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Vitamin D: A look at the research behind the recommendations

Ah, spring is in the air. For me, spring brings to mind flowers, sunshine and vitamin D! In a recent article on healthychildren.org, the American Academy of Pediatrics discuss the recommendation that all breastfed infants be supplemented with 400IU of vitamin D per day. They extend this recommendation to non-breastfed babies consuming less than 32 ounces (1,000 mL) of vitamin D-fortified infant formula as well. Canada has been recommending 400IU of vitamin D per day for the breastfed baby since 1967.  The Canadian Paediatric Society (CPS)  also recommend  a daily dose of 400IU of vitamin D during April-October for formula-fed babies in northern communities. While the idea of providing breastfed infants with vitamin D supplements is not new, newer findings on vitamin D are important to recognize and share with the parents that we work with.

Vitamin D supplementation is about more than preventing rickets

Rickets, a disease that results in abnormal bone growth, can occur when the body is deficient of vitamin D, calcium and phosphorus (an in-depth review of vitamin D deficiency can be found here). Despite vitamin D fortification of certain food items and public awareness strategies, rickets is still a problem in North America, especially in northern latitudes. The Canadian Paediatric Surveillance Program reported 104 confirmed cases of rickets between 2002 and 2004 and there were 228 reported cases in the United States between 1986-2006.

Although the current prevalence of rickets is concerning, vitamin D supplementation is about more than preventing rickets. More recent evidence has suggested that vitamin D deficiency has also been linked to an increased lifetime risk of osteoporosis; asthma; autoimmune diseases such as rheumatoid arthritis, multiple sclerosis and inflammatory bowel diseases; diabetes; disturbed muscle function; resistance to tuberculosis; and the pathogenesis of specific types of cancer (reviewed by the CPS).  It has been estimated that in the United States alone, vitamin D deficiency carries an economic burden of $40 billion to $53 billion dollars per year, an amount that includes only the burden of disease from rickets and osteomalacia, associated deformities, bone fractures, muscle weakness, and pneumonia, as well as multiple sclerosis and common cancers associated epidemiologically with vitamin D deficiency such as prostate, colon, and breast cancers. It has also been estimated that somewhere between 50,000 to 70,000 people in the United States will die prematurely each year as a result of cancer related to insufficient vitamin D.  It is clear that vitamin D sufficency has both short term and lifelong benefits.

 

Supplements are the main source of Vitamin D for young infants

Assuming a mother is vitamin-D sufficient, and assuming a breastfed infant is consuming an average of 750mL of breastmilk per day, the amount of vitamin D the baby is receiving from the breastmilk is approximately 11-38 IU per day. This amount can be even less if mother is vitamin-D deficient due to factors such as clothing choice, skin color, diet, and geographical location. The amount of vitamin D currently recommended for breastfed infants is 400 IU per day. Clearly another source of vitamin D is needed for these infants. Although exposure to sunshine can increase vitamin D levels, direct sun exposure is not recommended for infants under 6 months of age. Therefore, the best option for infants that are exclusively breastfeed without adequate sun exposure is a vitamin D supplement of 400 IU per day.

Although vitamin D deficiency is not as commonly diagnosed in formula-fed infants due to the fortification of infant formula, it is still possible for these infants to suffer from vitamin D deficiency. In a 2006 prospective study from the UK, 50% of the children aged 0 to 5 presenting with rickets were formula-fed. It is therefore important to determine the daily intake of vitamin D in formula-fed infants based on the amount of formula consumed and the vitamin D content of the formula. It is for this reason that the AAP recommends all non-breastfed infants who are consuming less than 32 ounces (1 litre) per day of vitamin D-fortified formula receive a vitamin D supplement of 400 IU a day. In addition, the CPS advises families in northern communities to supplement formula-fed infants with 400IU of vitamin D per day during the months of October to April, even if they are drinking 32 ounces (1 litre) of formula daily.

 

More Information for Parents

There are many great information sources for consumers. Here are a few sources of online information that you may wish to share with the parents you work with:

Vitamin D Quick Facts from the National Institutes of Health

Vitamin D and your Baby 

Vitamin D summary for parents from the CPS

A parent-friendly video from the Vancouver Island Health Authority in British Columbia, Canada.

Babies

  1. avatar
    B
    March 26th, 2012 at 13:43 | #1

    Is there anything in the recommendation about the specific form of vitamin D? I’ve seen some long discussions about D2 vs D3 and the relative absorption rates.

