Rickets

Anne Milton Excerpts

Tuesday 4th September 2012 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under your chairmanship this afternoon, Mr Hollobone. I congratulate the hon. Member for Stretford and Urmston (Kate Green) on securing the debate. She is right that these are important opportunities to raise awareness. Although we sometimes underestimate our impact, such debates are sometimes picked up by the media, and anything is useful.

As the hon. Lady eloquently set out, with vitamin D, we are talking about children, strong and healthy bones, and bone health generally. Often, rickets occurs because a child is born without enough vitamin D due to the mother’s deficiency in pregnancy. Alternatively, it can be a post-natal condition due to a poor diet or lack of sun exposure. That is why successive Governments have long recommended that young children and pregnant and breastfeeding women take a daily supplement of vitamin D.

As the hon. Lady says, most people would imagine that rickets is something from the Victorian era. The incidence of rickets fell dramatically in the 1920s, and, in the past, several public health policies have helped to reduce its incidence further. The law now requires the addition of vitamin D to all infant formula, and vitamin supplements containing vitamin D are made available for pregnant women free of charge and to young children from low-income families via the Healthy Start scheme.

Unfortunately, we do not have good data on the national prevalence of rickets in the UK. The hon. Lady has been provided with data on episodes of rickets recorded by hospitals in England, but sometimes a problem when we produce data is that they are about episodes, not people. I believe that she was given that information through an answer to a parliamentary question. The figures appear to be slightly higher, and looking at the percentage increases, the statistics are startling, but episode data do not represent the number of patients, because a person may be admitted more than once in a year. The number of patients diagnosed with rickets is therefore a better measure, and that has increased from 134 to 395 in 2010-11. It is important to consider those figures in the context of increased population size and improved reporting and recording. Those numbers appear quite low when compared with other diseases, but rickets is still a problem, particularly since hospital episode statistics do not show the number of children who may have been treated as outpatients or those diagnosed by a GP. We are aware that over the past few years there have been several reports of clinically apparent vitamin D deficiency and rickets in children from doctors in Manchester, London, Glasgow and Burnley. That is not an exhaustive list; there will be other places.

As the hon. Lady pointed out, the tragedy is that rickets is preventable. That is why it is so important that at-risk groups such as pregnant women, babies and toddlers take those vitamin D supplements. As she also rightly pointed out, that is particularly important for women of south Asian, African, Caribbean or middle eastern family origin, because people with darker skin do not produce as much vitamin D in response to sunlight. It is also important for women who are not exposed to much sunlight, either because they cover their skin for cultural reasons or because they do not spend much time outdoors. The hon. Lady referred to older people who might, due to immobility problems, not be able to get out.

Our national infant feeding survey tells us that about half of mothers across the UK reported taking some form of vitamin or mineral supplement other than folic acid during their pregnancy. On the one hand, that is encouraging but on the other it means that 50% do not. There is a problem and clearly more needs to be done.

[Kate Green]

The Minister is right that we should worry about the 50% that may not be taking the supplements that they may need, but another concern is the lack of clarity among pregnant women and others about what supplements they should be taking and in what dose.

[Anne Milton]

The hon. Lady is absolutely right. A huge amount of data and confusing information are given to women. That is one thing we need to tackle in our public health changes. She also talked about joining up services and having a strategic approach. Given the many different information sources, particularly on the internet and some very reputable websites, it is hard for women to know exactly what to do.

The 2005 infant feeding survey found that only 7% of infants aged eight to 10 months were given any type of vitamin supplement. The hon. Lady talked about raising awareness, which is indeed what we need to do. We need to ensure that GPs, midwives, health visitors and other health professionals—she talked about schools—are fully aware of the need for those groups of the population to take vitamin D supplements. That is why in February all four of the UK’s chief medical officers wrote to GPs, health visitors, practice nurses and community pharmacists to reiterate the Department of Health’s recommendations. I would put particular emphasis on the role that pharmacists can play in informing the public, as they have quite a lot of contact.

