been relatively recently described, it may have been the primary cause of nutritional rickets prior to the industrial revolution.

Case‐control study of breast milk calcium in mothers of children with and without nutritional rickets

Abstract Aim: Despite similarly low calcium intakes and normal vitamin D status, only some Nigerian children develop nutritional rickets. We hypothesized that mothers with children who had developed rickets might have lower breast‐milk calcium concentration than mothers with normal children and compared the breast‐milk calcium concentration of mothers who had had children with rickets with those who had not (controls). Methods: We collected breast milk from 35 Nigerian mothers who had previously had children with nutritional rickets. For each case mother, we collected breast milk from three matched control mothers at the same stage of lactation (±4 weeks) who had had no children with rickets. Data were collected about parity, stage of lactation, and the infant's intake. The mother's bone density was measured. Results: The mean breast milk calcium concentration of mothers of children with rickets (4.30±1.24 mmol/L) was less than that of control mothers (4.65±1.03 mmol/L; P=0.034 in multivariate regression controlling for duration of lactation and resumption of menses). Forearm bone mineral content was significantly related to breast milk calcium concentration (r = 0.20) after adjusting for height, weight, and bone area (P=0.028). Conclusion: : Reduced breast‐milk calcium concentration may contribute to a reduced calcium intake in infancy and predispose children to nutritional rickets.

Case-control study of breast milk calcium in mothers of children with and without nutritional rickets

Despite similarly low calcium intakes and normal vitamin D status, only some Nigerian children develop nutritional rickets. We hypothesized that mothers with children who had developed rickets might have lower breast-milk calcium concentration than mothers with normal children and compared the breast-milk calcium concentration of mothers who had had children with rickets with those who had not (controls). We collected breast milk from 35 Nigerian mothers who had previously had children with nutritional rickets. For each case mother, we collected breast milk from three matched control mothers at the same stage of lactation (+/-4 weeks) who had had no children with rickets. Data were collected about parity, stage of lactation, and the infant's intake. The mother's bone density was measured. The mean breast milk calcium concentration of mothers of children with rickets (4.30+/-1.24 mmol/L) was less than that of control mothers (4.65+/-1.03 mmol/L; P=0.034 in multivariate regression controlling for duration of lactation and resumption of menses). Forearm bone mineral content was significantly related to breast milk calcium concentration (r=0.20) after adjusting for height, weight, and bone area (P=0.028). Reduced breast-milk calcium concentration may contribute to a reduced calcium intake in infancy and predispose children to nutritional rickets.

Calcium supplementation during pregnancy and lactation: Effects on the mother and the fetus

Calcium consumption is essential for bone development and maintenance throughout life, yet more than one half of the female population in the United States does not consume the recommended amount of calcium. Calcium intake is especially crucial during pregnancy and lactation because of the potential adverse effect on maternal bone health if maternal calcium stores are depleted. There is often a transient lowered bone mineral density and increased rate of bone resorption, with the greatest consequence during the third trimester and throughout lactation. Studies indicate that calcium consumption should be encouraged, especially during pregnancy and lactation, to replace maternal skeletal calcium stores that are depleted during these periods. Because the fetus in utero and the neonate through breast-feeding are dependent on maternal sources for the total calcium load, adequate maternal calcium intake also can affect fetal bone health positively. Proper calcium consumption can be attained through the diet by the consumption of dairy products or leafy greens (such as kale), the consumption of fortified foods, or by supplementation with widely available calcium-containing supplement products. Because many women experience heartburn during pregnancy, calcium-based antacids are ideal for providing heartburn relief, and they offer a calcium supplement to ensure maternal and fetal bone health, without the danger of adverse effects on the neonate.

