I had all intentions on posting about Sleep Training this week. But, as I was feeding Jia her pumpkin puree and held her vitamin D dropper over her spoon to deliver her daily dose of D3 (400 International Units), I remembered a few months ago when one of my friends Natasha asked Facebook for opinions on Vitamin D supplementation for an exclusively breastfed baby. Her holdup was that her first child (non-supplemented) is perfectly healthy and that her breastmilk should be nutritionally complete. I commented back, citing the AAP (here and here) and CDC‘s recommendations supporting vitamin D supplementation. On the other hand, one of my old coworkers Katie made a very good point: her breastmilk should be complete in providing all the vitamins and minerals baby needs, without supplementation.
I continued to give Jia her daily drop of Carlson’s Baby D 400 IU of Vitamin D3 (cholecalciferol) plainly because it’s what our pediatrician instructed us to do, and if the CDC and AAP recommended it, that’s what I would continue to do. I guess you could say I was being a lazy nurse-mom and didn’t do my own thorough research to hear the arguments on both sides.
However, yesterday (pumpkin day) a different feeling overcame me. As we are in the start of flu season (September through March), I started to consider the following: treating a sick baby really only consists of humidified air, fluids, rest, and sometimes Tylenol or Motrin (if baby’s fever is significant enough). Excess medications can unnecessarily do more harm than good on an underdeveloped baby’s system, causing more problems than there were to begin with.
Just last week, I’d purchased a Vicks Warm Mist Humidifier after Jeff started to have mild symptoms of a cold, just in case Jia started to show signs of sickness. It has a little medication reservoir for VapoSteam (from Vicks), but what piqued my interest was reading many parents’ recommendation to place an essential oil-soaked a cotton ball in the reservoir for symptomatic relief in their babies. After I thought about the whole baby-getting-sick plan, I contacted Katie about essential oils for guarding against sickness for Jia. The use of oils is much safer and is even evidence-based to reduce the effects of viral infections, like from the flu.
So these scenarios begged the question:
Why use (unnecessary) medications – even vitamin supplementation – if we can keep Jia happy and healthy without?
Now, don’t get me wrong. I’m 100% on board with vaccinating children, I consider myself a pretty good nurse with a decent amount of common sense. But, I also see benefit in non-medicinal remedies to reduce the need for medications.
Getting back to the subject…
So back to Vitamin D. The main reason the CDC and AAP recommends Vitamin D supplementation in all babies – breastfed and formula fed – is because infants, specifically those less than 6 months old, are unlikely getting an adequate dose sunlight to make Vitamin D (your baby isn’t laying out by the pool, golfing, or hitting the tanning beds) and neither breastmilk nor formula meets baby’s Vitamin D needs (though there is more Vit D in formula than breastmilk). The AAP recommends no direct UV sunlight during the first 6 months of life, due to damaging effects on very sensitive skin. Vitamin D stores, passed on from when baby was in utero, also eventually deplete. Therefore, supplementation is recommended.
Breastfed babies, though receiving an endless list of benefits from human milk, are missing out on adequate Vitamin D. Even formula fed babies are missing out, until they are drinking more than 1 liter per day. Mayo Clinic states that Vitamin D is necessary for the absorption of calcium and phosphorous to build strong bones. Therefore, they recommend that in order to prevent the (albeit rare) onset of Nutritional Rickets (soft bones due to low bone-growing calcium and phosphorous), to supplement baby with 400 IU per day. The CDC reports a <2% risk of Vitamin D deficiency in children aged 1-11 (source), with an estimated 5 cases per 1 million children six months to 5 years old in 2006 (source). After your baby is drinking 1 liter (1000 mL, which is about 34 ounces) of breastmilk or formula and has a diet that consists of fatty fish, eggs, and fortified foods (like cereals, milk, and OJ), Vitamin D supplementation is no longer necessary. Remember – solids should be started after baby is 4-6 months of age, and eggs/milk/juices should not be consumed before 1 year of age! More about introducing solid foods here.
What about Mom’s D?
Mom’s intake of Vitamin D also has an influence in the amount passed through breastmilk (Source). Postpartum, breastfeeding moms are usually directed to continue their prenatal vitamin (mine has 100% the Daily Value of Vitamin D3, which is 400 IU).
So, I Click Clack Moo’d my way to scholar.google.com again to find some research sources to help make me make the decision on whether to keep supplementing or stop. Interestingly, I found a randomized control study published in 2013 by the Mayo Clinic, that tested serum (blood) levels of Vitamin D in exclusively breastfed babies whose moms supplemented with daily 5,000 IU vitamin D per day for 28 days versus moms who took one high 150,000 IU vitamin D.
I’ll spare you the details of the study, but basically the babies at the start of the study were mostly (66%) deficient of Vitamin D, breastfed alone (you can read the study to see how old the babies were, what their serum D levels were, etc). Both methods: taking the one mega dose (150,000 IU) of Vitamin D or the daily dose (5,000 IU) of Vitamin D provided the baby with a good enough serum level of Vitamin D through breastmilk. The breastmilk that was tested also had enough Vitamin D. However, they found that the daily dose group of moms had problems with actually taking the dose every day. Maybe they needed a phone alarm…?
KellyMom cites articles which conclude that a (breastfeeding) maternal intake of 4000 IU is as sufficient as 400 IU given to baby.