The chief nursing officer for England also highlighted the issue in her February newsletter bulletin for all nurses and midwives in England. The Department of Health is liaising with the Royal College of Midwives to explore how we can work with them to spread advice further. It was also encouraging to hear that the Royal College of Obstetricians and Gynaecologists welcomed the CMOs’ letter and that it, too, promotes the importance of daily vitamin D supplement during pregnancy.

The National Institute for Clinical Excellence’s public health guidance on maternal and child nutrition, and clinical guidance on antenatal care—quite a mouthful—also support the Department of Health’s advice on vitamin D, reiterating the importance of consistent messages. We have also asked NICE to develop public health guidance on how to improve implementation of the advice on vitamin D and on safe sunlight exposure for the UK.

As the hon. Lady alluded to, there have been issues concerning the availability of prescribable vitamin D preparations. The NHS London Medicines Information Service has produced a document that lists the preparations with appropriate levels of vitamin D for different age groups, so health professionals know exactly what to prescribe. That list was sent to pharmacy organisations in March.

Healthy Start vitamins are not available on prescription, but the Department encourages NHS organisations either to sell the vitamins or consider supplying them free of charge to target groups who are not eligible for the scheme. I was pleased to see the positive effect of the CMOs’ letter—I do not know whether the hon. Lady is aware of this—on the number of orders placed. Orders for the children’s drops have increased from around 72,000 bottles in quarter 4 of 2010-11 to more than 97,000 bottles in quarter 4 of 2011-12. That is a significant increase, which demonstrates, although we are starting from a low base, that we can have an impact. Similarly, orders for the women’s tablets have increased from around 58,000 to more than 105,000 in the same period—an 80% increase.

We all need to keep up our efforts. The hon. Lady raised the issue of awareness and training, which, I suggest, should apply to all the professions. There would be no harm in the person who takes blood from a pregnant woman also reiterating some of the simple advice.

The Department of Health has produced a leaflet entitled “Vitamin supplements and you” as part of its Start4Life campaign. That contains up-to-date advice on the importance of vitamin D. Health care and child care professionals can download it. On top of that, in May we launched what I think will be one of the most significant initiatives, the new NHS information service for parents. Through regular e-mails, online videos and texts, it gives parents information and advice as they progress through their pregnancy and beyond. The service is very new. About 47,000 parents have already signed up, and I would urge those who are reading or listening to this debate to encourage the people they know to do so, too. Members of this House can have a significant impact by raising the issue in their local press and getting people to sign up. This is about trusted advice from the Department, cutting across a lot of the confusion.

We have also asked the Scientific Advisory Committee on Nutrition to undertake a comprehensive review of the scientific evidence on vitamin D and health. That will include a review of the existing dietary recommendations on vitamin D for all population groups, as well as looking at the options to improve the amount of vitamin D we get as a population. The risk assessment is due to be completed in 2014. In the meantime, it is important to ensure that the existing recommendations are put into practice, which is what this debate is all about.

The hon. Lady raised a number of other issues. I probably cannot give them the time they deserve today but I am happy, if she would like to know more detail, to talk to her on another occasion. We strayed a little into EU legislation—worthy of a three-hour debate—about health claims of vitamin supplements. She also asked about universal access and food fortification. Some of those issues are quite tricky. One needs to be sure that what is done has the desired impact. There is also quite a lot of resistance to fortification of food from another quarter.

In the final minutes, I would mention the public health outcomes framework, which she mentioned, the health and wellbeing boards and the opportunities that lie ahead. To some extent we now have an opportunity we have not had before, with public health moving into local authorities. Local authorities will have a remit to do a lot more work in this area. The hon. Lady mentioned schools. I think we will see an opportunity for local areas emerging, particularly when the joint strategic needs assessment reveals some of the issues. There may be opportunities, for example, where there is a high proportion of people who may be at risk from low vitamin D, for local areas to take action. That can be across the board, involving not just GPs and midwives, but schools. We will see changes. We will keep this under review; we know how important it is. The numbers might be relatively small but the increase is significant.

Question put and agreed to.