Thursday 30 May 2024

Vitamin D : post-operative complications in ethnic Black children

I would like to draw your attention to the first of three recent articles that have been published in the UK national newspaper the Guardian. These were very important in themselves, but unfortunately the important connection between the stories was not recognised.

Why do ethnic Black children suffer from an excess of complications after appendix surgery?

The first story appeared on February 22nd 2024, written by the excellent Tobi Thomas, Health & Inequalities Correspondent. It reported a finding that in England ethnic Black children suffer “more complications” after appendix surgery. 

Surgical removal of the appendix (appendicectomy / appendectomy) is usually an emergency operation performed because of acute appendicitis, a rapidly progressive infection of the appendix. If untreated there will be catastrophic infection within the abdomen (“ruptured or burst appendix”) with a fatal outcome. This an infective process, for which surgical cleaning should be undertaken and antibiotics will be given. However as with any infection our innate defensive immunity is essential.

We know that ethnic Black African people in general and children in particular, when living in the UK are more deficient of vitamin D than ethnic White people. Production of vitamin D in the skin is suppressed by reduced penetration of UV into dark skin, and by relative lack of required UV energy when living closer to the North Pole than to the Equator. This is known and beyond dispute.

We know that the hormone cholecalciferol, also known as vitamin D, is produced in the skin and is essential for optimal immunity, and that low blood levels lead to an increased risk of serious infection. This has been established clearly during the Covid-19 pandemic, but it was previously known in respect of tuberculosis.

It has also been demonstrated that the risk of post-operative infection and hospital acquired infections in general, are increased with low blood levels of vitamin D, and that such infections are rare in people with good blood levels. 

The risk of poet-operative infection related to blood level of vitamin D. 

It would appear that a blood level of 60ng/ml, 150nmol/L 

puts an individual into the safe range.

The problem appears to be straightforward: the most simple explanation of why ethnic Black children have an unusual high incidence of complications after appendix surgery is because they are seriously deficient of vitamin D.  We know this from the observations of infantile rickets in these children. 

Why this is not recognised by health professionals is a mystery. It is an obvious theory, without an obvious alternative explanation. Intervention is simple. Are we dealing with medical ignorance, or do they not care about ethnic Black children?

Even if the problem came to their attention, many so-called medical scientists would almost certainly argue that there must be a randomised controlled trial (RCT) of correcting deficiency of the natural hormone cholecalciferol / vitamin D when given before appendix surgery in ethnic Black children, and that the trial must precede a hormone replacement policy The impossibility would probably not occur to them. Doing one’s best to help individual patients might not be part of their responsibility. Instituting physiological hormone replacement therapy is not the same as testing a new pharmaceutical preparation.

If we think about an RCT we must consider the following. How many ethnic Black children have appendix surgery in the UK each year? How many hospitals would be involved to reach a necessary sample size? How would it be co-ordinated? Where would administrative funding come from? Is there an incentive to make an RCT happen? Does anyone with influence really care? Would the randomisation process, which must include informed consent by the parents, delay what must be emergency surgery? With existing knowledge, would ethical approval be given?

We know that vitamin D given by mouth or injection takes several days to become part-activated into the circulating form 25(OH)D. How does this fit into preventing complications resulting from emergency surgery? The answer is that the child must receive 25(OH)D, calcifediol, which acts within two hours, and which proved itself in the Covid-19 pandemic. How many doctors know this? How many know that calcifediol is now available in the UK for human as well as animal use?

Recruitment into an RCT requires informed consent. Information given by the study administrator might go like this: “We know that ethnic Black children have a high incidence of complications following appendix surgery compared to ethnic White children, and we suspect that this is due to deficiency of the natural hormone vitamin D. We want to try to either prove or disprove this by a randomised trial of vitamin D (as calcifediol) given before surgery. If you give consent to the trial it means that your child might receive vitamin D or might receive a placebo of just olive oil, which has no effect.

The parents are likely to say “I want you to do your best for my child. As vitamin D, being a natural hormone, when given in this way has no dangers and probably has great advantages, after your explanations I want him to have vitamin D, not the placebo”.

The sensible approach is to give vitamin D as Calcifediol to ethnic Black African children with acute appendicitis, and compare the incidence of post-operative complications with historical records.

To appreciate the importance of calcifediol over “raw” vitamin D in emergency care, see:


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