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By Kelly Bonyata, IBCLC
  • Is your baby at risk for vitamin D deficiency?
  • Recommended vitamin D intake
  • How much sunlight is needed to generate adequate vitamin D?
  • Food sources for vitamin D
  • Can we supplement the mother instead of the baby?
Is your baby at risk for vitamin D deficiency?

First of all, babies rarely need vitamin D supplements. The babies who do need these supplements need them due to a lack of sufficient sunlight. Factors that put your breastfed baby at risk for vitamin D deficiency (rickets) are:

• Baby has very little exposure to sunlight. For example: if you live in a far northern latitude, if you live in an urban area where tall buildings and pollution block sunlight, if baby is always completely covered and kept out of the sun, if baby is always inside during the day, or if you always apply high-SPF sunscreen.

• Both mother and baby have darker skin and thus require more sun exposure to generate an adequate amount of vitamin D. Again, this is a “not enough sunlight” issue – the darker your skin pigmentation, the greater the amount of sun exposure needed. There is not much information available on how much more sunlight is needed if you have medium or darker toned skin. See the section below regarding amount of sunlight needed.

• Mother is deficient in vitamin D – there is increasing evidence in the last few years indicating that vitamin D deficiency is becoming more common in western countries. The amount of vitamin D in breastmilk depends upon mom’s vitamin D status. If baby gets enough sunlight, mom’s deficiency is unlikely to be a problem for baby. However, if baby is not producing enough vitamin D from sunlight exposure, then breastmilk will need to meet a larger percentage of baby’s vitamin D needs. If mom has minimal exposure to sunlight (see above examples) and is not consuming enough foods or supplements containing vitamin D, then she may be vitamin D deficient. More below on supplementing mom with vitamin D.

Vitamin D supplementation is often recommended, particularly in Canada and other northern latitudes since these areas don’t receive much sunlight during certain parts of the year. If you don’t get much sunlight exposure, consider taking a vitamin D supplement. The 2002 results of the Canadian Paediatric Surveillance Program confirmed 20 cases of nutritional rickets in Canada during 6 months of study. The researchers noted that:

“Intermediate- and dark-skinned children who were breast-fed without vitamin D supplementation were at risk for the disease. Among identified cases, the mothers were frequently veiled, did not receive vitamin D supplementation following delivery, and infrequently ingested milk (thus eliminating a potential dietary source of vitamin D)… A subset of residents in Canada are particularly at risk for nutritional rickets, including darker-skinned, breast-fed infants whose mothers adhere to a diet that is low in vitamin D and have limited sun exposure.” [p. 43-44]

Per [Hamosh 1991, p. 156],
“In summary, exclusive breastfeeding results in normal infant bone mineral content when maternal vitamin D status is adequate and the infant is regularly exposed to sunlight. If the infant or mother is not exposed regularly to sunlight, or if the mother’s intake of vitamin D is low, supplements for the infant may be indicated.” World Health Organization information [Butte 2002, p. 29 ] states,

“…although there is abundant evidence suggesting that breastfed infants often receive less vitamin D than is required, most studies fail to find rickets in breastfed infants less than 6 months of age… infants who are exclusively or predominantly breastfed for 6 months or longer can be at an increased risk of rickets if their mothers are at risk of vitamin D deficiency, and the infants receive limited sun exposure and no vitamin D supplements.” If you are in doubt as to whether vitamin D supplements are needed and prefer not to give supplements “just in case” — getting a blood test to determine the vitamin D status of you or your child is always an option.

Recommended vitamin D intake

In the US, the recommended intake of vitamin D for infants and children (including adolescents) is 400 IU (10 micrograms) per day. The recommended intake of vitamin D for lactating mothers is currently 200 IU (5 micrograms) per day, the same as for all adults under the age of 50. Many feel that the recommended level for adults is too low, based upon recent research on vitamin D; per the AAP’s 2008 Policy Statement on prevention of vitamin D deficiency, “New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer.”

Infants 0-12 months should not exceed 1,000 IU (25 µg) per day. Anyone aged 1-50 years should not exceed 2,000 IU (50 µg) per day. The amount of vitamin D in human milk is small: 0.5-3.4 µg/liter (20-136 IU/liter) [Hamosh 1991, Good Mojab 2002] in mothers who are not vitamin D deficient. However, the vitamin D in human milk is in a form that is very easily used by the baby and therefore adequate for most infants, when combined with a small amount of sun exposure.