The Effect of High-Dose Vitamin D Supplementation on Serum Vitamin D Levels and Milk Calcium Concentration in Lactating Women and Their Infants

Improve vitamin D status in lactating women and their recipient infants, and measure breast milk calcium concentration [Ca] as a function of vitamin D regimen. Fully breastfeeding mothers were randomized at 1 month postpartum to 2000 (n = 12) or 4000 (n = 13) IU/day vitamin D for 3 months to achieve optimal vitamin D status [serum 25(OH)D > or =32 ng/mL (80 nmol/L)]. Breast milk [Ca], maternal and infant serum 25(OH)D and serum Ca, and maternal urinary Ca/Cr ratio were measured monthly. Mothers were similar between groups for age, race, gestation, and birth weight. 25(OH)D increased from 1 to 4 months in both groups (mean +/- SD): +11.5 +/- 2.3 ng/mL for group 2000 (p = 0.002) and +14.4 +/- 3.0 ng/mL for group 4000 (p = 0.0008). The 4000 IU/day regimen was more effective in raising both maternal and infant serum levels and breast milk antirachitic activity than the 2000 IU/day regimen. Breast milk [Ca] fell with continued lactation through 4 months in the 2000 and 4000 IU groups. Decline in breast milk [Ca] was not associated with vitamin D dose (p = 0.73) or maternal 25(OH)D (p = 0.94). No mother or infant experienced vitamin D-related adverse events, and all laboratory parameters remained in the normal range. High-dose vitamin D was effective in increasing 25(OH)D levels in fully breastfeeding mothers to optimal levels without evidence of toxicity. Breast milk [Ca] and its decline in both groups during 1 to 4 months were independent of maternal vitamin D status and regimen. Both the mother and her infant attained improved vitamin D status and maintained normal [Ca].

Randomized, placebo-controlled, calcium supplementation study in pregnant Gambian women: effects on breast-milk calcium concentrations and infant birth weight, growth, and bone mineral accretion in the first year of life

Growth and bone mineral accretion in Gambian infants are poorer than those in Western populations. The calcium intake of Gambian women is low, typically 300-400 mg Ca/d, and they have low breast-milk calcium concentrations, which result in low calcium intakes for their breastfed infants. A low maternal calcium supply in pregnancy may limit fetal mineral accretion and breast-milk calcium concentrations and thereby affect infant growth and bone mineral accretion. We investigated the effects of calcium supplementation in Gambian women during pregnancy on breast-milk calcium concentrations and infant birth weight, growth, and bone mineral accretion. A randomized, double-blind, placebo-controlled supplementation study was conducted in 125 Gambian women who received 1500 mg Ca/d (as calcium carbonate) or placebo from 20 wk of gestation until delivery. Infant birth weight and gestational age were recorded. Breast milk was collected, and infant anthropometric and bone measurements were performed at 2, 13, and 52 wk after delivery. Infant bone mineral status was assessed by using single-photon absorptiometry of the radius and whole-body dual-energy X-ray absorptiometry. Compliance with the supplement was high. No significant differences were detected between the groups in breast-milk calcium concentration, infant birth weight, or growth or bone mineral status during the first year of life. A slower rate of increase in infant whole-body bone mineral content and bone area was found in the supplement group than in the placebo group (group x time interaction: P = 0.03 and 0.02, respectively). Calcium supplementation of pregnant Gambian women had no significant benefit for breast-milk calcium concentrations or infant birth weight, growth, or bone mineral status in the first year of life.

Factors Associated with Stunting in Infants Aged 5–11 Months in the Dodota-Sire District, Rural Ethiopia

The contribution of various factors to malnutrition, particularly stunting, may differ among areas and communities. This cross-sectional study aimed to estimate the level of malnutrition and identify factors associated with the high level of stunting in breast-fed infants aged 5-11 mo living in Dodota-Sire District, Ethiopia. Infants (n = 305) and their mothers were examined physically, and anthropometric and demographic data were collected. The content of zinc, calcium and copper in breast milk was measured, and data collected on the type, frequency of consumption, and time of introduction of supplementary feeding. Overall, 36% were stunted, 41% underweight and 13% wasted. The highest prevalence of malnutrition was seen in infants aged 9-11 mo. Among mothers, 27% had chronic energy deficiency (body mass index, <18.5 kg/m(2)) and 20% were night blind, indicating that vitamin A deficiency was a serious problem. Infants fed >3 times/d, consuming >600 mL/d or consuming cow's milk in addition to cereals and/or legumes had markedly higher length-for-age Z-scores than their peers fed less frequently, consuming less food or not consuming cow's milk [differences: 0.39, 95% confidence interval (CI): 0.04-0.74; 0.17, 95% CI: 0.02-0.32; 0.40, 95% CI: 0.07-0.72, respectively). Infants of mothers with low concentrations of zinc in their breast milk were more stunted. In conclusion, the quality and quantity of foods consumed by infants is insufficient to prevent stunting. Thus it is necessary to increase the nutrient supply to infants by increasing intake and nutrient concentration of breast milk and of supplementary foods they consume, and by providing supplements to infants where appropriate.

