Tuesday, December 2, 2008

The Skinny on Vitamin D Supplementation

We recently had a reader query regarding Vitamin D supplementation for her breastfeeding infant. Thanks to Alex (a doc-in-training, fellow mother, Catholic, and Princeton alum), we have the latest insight into this important issue.  Below is a question/answer session with Doc Alex, who cites a new AAP Policy Revision in Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents (Pediatrics Nov. '08) as the source for many of her recommendations.

Doc Alex, what is the big issue with Vitamin D and babies?
The main source of vitamin D for all humans is skin exposure to the sun's UV rays (UV-B rays, specifically). The sunlight stimulates the skin to make active forms of vitamin D that are necessary for our bones and other bodily functions. Unfortunately, it is very hard to determine how much sunlight exposure is enough to make sufficient amounts of vitamin D, especially in small children.  Furthermore, we now know the dangers of direct exposure to UV light without the protection of sunscreen or clothing and to keep our infants under 6 months of age out of direct sunlight. This is great for the prevention of various skin cancers but is not good news for our production of vitamin D.  Breastfed babies and infants with darker skin color are particularly susceptible to a condition known as rickets, or extreme vitamin D deficiency. 

Why should we worry about Rickets?
Rickets is a dangerous condition because the extreme vitamin D deficiency occurs months before the appearance of any physical signs that a doctor could spot or which could be seen on an X-ray. Vitamin D deficiency may also first present itself in forms as serious as seizures, growth failure, lethargy, irritability or a predisposition to respiratory infections during infancy. Rickets also eventually causes the skull, rib cage and joints to enlarge, and causes curving of the spine and femurs (i.e. bowed legs).

Doc Alex, what should we do?  How should we prevent Rickets in our babies?
To prevent rickets and vitamin D deficiency in *healthy* infants, children and adolescents, The National Academy of Sciences Panel for Vitamin D recommends a supplement of 400IU/day, beginning in the first few days of life and continuing throughout childhood. Any breastfeeding infant, regardless of whether he/she is being supplemented with formula, should be supplemented with 400 IU of vitamin D.

Does this mean formula-fed infants are safe from developing a vitamin D deficiency?
All infant formulas sold in the United States have at least 400 IU/L of vitamin D. Since most formula-fed infants eat nearly 1L or 1 quart of formula per day after the first month of life, they will get the necessary amount of vitamin D in their diet. Any infant who regularly eats less than 1L or 1 quart of formula per day can get the recommended amount of vitamin D through vitamin supplements.

What kind of supplements are available?
The required amount of daily vitamin D can be found in many liquid multi-vitamin supplements as well as in new vitamin D-only preparations. These vitamin D-only supplements are particularly good for a breastfed infant who has no need for multi-vitamin supplements.  As infants are weaned from breast milk and/or formula, vitamin D-fortified milk is recommended to provide 400 IU of vitamin D per day, however is not recommended to give cow's milk until after 12 months of age (use the vitamin supplements to get the needed vitamin D before that time).  Also, adolescents who do not obtain 400 IU of vitamin D per day through vitamin D-fortified milk and vitamin D-fortified foods (like fortified cereals and egg yolks) should receive a vitamin D supplement of 400 IU/day.

Doc Alex, to wrap up, what is your "take" on vitamin D supplementation?
Parents in previous generations did not give their children vitamin D supplements and most of us "did just fine," but we now know the risks of getting unprotected sunlight exposure (which is, unfortunately, the only kind that generates vitamin D!) and so parents are tending to avoid UV rays to protect their children from skin cancer and, simultaneously, are putting them at risk for rickets. Rather than "picking your poison," just have your children wear sunscreen AND take vitamin D supplements and enjoy the best of both worlds!

Thank you, Doc Alex, for bringing such insight to us over here at Building Cathedrals!
God bless!


4ddintx said...

My pediatrician mentioned vit D supplementation to me when my baby was born (6 weeks ago).

I've been wondering, if the breastfeeding Mom takes cod liver oil or supplements with some other rich source of vit D, is supplementation for the baby necessary? Or maybe even harmful? I take Cod liver oil and don't want to overdo it for my babe.

B-Mama said...

4ddintx, that brings up another good question: can people consume too much vit. D? Is it water soluble?

4ddintx said...

I'm pretty sure it's a fat soluble vitamin (hence it being in large amounts in cod liver oil). I think you can OD on it, but I need to do more research to refresh my memory on that one.