How much sunlight is needed to generate adequate vitamin D?

The best way to get vitamin D, the way that our bodies were designed to get the vast majority of our vitamin D, is from modest sun exposure. Going outside regularly is generally all that is required for you or your baby to generate adequate amounts of vitamin D. (Keep in mind that there is a concern of sunburn and increased risk of skin cancer with too much sun exposure, however.)
Per “Infant feeding: the physiological basis” [WHO, 1991] by James Akre,

“…it is now understood that the optimal route for vitamin D ingestion in humans is not the gastrointestinal tract, which may permit toxic amounts to be absorbed. Rather, the skin is the human organ designed, in the presence of sunlight, both to manufacture vitamin D in potentially vast quantities and to prevent the absorption of more than the body can safely use and store.”

Per Cynthia Good Mojab, MS, IBCLC, RLC in Frequently Asked Questions About Vitamin D, Sunlight, and Breastfeeding:

The amount of sunlight exposure needed to prevent vitamin D deficiency depends on such factors as skin pigmentation, latitude, degree of skin exposure, season, time of day, amount of pollution, degree of use of sunscreen, altitude, weather, the vitamin D status of the lactating mother, and the current status of vitamin D stores in the infant’s body. Recommendations do and should, therefore, vary around the world, taking into account local conditions and practices.

World Health Organization information [Butte 2002, p. 27 ] states, “Two hours is the required minimum weekly amount of sunlight for infants if only the face is exposed, or 30 minutes if the upper and lower extremities are exposed.” This guideline is from a study [Specker 1985] of exclusively breastfed Caucasian infants under six months old at latitude 39°N (Cincinnati, Ohio, USA). Darker skinned infants may require a longer time outside (three to six times the sunlight exposure) to generate the same amount of vitamin D [Good Mojab 2002].

It is not necessary to get sun exposure every single day, as the body stores vitamin D for future use. Per [Good Mojab 2003], “Studies have shown that children can store enough vitamin D to avoid deficiency for several months when they are exposed to only a few hours of summer sunlight.”

Sunlight exposure needed to achieve adequate vitamin D status*
Infant Group
Clothing
Minutes/Week
Average Minutes/Day
Reference
Caucasian infants,
0-6 months old,
latitude 39°9’N,
Cincinnati, Ohio, USA
fully clothed without a hat
diaper only
120 min/wk (2 hours)
30 min/wk (1/2 hour)
17.1 min/day
4.3 min/day
Specker 1985
Chinese infants,
1-8 months old,
latitude 39°55′N,
Beijing, China
fully clothed without a hat
168 min/wk (2 hrs, 48 min)
24 min/day
Ho 1985

* In these studies, this was defined as the amount of sunlight exposure necessary to maintain blood serum concentrations of 25-hydroxyvitamin D at a level above the lower limit of the normal range (11 ng/ml).

Food sources for vitamin D

Vitamin D is available in fortified foods (where vitamin D has been added) such as milk, cereals, or margarine. There is also a new vitamin D fortified orange juice available (fortified with the same amount of vitamin D as used in milk). Vitamin D is found naturally in a few foods including fatty fishes & fish oils (salmon, mackeral, sardines, herring, cod liver oil), liver and egg yolk.

Can we supplement the mother instead of the baby?

During pregnancy: The primary source of vitamin D for babies, other than sunlight, is the stores that were laid down in baby’s body prior to birth. Per [Hamosh 1991, p. 155], several studies “suggest that infants born to mothers with inadequate vitamin D status are highly dependent on a regular supply of vitamin D through diet, supplements or exposure to ultraviolet light.” Because mom’s vitamin D status during pregnancy directly affects baby’s vitamin D stores at birth and particularly during the first 2-3 months, it would be very helpful for pregnant women to make sure they are getting enough vitamin D. It is easy to determine if mom is vitamin D deficient by using a simple blood test to check parathyroid hormones. If these hormones are elevated, it can indicate a deficiency in vitamin D. Baby’s fetal stores of vitamin D are sufficient for around 3 months if baby gets very little sunlight, but will last much longer if baby is exposed to sunlight regularly.

