Counsel a family given a new diagnosis of vitamin D deficiency rickets — OSCE

Communication framework

Establish what the parents already understand and fear. Ask the mother to recount what she has been told and what she has read, and acknowledge her tears and her guilt directly. The fear that breastfeeding caused the disease and that the baby will be disabled are the two you will spend the most time on, and you address them with the reassurance that exclusive breastfeeding was the right choice and that the disease is fully treatable. Do not correct her before you have heard her. ^{[3] [1]}

Explain the disease in plain language. Your baby's bones are soft because they are not getting enough of a vitamin called vitamin D, which the body uses to lay down calcium in the growing bone. Breast milk is the perfect food for your baby, but it carries very little vitamin D, which is why every breastfed baby is recommended a small daily supplement from soon after birth. Because the supplement was missed, the bones softened, and that is why the wrists look swollen and the bones bowed on the X-ray. This is called rickets, and it is fully treatable. ^{[2] [1]}

Address the guilt and the disability fear directly. You did not cause this, and exclusive breastfeeding was absolutely the right thing to do. The only thing that was missing was the small daily vitamin D drop, which is recommended for every breastfed baby, and that is a public-health gap rather than anything you did wrong. Because we caught it, the bones will heal completely with treatment, your baby will grow and develop normally, and there will be no long-term disability. ^{[3] [1]}