Right Said Red said...

Thanks B-Mama for this post!

A couple of questions/thoughts.

1) If a breastfeeding mother supplements with vit D, do you still need to supplement the baby? I ask only because my general philosophy with these sorts of things is that if I am getting enough, the baby is getting enough. I take a very good multi-vitamin supplement, as I believe all breastfeeding mothers need those extra nutrients.

2) I have heard that redheads are at a decreased risk for rickets and so are less likely to need extra vit. D. http://en.wikipedia.org/wiki/Rickets

Thanks Doc Alex for all your research and words of advice/wisdom!

AWOL Mommy said...

Doc Alex, thank you for your time. I am close with a priest who is currently suffering from rickets, and it is not pretty. Thank you for keeping us abreast of the latest.

margaretjdmom said...

Not to be Debbie Downer, but how adequately have they tested the effects of Vitamin D supplements on infants? They are recommending giving them to brand new infants...am I the only one a little bit skeptical? It seems like the AAP changes their minds or gives out new recommendations every month on these sorts of things. Were there studies done on infants? I am guess I am just wary of supplements for the wee ones. What about getting non-sunscreened sun during non-peak hours of sunlight- i.e. after 3pm?? Wouldn't that work?

margaretjdmom said...

MEA CULPA. I should read the journal article first before firing off questions...I will do that later!!

Alex said...

Some thoughts in response to these questions:

Vit. D is indeed a fat soluble vitamin and can be harmful if consumed in excess. However, toxicity in humans is thought to occur after regular daily consumption of approx. 40,000 IU/day, 100x the normal recommended dose of 400IU (this info provided by the Vitamin D Council's "Truth About Vitamin D Toxicity").

I have never found a reported case of a lactating mother causing vit. D overdose in her infant by combining the maternal and child supplements-- in fact, both are recommended. If a breastfeeding mom is vit. D deficient, it can contribute to the infant's vit. D deficiency. However, even in mothers who are NOT vitamin D deficient, the amount of vit. D in breastmilk is relatively small and should be combined with another source in order to achieve adequate levels of the vitamin.

The article referenced in the original post describes how the AAP's recommendations are based on recent studies and how trying to quantify the amount of UV rays actually absorbed and available for making vit. D is very complicated based on the variables of weather, individual pigmentation, body size, season of the year, cloud cover, latitude, clothing and sunscreen worn, etc.

Mary Alice said...

Here is a logistical question for any organized moms out there -- any tips or systems for remembering to give the supplements? I have a multi for my kids but I admit that we only remember a few days a week, and I know that when I have a newborn my brain is, well, not very helpful. I even have a hard time making sure that I am getting decent nutrition in the first six weeks post partum.

On a related note, my friend Chris offered a great tip for getting enough water, you put out a pitcher in the morning with a glass by it and just refill the glass everytime you walk by. I am going to start this, as I am currently dehydrated and I know this can be a problem with nursing too.

Anonymous said...

1) are the infant vit D supplements OTC?

2) I've read if you need to do the same thing every day, make it part of your breakfast routine because breakfast is the most similar thing from day to day. [My grandfather once sat on a plane next to the guy who helped design the ad campaign that convinced our grandparents oj was a necessary part of breakfast]

3) In our family, all children must take their vitamin at the same time - their multi has iron and I don't want to give someone an extra. This way there's no question who has taken it and who hasn't. However, they only get them if someone remembers to ask - they eat well enough that they don't need one every day.

Alex said...

Last time I checked, both the multivitamins containing 400 IU of vitamin D per mL and the new preparations containing 400 IU/mL of vitamin D only are both available over the counter.

B-Mama said...

One last question--why hasn't my current ped. (or the other two we had before) ever recommended this? You'd better believe I'll be raising the issue at our next well-baby visit!! Thankfully my oldest two kiddos are Rickets-free and should be fine thanks to milk consumption.

Catherine said...

Cod liver oil is probably the best natural source of Vitamin D. I always prefer to find food sources of vitamins rather than give synthetic supplements. CLO is a great supplement because it provides essential fatty acids as well, which are very important for brain development and sorely lacking in the typical American diet. All four of my kids (including the two who are still nursing) take it daily. My mom remembers taking CLO as a child and she can't believe my kids like it (it's lemon-flavored now)!

texas mommy said...

Thanks for taking the time to share this information with us, Alex!

Bertha said...

My friend suggested eVitamins to me for all king of vitamin supplements.