During lactation: Adding a vitamin D supplement to mom’s diet and/or exposure to ultraviolet light will increase the amount of vitamin D in her breastmilk. As long as mom is not vitamin D deficient, her breastmilk will have the right amount of vitamin D. However, babies were “designed” to get only part of their vitamin D from breastmilk and the remainder from sun exposure – what if baby does not get a minimum amount of sun? A 2004 study [Hollis & Wagner 2004] determined that supplementing the mother with 2000-4000 IU vitamin D per day safely increased mother’s and baby’s vitamin D status: the 2000 IU/d dose resulted in a limited improvement, and “A maternal intake of 4000 IU/d could achieve substantial progress toward improving both maternal and neonatal nutritional vitamin D status.” A Finnish study [Ala-Houhala 1986] showed that supplementing the mother with 50 µg (2000 IU) vitamin D per day was as effective for maintaining baby’s vitamin D levels as supplementing the baby with 10 µg (400 IU) per day. However, some feel that higher levels of maternal supplementation (greater than the “safe” level of 2000 IU) would be needed to maintain adequate infant vitamin D levels.

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By: Mothering Editorial
Posted 1/7/12 • Last updated 1/9/12 • 431 views • 0 comments

Cynthia Good Mojab, Issue 117, March/April 2003

Making informed decisions about complex and controversial health issues, such as vitamin D supplementation of breastfed infants, is inherently challenging. When evaluating information, mothers may wish to consider the goals, potential biases, and sources of funding of health organizations, researchers, healthcare providers, and vitamin manufacturers; the depth, breadth, and limitations of the information on which public health policies are based; whether a recommendation might be out of date or applicable in only some situations; whether any conflicts of interest might be involved; and whether the organization or individual making the recommendation is in full compliance with the letter-and spirit-of the WHO/UNICEF International Code of Marketing of Breast-Milk Substitutes. 1, 2 A review of the related scientific literature, though essential, is just the beginning.

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What Is Vitamin D?

Vitamin D is actually not a vitamin at all, but a steroid hormone produced in the body after direct exposure of the skin to ultraviolet B (UVB) radiation in sunlight. Vitamin D plays a critical role in the maintenance of proper blood calcium and phosphorous concentrations, and in bone mineralization by stimulating the absorption of calcium and phosphorous in the small intestine. It also acts as a chemical messenger in a wide variety of other biological responses.3

What Is Vitamin D Deficiency and What Are Its Consequences?

In the absence of underlying organic causes, such as prematurity or liver or kidney disease, vitamin D deficiency is sunlight deficiency. Vitamin D deficiency can lead to bone disease: osteomalacia in adults, rickets in infants and children. Research has shown that higher latitude and lower vitamin D levels are related to several cancers, type 1 diabetes, and other diseases.4-6

How Do People Get Enough Vitamin D?

The direct, casual exposure of skin to sunlight is the most common and the biologically normal way that human beings attain sufficient levels of vitamin D. However, sunlight exposure for many people around the world has been reduced by industrialization, urbanization, migration, concern about skin cancer, and social inequities. Because only a few foods naturally contain significant levels of vitamin D (e.g., the oils and livers of some fatty fish), it would be unusual for people to obtain adequate vitamin D from their diet alone without supplementation or enrichment.7
The skin has a large capacity to produce vitamin D. Exposure of the entire adult body to the smallest amount of UVB radiation that produces transient, just perceptible skin reddening is comparable to taking an oral dose of 10,000 to 25,000 IU of vitamin D.8, 9 Therefore, sufficient levels of vitamin D can be developed from partial exposure of the body to sunlight well before sunburn occurs.
Levels of vitamin D vary seasonally among people exposed to sunlight at higher latitudes, where UVB radiation is higher in the summer and lower in the winter.10, 11 With inadequate summer exposure, vitamin D deficiency and insufficiency can result, particularly during the winter.12, 13 However, with adequate exposure to sunlight in the summer, vitamin D can be stored in the body for winter use.14 The lower vitamin D stores of the spring can be replenished with exposure to the higher UVB radiation of summer sunlight.

How Do Nurslings Get Enough Vitamin D?