Fracture of the neck of the femur and osteomalacia in pregnancy

Case reportA 24 year old Muslim woman in full purdah, (no skinexposed in public, including veiling of the face and glovingof the hands), appeared at the antenatal clinic in a wheel-chair at term. This was her third pregnancy, havingreceived no antenatal care until consulting her generalpractitioner at 38 weeks of gestation by uncertain dates.She had had two previous vaginal deliveries, in January1999 and May 2000, both at term. Her second pregnancyhad been complicated by right-sided ‘sciatica’ in the thirdtrimester, but her obstetric and medical history was other-wise unremarkable and she took no medications apart fromiron supplements. Antenatal blood results were normal aswas an ultrasound scan. She had complained to her generalpractitioner of severe right-sided leg pain on mobilising.Doppler ultrasound examination of her legs was normal. Nofurther examination or investigation of her leg was under-taken at the antenatal clinic. The pain, which continued toconfine her to a wheelchair, was again thought to be due to‘sciatica’.At 42 weeks of gestation by a late ultrasound scan shewas admitted to the delivery suite in early labour. Herlabour progressed slowly over the following 22 hours andthe fetal head failed to engage into the pelvis. The womanagreed to a caesarean section, resulting in the delivery of ahealthy boy weighing 4285 g. On the fourth day after hercaesarean section, it was noted that the woman walked withextreme difficulty. On examination, the right quadricepsand gastrocnemius muscles were wasted and there wasweakness of the muscles of the right hip. Her reflexes werenormal and there was no loss of sensation. She had amarkedly abnormal gait. Plain X-rays of her pelvis andright hip showed a fracture of the neck of her right femur,with significant displacement. In addition, there were sub-acute healing fractures of the left superior and inferiorpubic rami, a sclerotic area of the right ischium suggestiveof an old healing fracture and generally osteopenic boneswith subcortical tunnelling and thinning of the cortex.The results of bone mineral densitometry were in keep-ing with established osteoporosis. The results of bonebiochemistry are shown in Table 1. A bone scan showedabnormal focal uptake throughout the ribs bilaterally, theintertrochanteric area of the right femur, the neck of the leftfemur medially and the distal part of the left femur, inkeeping with multiple fractures. Bone marrow biopsyperformed 16 days postnatally was normal, showing normalcellularity, a little patchy endosteal fibrosis and some boneresorption and remodelling with groups of osteoclasts.Screening for the malabsorption syndrome found a highIgG gliadin but normal IgA and endomysial antibody.A diagnosis of osteomalacia secondary to vitamin Ddeficiency was made, with superimposed osteoporosis andpossibly a component of malabsorption (the woman pre-ferred not to undergo further gastrointestinal investi-gations). Her vitamin D deficiency was thought to be acombination of lack of exposure to sunlight (she had beenwearing full purdah since arrival in Australia four yearspreviously), poor nutrition and possible malabsorption. Shedenied the possibility of physical abuse when questionedthrough a female interpreter by a female doctor without herhusband present, and there were no marks on her body tosuggest this alternative diagnosis.Closed reduction of the right hip fracture and insertion ofthree cannulated screws was performed by the orthopaedicteam. The woman was discharged 23 days postnatallypartially weight-bearing on her left leg (the bone scansuggested incipient left-sided femoral fracture) and stillnon-weight-bearing on her right leg. She was given600,000 units of vitamin D intramuscularly before herdischarge. She went home taking ergocalciferol 1000 Utwice daily and calcium 600 mg twice daily. Her babyshowed no signs of neonatal hypocalcaemia and hadnormal alkaline phosphatase but low vitamin D levels.DiscussionAlthough symptomatic osteomalacia in pregnancy hasbeen reported previously, we believe this is the first caseof fractured neck of femur in pregnancy secondary toosteomalacia. The fetus at term contains approximately30 g of calcium and lactating women excrete approxi-mately 210 mg/day of calcium in breast milk