The Tolerable Upper Intake Level (UL) of Vitamin D for adults is 4000 IU per day. The UL is a dose amount that has been defined by the USDA as the “highest dose of a nutrient that is likely to pose no risk of adverse health effects to almost all individuals in the general population.” If you exceed this upper limit dose, the potential for adverse effects increases. The study from Mayo Clinic gave moms doses of 150,000 IU and 5,000 IU. That’s way above the UL!! Yikes!
My conclusion:
So basically, either mom needs to super supplement with an insane amount (possibly dangerous) of Vitamin D or baby needs a normal dose of liquid Vitamin D that can be found in a dropper. The 100% Daily Value of Vitamin D for adults and babies is 400 IU. Vitamin D is a fat-soluble vitamin (along with Vitamin A, E, K), which means it gets stored in the fat tissue and does not just leave the body easily like water-soluble vitamins (like vitamin C). This means that if you take way more than you’re supposed to, you run the risk of problems with the build-up in your body.
So, with understanding that my prenatal/lactating mom’s multi-vitamin is packed with a conservative 400 IU of Vitamin D3 and that in order for Jia to get a “sufficient dose” I would have to supplement my own diet with a potentially dangerous amount of a fat-soluble vitamin, I personally will continue to give Jia her Carlson’s drop. To me, even though she is most likely not going to wind up with a rare condition being breastfed and supplementing with solid foods, what’s giving one drop?
My Message to Parents on the Fence:
Chances are, if you choose not to give your baby Vitamin D drops, your baby won’t develop Nutritional Rickets. With an estimated 5 cases per 1 million children, that’s a 0.000005% chance! Even if the CDC was off on their estimate, chances are near-rockbottom.
Making sure your baby has an adequate blood level of Vitamin D will help their bones grow strong and dense so they aren’t prone to fracturing and breaking. In my opinion, this is probably something more parents of boys have on their minds!
Symptoms of rickets (source) include:
- Bone Pain
- Decreased muscle tone (calcium affects muscle contractions) or muscle cramps
- Cavities or poor teeth
- Delayed formation of teeth
- Impaired growth
- Increased bone fractures
- Skeletal deformities (like bowed legs, bumps in the rib cage, pigeon chest where the rib cage is pushed forward, spinal problems like kyphosis – hunched back, or scoliosis)
- Short stature
If you have a family history of any hereditary disorder affecting bone health (such as but not limited to osteoporosis, rickets, osteomalacia, osteopenia) or GI disorders that affect absorption of fat soluble vitamins or minerals (such as but not limited to kidney disease, celiac disease, or any malabsorption issue) you can always ask your pediatrician to run a “serum calcium” test on a blood sample from your baby. According to MedlinePlus, if bones are still growing and baby is D deficient, it’s definitely possible to replenish baby’s nutritional stores with the help of your pediatrician.
Infants can and do develop rickets, but by the time baby is 1 year old, fortified foods become a larger component of their diet. Whatever you decide, just make sure you make an informed decision. Talk to your pediatrician about your concerns and be proactive in your baby’s health!
Interesting Note: When I started this post, I thought I was going to find evidence that would convince me to stop giving Jia her Vitamin D drops.
Next Week’s Topic: Sprouting a Tooth – Teething & Dental Care
Sources:
American Academy of Pediatrics on Vitamin D Supplementation for Infants: http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Vitamin-D-Supplementation-for-Infants.aspx and http://www.healthychildren.org/English/healthy-living/nutrition/Pages/Vitamin-D-On-the-Double.aspx
Centers for Disease Control and Prevention – Vitamin D Supplementation for Infants: http://www.cdc.gov/breastfeeding/recommendations/vitamin_d.htm
Mayo Clinic: Vitamin D For Babies: Are Supplements Needed? http://www.mayoclinic.org/healthy-living/infant-and-toddler-health/expert-answers/vitamin-d-for-babies/faq-20058161
CDC Nutrition Report on Fat Soluble Vitamins & Nutrients: http://www.cdc.gov/nutritionreport/pdf/Fat.pdf
Kelly Mom – Does my Baby Need Vitamins? http://kellymom.com/nutrition/vitamins/vitamins/
Maternal Vitamin D Supplementation to Improve the Vitamin D Status of Breast-fed Infants: A Randomized Controlled Trial. Mayo Clinic Proceedings. Oberhelman S., Meekins M., Fischer P., Lee R., et al. 2013, 88(12): 1378-1387. (Link: http://ac.els-cdn.com/S0025619613008318/1-s2.0-S0025619613008318-main.pdf?_tid=2af2bfce-4fe2-11e4-868f-00000aab0f26&acdnat=1412879533_d2c17d5c715984dbb3d8ec9b68ff9a69)
USDA Interactive DRI Glossary, Upper Limit: http://fnic.nal.usda.gov/interactive-dri-glossary#ul
Rickets: Not a Disease of the Past. Nield, L., Mahajan, P. Joshi, A., Kamat, D. American Family Physician. Aug 15 2006. 74(4): 619-626. (link: http://www.aafp.org/afp/2006/0815/p619.html)
MedlinePlus Medical Encyclopedia: Rickets. http://www.nlm.nih.gov/medlineplus/ency/article/000344.htm