The natural sources of vitamin D for nurslings are primarily the stores they developed prenatally (for newborns) and the vitamin D they produce with exposure of their skin to sunlight; a smaller additional contribution is from human milk.15, 16 The concentration of fat-soluble vitamin D in human milk varies from 5 to 136 IU/L, depending on how its activity is measured and on maternal vitamin D status during lactation.17-19 This concentration provides less than the 200 to 400 IU/day commonly recommended for infants under one year of age.20 However, human milk should not be considered “deficient” in vitamin D, because the biologically normal means of obtaining sufficient vitamin D in humans is via sunlight exposure, not diet.21-23
The neonate’s stores of vitamin D depend on maternal vitamin D status during pregnancy.24, 25 A study of exclusively breastfed infants in Tampere, Finland (61° N) in winter showed that, without UVB exposure or vitamin D supplementation, vitamin D stores of fetal origin were depleted by eight weeks of age.26 Although these vitamin D-depleted infants had serum levels of vitamin D at which rickets can occur, none had active or biochemical rickets. The concentration of vitamin D in human milk increases significantly with what are currently considered pharmacological doses of vitamin D supplements.27, 28 Administration of 2,000 IU-but not 1,000 IU-to lactating mothers in another study normalized the 25-hydroxyvitamin D levels of their infants in winter.29 Supplementation with over 1,000 IU/d is currently considered to greatly exceed normal maternal vitamin D needs (200 IU/d).30
Studies have shown that children can store enough vitamin D to avoid deficiency for several months when they are exposed to only a few hours of summer sunlight.31-33 Exclusively breastfed Caucasian infants under six months of age (39° N; Cincinnati, Ohio, US) are expected to achieve adequate vitamin D status when exposed to sunlight for 30 minutes per week (diaper only) or two hours per week (fully clothed without a hat). 34 The sunlight exposure needed by darkly pigmented infants is poorly understood.35 Studies of the influence of skin pigmentation on the cutaneous production of vitamin D in adults have shown conflicting results.36, 37 However, a study by Brazerol and colleagues showed that darkly and lightly pigmented adults were equally capable of producing vitamin D when episodes of UVB exposure occurred periodically over time (i.e., biweekly for six weeks in their study).38

Who Is at Risk for Vitamin D Deficiency?

Anyone with inadequate exposure to UVB radiation in sunlight is at risk for vitamin D deficiency. Risk factors for nurslings and their mothers overlap and interact, and include indoor confinement during the day (e.g., due to exclusively indoor daycare, unsafe neighborhoods, custom),39 living at higher latitudes (e.g., essentially no vitamin D is produced with sun exposure from November to February in Boston [42° N] and from mid-October to mid-April in Edmonton, Canada [52º N]),40, 41 darker skin pigmentation,42-45 living in urban areas with pollution and/or buildings that block sunlight,46-48 sunscreen use,49-51 seasonal variations resulting in less ultraviolet radiation (e.g., late winter and early spring in the northern hemisphere),52, 53 covering much or all of the body when outside (e.g., due to custom, fear of skin cancer, cold climate),54-57 increased birth order (e.g., a mother’s sixth child has a higher risk of vitamin D deficiency than does her first child),58, 59 the replacement of human milk with foods low in calcium,60-64 the replacement of human milk with foods that reduce calcium absorption (e.g., grains and some green leaves containing phylates, oxalates, tannates, and phosphates; cereals grown in soil high in strontium),65-67 and exposure to lead (due to lead’s inhibition of vitamin D synthesis).68, 69

What Is Rickets?

Vitamin D-deficiency rickets is a disease of childhood caused by lack of sunlight exposure. Rickets can also be caused by calcium deficiency and underlying disease. The symptoms of rickets vary with age of onset and include bone deformities and fractures, muscle weakness, developmental delays, short stature, failure to thrive, respiratory distress, tetany, and, rarely, heart failure.70 Rickets that develops in breastfed infants during the first six months of life is likely to be related to maternal vitamin D and/or calcium deficiency during pregnancy, which is often asymptomatic.71, 72 Among younger infants, rickets has been reported among formula-fed infants and breastfed infants receiving vitamin D supplementation.73 In that report, no correlation was found between season of birth, breast- or formula feeding, or routine vitamin D supplementation, suggesting that maternal vitamin D status was the direct cause of rickets in that population (i.e., Asian infants living in the United Kingdom).74 In a study of African children older than six months, vitamin D deficiency appeared unlikely to be the primary cause of rickets; insufficient dietary calcium probably interacted with genetic, hormonal, and other nutritional factors to cause rickets in susceptible children.75 Many children affected by early childhood rickets come from poor socioeconomic conditions and sometimes show signs of general malnutrition.76

How Common Is Rickets in Nurslings?

