Sir, We appreciate the interest shown in our article by Dr. Miller. We do not, however, agree with his suggestion that the metaphyseal fractures identified in the three infants born at our institution over a 22-year period may have been due to a lower newborn bone strength caused by fetal immobilization as a result of their breech presentation or maternal diabetes. Although none of these infants had bone densitometry performed, the plain radiographs obtained showed no evidence of osteopenia. A workload audit is performed annually in our hospital. A review of the past 22 years has revealed a total of 2,313 multiple pregnancies, 2,622 infants who had a breech presentation, 1,814 of whom were delivered by caesarean section and 664 infants born to mothers who had insulindependant diabetes mellitus. Over the past 15 years there have been a further 1,199 infants born to mothers with gestational diabetes. If this large group of infants, as Dr. Miller proposes, were likely to have decreased bone strength and increased susceptibility to fractures, we would expect to have identified many more such metaphyseal injuries. In addition, we are not aware of any reports of an increased incidence of metaphyseal fractures in other institutions caring for similar large patient groups. Finally, we would like to draw Dr. Miller’s attention to the article “Critical review of ‘temporary brittle bone disease’” by Kenneth Mendelson in this journal in 2005, which, following detailed literature analysis, concludes that Miller and Hangartner [1] failed to demonstrate a relationship between fracture patterns and intrauterine confinement or decreased bone density [2].