Vitamin D Supplementation

The American Academy of Pediatrics is now recommending that all children receive vitamin D supplementation to prevent rickets.  

What is Vitamin D?    

Vitamin D isn't really a vitamin. Vitamins cannot be synthesized in the body and therefore need to be found in the diet. But  Vitamin D is formed through interaction of sunlight with skin, so it is better classified as a hormone.  It is a hormone necessary for bone strength and growth and it's a potent immune system modulator.  Insufficiency of vitamin D has been associated with a number of auto-immune disorders, including rheumatoid arthritis and multiple sclerosis.  And here in the Midwest, we are all likely to be a bit insufficient.

Rickets: Vitamin D deficiency

The deficiency of vitamin D shows up as a bone disease called rickets.  Rickets was very common in the United States in the early part of the 20th century, with weak bones, seizures and death being all too common until experiments showed that deficiency of vitamin D was the cause and fortification of milk was started.

Other symptoms of rickets include bowed legs in toddlers, small stature, bone pain and delayed walking.  The disease can be diagnosed with x-rays and blood tests but can occur before symptoms are visible on a physical examination.

What are the Risk Factors for Vitamin D Deficiency?

Children can be deficient in vitamin D if they have inadequate stores of it, or if they have inadequate exposure to sunlight.

Children who are most likely to have inadequate stores are those who were born prematurely, or those born to mothers with low stores of vitamin D (usually because of poor nutrition) at the time of delivery.

The rest of us are in the category of inadequate exposure to sunlight. We aren't in the sun much, especially for those of us in colder climates.  And when we are in the sun, we are covered by clothes, or sunscreen. We should never be exposed to sun without sunscreen, but sunscreens markedly depress vitamin D production in skin. And the darker your skin color, the less vitamin D you make from sunshine. 

Why Do We Need a Supplement ?

No mammalian milk contains the level of vitamin D that sunlight provides. Cow's milk from the grocery store, and formula are all fortified with vitamin D.  

Breastmilk has a very specific recipe, designed over many hundreds of years to provide exactly what nutrients, vitamins and  infection protection infants need. Breastmilk was never expected to provide more than a slight supplement to the sun. So adequate sunshine is necessary to complement breastfeeding.  

But we should be avoiding direct sunlight exposure because of the risk of skin cancer. Since the rates of exclusive breastfeeding for longer periods of time have risen in the United States,  the CDC has confirmed more cases of rickets.  Rickets can be prevented with vitamin D supplements.

Is There Something Wrong with Breastmilk?

The vitamin D problem we are addressing is not a breastmilk problem, it is a sunlight exposure problem.  This recommendation affects mostly breastfed children because formula and cow's milk is already fortified with vitamin D.  

Recommendations for Supplementation

Since we can't identify all the children at risk for rickets, we are recommending that all children start fortification with vitamin D within 2 months of age, the age at which the baby's stores of vitamin D from mom are depleted.  Universal supplementation of all infants with vitamin D is safe and of proven effectiveness. 

All children should receive 400 units daily, an amount found in over the counter liquid multivitamins, starting at birth.

Children and adolescents who do not take at least 17 ounces of vitamin D fortified milk should also receive a supplement.

Supplementation should continue through childhood and adolescence.

New....Don't want to give your breastfeeding baby the vitamins because they taste like vomit?-- state of the art research

Fantastically cool research is coming out that supplementing mom will help both mom and baby achieve normal Vitamin D levels.  In fact, all the above info and the policy statement from the AAP is being revised because of these studies,  We are likely to see a recommendation that mom can safely take as much as 6400IU (!) of Vitamin D and bring her own stores up and increase the levels in breastmilk.  Those of us here in sometimes-sunny Wisconsin are likely to be vitamin D insufficient and maternal supplementation sounds like the best answer to me.  My opinion is strongly in favor of supplementing the nursing mom (and even those not nursing.)  1000 IU tablets can be found over the counter-- I just found them at Sam's Club and Pick n Save and I wasn't even looking that hard!

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updated May 17, 2008