There are currently no national data on the prevalence of rickets in the US,77 though case reports and descriptive studies clearly indicate that rickets is not a disease of the past. At the start of the 20th century, rickets was epidemic in industrialized cities of northern Europe and North America. Through the use of vitamin D supplementation and the fortification of cow’s milk, it was virtually eliminated in most developed countries by the 1960s. Rickets in breastfed infants has been documented among at-risk populations in northern Europe, North America, and former Soviet countries since the 1970s.78 In some developing countries it remains a serious health problem.79-82 Overt rickets is more common in children 6 to 36 months of age than in infants under 6 months of age.83-86 Findings of bone deformities suggestive of rickets are very rare in full-term or premature neonates.87

What are Current Recommendations for Preventing Vitamin D Deficiency in Nurslings?

Public health policies regarding vitamin D supplementation vary globally, reflecting different incidences of and risk factors for vitamin D deficiency, cultural practices, and financial resources.88 No global consensus exists on whether or how to screen nurslings or mothers for vitamin D deficiency or on how to prevent vitamin D deficiency among nurslings. Recommendations for prevention vary, from supplementing all breastfed infants (universal supplementation) to supplementing only at-risk infants (conditional supplementation) to exposing infants to regular small doses of sunshine. (See sidebar, “Recommendations Around the World.”)
The American Academy of Pediatrics’ policy on vitamin D supplementation for breastfed infants has been in development and discussion for two years.89 It is now before the AAP Board of Directors for consideration. If approved, it will become official AAP policy once it is published in the journal Pediatrics. In Breastfeeding and the Use of Human Milk, the AAP currently states that vitamin D may be needed for infants younger than six months whose mothers are vitamin D-deficient or for infants who are not exposed to adequate sunlight.90 However, it seems likely that the AAP will soon recommend universal supplementation for breastfed infants beginning sometime during the first six months of life.91, 92
Some policy makers, researchers, healthcare providers, and mothers in Western or Westernized countries may prefer vitamin D supplementation of all breastfed infants (rather than vitamin D supplementation of only those infants at risk of vitamin D deficiency), in part, because of culturally based discomfort with processes-such as UVB exposure-that are natural, irregular, and not easily measured.93-96 Whether recommendations are universal or conditional, breastfeeding mothers have the right to talk with their healthcare providers about their and their nurslings’ specific risks of vitamin D deficiency and about whether conducting blood tests to determine their and their children’s actual vitamin D status would be appropriate.

Are there Any Risks of Vitamin D Supplementation?

Prophylactic vitamin D supplementation is demonstrably useful for infants at risk of vitamin D deficiency. No known risks of supplementation exist with 200 to 400 IU/day. Supplementation and fortification with vitamin D has been used for decades in many countries. According to the Canadian Department of National Health and Welfare, “It seems probable that the widely accepted figure of 10 µg (400 IU) per day considerably exceeds the true requirements of the great majority of infants, but that amount can be recommended as an effective and safe prophylactic level of intake from all sources.”97 Vitamin D intoxication can occur with excessive intake of dietary vitamin D (i.e., more than 40,000 IU/day for many months in normal adults), but not with endogenous production via sun exposure.98

Many potential risks of vitamin D supplementation, however, have not been investigated. No one knows whether vitamin D supplementation has any deleterious physiological effects on the infant, such as aspiration when supplementation is not tolerated, harmful alterations of the infant gut, or increased rates of infection.99 When studies of health outcomes based on infant feeding routinely fail to define “exclusive breastfeeding” clearly and consistently or even to include truly exclusive breastfeeding (nothing other than human milk fed to the infant directly from the mother’s breasts), it is impossible to know the full effects of vitamin D or other supplementation on infant health and development.100, 101 When studies have differentiated between health outcomes for exclusively and partially breastfed babies, significant differences between the two groups have been shown. For example, in a study by Coutsoudis and colleagues, partially breastfed infants of HIV-positive mothers had a greater risk of becoming HIV-positive than exclusively breastfed infants (who had a risk similar to never-breastfed infants).102

In addition, the effects of universal recommendation of vitamin D supplementation on breastfeeding beliefs and behaviors (e.g., use of other supplements, premature introduction of other foods, weaning) have not been studied. No one knows how vitamin D supplementation affects the likelihood of other types of supplementation. Some breastfeeding mothers may see no difference between the feeding of a vitamin D supplement and the feeding of a small amount of another liquid or food. Some breastfeeding mothers may see universal supplementation as evidence that breastfeeding is inadequate. The importance of exclusive breastfeeding in the first six months of life, however, is well supported.103 If mothers-or other caregivers-see no difference between vitamin drops and other supplementation or believe that human milk is inadequate because supplements are recommended for all breastfed infants, then recommendations of universal vitamin D supplementation could indirectly serve to increase the risk of illness and disease for many infants, including those not at risk for vitamin D deficiency.