  2. March 26th, 2012 at 13:51 | #2

    Thanks for doing this. I’ve been wondering about vitamin D for awhile but had no time to look it up. I’ll be briefly sharing this info in my ongoing Lamaze classes.

  3. March 26th, 2012 at 14:18 | #3

    Great question! The 2008 Pediatrics review suggests that D3 is more potent in raising 25(OH)-D levels and recommends looking for supplements containing D3. However, a more recent publication from the NIH states that vitamin D2 may be less potent only in large doses. At nutritonal doses, both Vitamin D2 and D3 appear to be equivalent options. I refer you to this link from NIH for further discussion.

  4. avatar
    Indie
    March 26th, 2012 at 20:54 | #4

    I ran across one study awhile back that found infants supplemented with vitamin D had higher rates of atopic disease in adulthood. How much effort has been put into studying the possible risks and side effects of supplementing with vitamin D for the fully breastfed infant? Also, this article states that it is not recommended to take an infant under six months out in the sun. What is the justification for this? I personally know of one child with rickets. This child is black, has absorption issues and was premature. How often often are there underlying factor in those who suffer from vitamin D deficiency?

    Also, how safe are the current supplements on the market? Most that I’ve seen include additional vitamins not needed by any fully breastfed baby. We know that some vitamins can actually interfere with the absorption of the more bioavailable ones found in breastmilk. At least one supplement that only contains D is in a medium of corn oil. Has any research been done to ensure that this is safe for the otherwise exclusively breastfed baby without other risk factors for vitamin D deficiency? Is the corn oil made from GMO corn?

    When I was making this decision for my own children, our pediatrician was very insistent that we use a vitamin D supplement. When I explained that we were choosing moderate sun exposure over the supplement, she admitted that she had done the same for her babies.

    I am not arguing that vitamin D supplementation is not necessary in many cases nor am I unaware of the seriousness of vitamin D deficiency (beyond just rickets), but I also question a one size fits all approach for an otherwise healthy infant.

  5. March 27th, 2012 at 21:20 | #5

    A study published by Wagner et al in 2006 showed that breastfeeding mothers that supplemented with 6400 IU/day provided between 350-800 IU of vitamin D per L of breast milk, while breastfeeding mothers who supplemented with 400 IU/day, provided 40-70 IU of vitamin D per L of breast milk.

    If the mother is sufficient (~40-50+ ng/ml) in vitamin D, breast milk is sufficient in supplying the infant vitamin D. If the mother is not, and most are not, the infant needs to supplement. Wagner et al found that when the mother supplemented with 400 IU/day, breastfed and supplemented her child with 300 IU/day, it was equivalent in raising the infant’s blood levels to when the mother took 6400 IU/day, breastfed and did not supplement her child with 300 IU/day.

    There have been no controlled trials on supplementing infants and then following long term health outcomes in those children. There have been observational studies showing a wide array of outcomes. The study Indie is referring to is a study that measured vitamin D levels in pregnant women at 9 months and then retrospectively observed children at 9 months and then 9 years after birth. They found that the higher the maternal vitamin D level at 9 months pregnant, the more likely a child would have asthma at the age of 9.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629513/?tool=pubmed

    There have been many observational studies that show the opposite or show nothing at all. That the higher the vitamin D level of the pregnant mother, the less likely a child is to develop asthma. Here is a study along those lines.

    http://www.ncbi.nlm.nih.gov/pubmed/19840962

    Keep in mind that these are “poor quality” findings and don’t answer the question at hand either way. There is a theory that a window during pregnancy is the most important to be sufficient in vitamin D for an array of health outcomes.

    The Council is of the opinion that vitamin D is important during pregnancy and infant development. Here is a blog on our site that discuss a randomized controlled trial during pregnancy, the only one we have to date.

    http://blog.vitamindcouncil.org/2012/03/13/optimal-levels-of-vitamin-d-during-pregnancy/

  6. March 27th, 2012 at 21:22 | #6

    Also, here is the link to the Wagner study:

    http://www.ncbi.nlm.nih.gov/pubmed/17661565

  7. avatar
    Nicole
    March 28th, 2012 at 18:27 | #7

    It may be reasonable for you to choose moderate sun exposure for your child, but for many people that is not an option – the weather and latitude prevent babies from making Vit D in sufficient quantities.

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