Disturbingly, vitamin D supplements are produced by formula manufacturers in some countries (e.g., D-Vi-Sol by Mead Johnson in Canada). Formula manufacturers commonly violate the International Code of Marketing of Breast-Milk Substitutes by engaging in unethical marketing practices, such as advertising formula directly to the general public.104 Mead Johnson’s marketing of D-Vi-Sol includes advertising of its formula.105, 106 Formula advertising has been shown to decrease the duration and exclusivity of breastfeeding.107 Therefore, in countries with no legislation enforcing the Code, such as the US, and in which formula companies manufacture vitamin supplements, a universal recommendation of vitamin D supplements for breastfed infants will result in the routine exposure of large numbers of breastfeeding mothers to formula advertising-with a concomitant increased risk of additional supplementation, premature weaning, and deleterious health consequences for infants and mothers.

Are there Any Risks of Producing Vitamin D via Sun Exposure

Chronic, excessive sun exposure is strongly associated with a marked increase in the incidence of skin cancer in fair-skinned populations worldwide, as well as with the development of cataracts regardless of skin pigmentation.108 Skin cancer is the most common form of cancer in the US.109 More than a million cases of basal- and squamous-cell skin cancer and more than 53,000 cases of malignant melanoma are diagnosed in the US each year.110 Malignant melanoma occurs ten times more frequently in Caucasians than in African Americans.111 Risk factors for skin cancer include fair to light skin complexion, a family and/or personal history of skin cancer, chronic exposure to the sun, a history of sunburns during childhood, atypical moles, a large number of moles, and freckles (an indicator of sun sensitivity and sun damage).112 No research exists examining the relationship between the risk of skin cancer and a lifetime of minimal levels of sun exposure just sufficient for the endogenous production of adequate levels of vitamin D. Therefore, there currently is no evidence that such levels of sun exposure increase the lifetime risk of skin cancer.

The American Academy of Pediatrics recommends that infants under six months of age be kept out of direct sunlight.113 However, the Global Solar UV Index: A Practical Guide, a joint recommendation of the World Health Organization, World Meteorological Organization, United Environment Programme, and International Commission on Non-Ionizing Radiation Protection, states: “Small amounts of UV radiation are beneficial for people and essential in the production of vitamin D.”114 According to UNICEF, cases of vitamin D deficiency that occur outside of temperate regions with weak sunlight “are the result of the overprotection of certain individuals from the sun. “The best prevention is to change these habits, and health professionals must insist on the need to be in sunlight.”115

What is the Greater Context of Sunlight Deficiency?

The many social causes and health consequences of sunlight deficiency cannot be fully ameliorated through vitamin D supplementation. While supplements are an invaluable tool for preventing rickets in at-risk infants, they do not, for example, protect nurslings from other negative effects that poverty, pollution, unsafe neighborhoods, and crowded inner cities have on the health and development of all infants living in those contexts. Nor do they prevent the negative health consequences of inadequate sunlight on mental health (e.g., seasonal onset and remission of depressive episodes) and women’s reproductive systems (e.g., irregularities of the menstrual cycle and premenstrual syndrome).116-118
When rickets occurs in breastfed infants, it indicates that something is very wrong with the context in which breastfeeding is happening, not with breastfeeding itself. Social and environmental problems in that context warrant assessment, further research, and amelioration. Breastfeeding is the foundation of normal health and development, the original paradigm for nourishing and nurturing young human beings. Health policies and healthcare systems must first and foremost protect breastfeeding. Otherwise, they will ultimately serve to undermine the health they seek to enhance.

Cynthia Good Mojab, MS (clinical psychology), IBCLC, RLC, is Research Associate in the Publications Department of La Leche League International and Senior Editor at Platypus Media. She is the co-author of Breastfeeding at a Glance: Facts, Figures, and Trivia about Lactation (Platypus Media, 2001). Her publications can be accessed from her website, Ammawell home.attbi.com/~ammawell, which provides breastfeeding and parenting information.

http://www.mothering.com/community/a/sunlight-deficiency-a-review-of-the-literature

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Research Into Practice

How Do We Help Mothers with Vitamin D Questions?

Melissa Clark Vickers, MEd, IBCLC
Huntingdon, TN, USA
From: Leaven, Vol. 45 No. 1, 2009, p. 7

Human milk deficient? Most LLL Leaders bristle at a statement like this — we know that human milk is perfectly designed for human infants, and it is inconceivable that such a perfect substance could possibly be lacking in anything. Often, when we hear about a human milk deficiency, a closer look reveals some kind of bias that starts with using something other than human milk as the standard. So why is vitamin D any different?
As Dr. Will, Dr. Taylor, and Dr. Wagner note in the lead article, the potential for vitamin D deficiency in human milk is not through some error of nature. Instead, we have to look at the broader picture. Human milk is perfectly designed for humans, who are physiologically capable of getting the needed vitamin D through the simple act of daily sun exposure. Our skin cells make the precursor for vitamin D, and a little ultraviolet B (UVB) radiation converts it to vitamin D. This natural system works without worrying about how much vitamin D might be in a mother’s milk to be passed along to her infant. So why the problem?
Sun exposure is a key issue in vitamin D deficiency. Whereas our ancestors spent much of their lives in the sun, today we try to avoid such exposure for fear of skin cancer. If we go out in direct sunlight, we are cautioned to cover exposed skin with clothing and sunscreen to block those UVB rays that are otherwise helpful in vitamin D formation. Even adults who ignore these warnings are likely to take them quite seriously when it comes to protecting their infants. The result of this needed protection from harmful sun damage is an inadvertent disabling of the skin’s vitamin D manufacturer. It is not surprising, therefore, that vitamin D deficiency is rapidly increasing across the globe — in adults and children. Because we protect the infant from the sun, we have to make sure he gets the vitamin D he needs.

Can’t we just supplement the mother?

As the article points out, it is possible to increase the amount of vitamin D in human milk through supplementation of the mother. So why can’t we just ask her to take additional vitamin D? Vitamin D is fat-soluble vitamin, which makes toxicity an issue. Toxicity with water-soluble vitamins such as vitamin C is much less of a concern, because excess amounts are readily excreted in urine. The fat-soluble vitamins can collect and be more difficult to get rid of.
Whereas there are official recommended daily amounts of vitamin D for lactating mothers and women in general, we really don’t have enough solid research yet to know how much is too much, and how much would really be needed in order to provide enough vitamin D in human milk for a growing infant’s needs. Research is being conducted, and perhaps soon we’ll have a better solution for our breastfeeding infants. Until then, however, we are left with the reality that the infant requires vitamin D in larger amounts than is likely to come through his mother’s milk. We are also not sure of how much sun exposure is needed to provide the naturally forming vitamin D in the infant’s skin. This is further complicated by such things as latitude (and related sun exposure) and color of the skin (darker skinned people are more at risk for vitamin D deficiency because of the added protection from the sun’s harmful rays by that darker pigment).
We also know that there are serious consequences of a vitamin D deficiency, ranging from the commonly mentioned rickets, to more serious immunological disorders and cancer. Long-term effects of vitamin D deficiency — or even just insufficiency — are not well known at this time, and are not worth risking an infant’s long-term health to find out.

How do we help the mother who comes to us with a vitamin D question?

It is important that Leaders share appropriate information with mothers who ask if vitamin D supplementation is really necessary. There are a number of points that can be made:

• Human milk does not appear to have adequate amounts of vitamin D for a growing infant.

• This is not an indication that human milk is somehow inferior to a commercial formula that has adequate amounts of vitamin D already in it.

• It is our change in lifestyle that has necessitated vitamin D supplementation. Lack of adequate sun exposure is the direct culprit for this change — and the dangers of repeated sun exposure are well documented.

• The American Academy of Pediatrics now recommends that all infants and children should be supplemented with a minimum of 400 IU per day of vitamin D, beginning in the first few days of life.

• Adults also need to ensure adequate vitamin D intake. This is especially true for women who are pregnant or breastfeeding. Not only are they protecting themselves, but they are also helping to protect the growing fetus or infant.

• Vitamin D — either by itself or as part of a multi-vitamin supplement — is readily available and inexpensive in many areas.

• Mothers should dialogue with their health care professionals about appropriate vitamin D supplementation.

The Bottom Line

Human milk is still the standard for infant feeding. Further research may lead to new recommendations on vitamin D supplementation, but in the meantime, a mother should feel confident in continuing to breastfeed her child — while supplementing with vitamin D.

Page last edited 2009-10-25 23:24:08 UTC.

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