Pediatrics. 2013 May;131(5):e1676-83. doi: 10.1542/peds.2013-0420. Epub 2013 Apr 29.
Abrams SA; Committee on Nutrition; Collaborators (6)
Bone health is a critical concern in managing preterm infants. Key nutrients of importance are calcium, vitamin D, and phosphorus. Although human milk is critical for the health of preterm infants, it is low in these nutrients relative to the needs of the infants during growth. Strategies should be in place to fortify human milk for preterm infants with birth weight <1800 to 2000 g and to ensure adequate mineral intake during hospitalization and after hospital discharge. Biochemical monitoring of very low birth weight infants should be performed during their hospitalization. Vitamin D should be provided at 200 to 400 IU/day both during hospitalization and after discharge from the hospital. Infants with radiologic evidence of rickets should have efforts made to maximize calcium and phosphorus intake by using available commercial products and, if needed, direct supplementation with these minerals.
TABLE 1 High-Risk Criteria for Rickets in Preterm Infants
Born at <27 weeks' gestation Birth weight <1000 g
Long-term parenteral nutrition (eg, >4 to 5 weeks)
Severe bronchopulmonary dysplasia with use of loop diuretics (eg, furosemide) and fluid restriction
Long-term steroid use
History of necrotizing enterocolitis
Failure to tolerate formulas or human milk fortifiers with high mineral content
PDF is attached at the bottom of this page
- Overview of Rickets and Vitamin D
- Calcium reduced some rickets in Nigerian children – Feb 2012
- Premature infants need 400 to 800 IU of vitamin D
- More Calcium absorbed from formula than breast milk, lacking vitamin D – Aug 2012
- Very short children were very low on vitamin D and Calcium – Aug 2010 stunting?
- Many preemies need at least 800 IU of vitamin D – RCT May 2013
- Low vitamin D pregnancy associated with both low birth weight and more weight in child later – July 2012
- Why higher levels of vitamin D reduces premature birth - April 2011
- Premature delivery associated with low vitamin D in Japanese women – Mar 2011
Infant-Child category starts with
- No consensus on MINIMUM International Units (IU) for healthy infant of normal weight
- 400 IU Vitamin D is no longer enough
Was OK in the past century, but D levels have been dropping for a great many reasons.
FDA doubled the vitamin D level in milk in July 2016
- No consensus: range is 600 to 1600 IU – based on many randomized controlled trials
- Fewer infants were vitamin D deficient when they got 800 IU – RCT Feb 2014
- 1600 IU was the conclusion of three JAMA studies
1000 IU recommended in France and Finland – 2013 - appears to be a good level
A recommended level may be agreed upon around the world by 2020
- 5X less mite allergy after add vitamin D
- Child bone fractures with low vitamin D were 55X more likely to need surgery
- 75 % of SIDS had low vitamin D
- Children stayed in ICU 3.5 days longer if low vitamin D – Dec 2015
- 5 out of 6 children who died in pediatric critical care unit had low vitamin D – May 2014
Having a good level of vitamin D cuts in half the amount of:
- Asthma, Chronic illness, Doctor visits, Allergies, infection
Respiratory Tract Infection, Growing pains, Bed wetting
Need even more IUs of vitamin D to get a good level if;
- Have little vitamin D: premie, twin, mother did not get much sun access
- Get little vitamin D: dark skin, little access to sun
- Vitamin D is consumed faster than normal due to sickness
- Older (need at least 100 IU/kilogram, far more if obese)
- Not get any vitamin D from formula (breast fed) or (fortified) milk
Note – formula does not even provide 400 IU of vitamin D daily
Infants-Children need Vitamin D
- Sun is great – well known for 1,000’s of years.
US govt (1934) even said infants should be out in the sun
- One country recommended 2,000 IU daily for decades – with no known problems
- As with adults, infants and children can have loading doses and rarely need tests
- Daily dose appears to be best, but monthly seems OK
- Vitamin D is typically given to infants in the form of drops
big difference in taste between brands
can also use water-soluable form of vitamin D in milk, food, juice,
- Infants have evolved to get a big boost of vitamin D immediately after birth
Colostrum has 3X more vitamin D than breast milk - provided the mother has any vitamin D to spare
- 100 IU per kg of infant July 2011, Poland etc.
More than 100 IU/kg is probably better
Getting Vitamin D into infants
Many infants reject vitamin D drops, even when put on nipple
I speculate that the rejection is due to one or more of: additives, taste, and oils.
Infants have a hard time digesting oils, 1999 1997 and palm oils W.A. Price 1 2 3
Coconut oil, such as in D-Drops, is digested by infants. 1, 2 3
Bio-Tech Pharmacal Vitamin D has NO additves, taste, oil
One capsule of 50,000 Bio-Tech Pharmacal Vitamin D could be stirred into monthly formula
this would result in ~1,600 IUs per day for infant, and higher dose with weight/age/formula consumption
- Vitamin D Council summary of the publication
For babies that weigh less than 1500 g (3.3 lbs), they should get biochemical testing for bone mineral status starting 4 to 5 weeks after birth. Babies that weigh over 1500 g do not necessarily need this testing.
If the babies’ serum alkaline phosphatase activity is greater than 800 IU/L to 1000 IU/L or the baby is getting fractures, they should receive radiographic evaluation for rickets and treated with calcium and phosphorus as necessary.
Preterm infants weighing less than 1800 to 2000 g (4.4 lbs) should receive human milk fortified with minerals or take formula specifically designed for preterm infants.
For preterm and very low birth weight infants that weigh less than 1500 g, they should get 200 to 400 IU of vitamin D/day.
For infants that weigh over 1500 g, they should get 400 IU/day. The maximum preterm and very low birth weight infants can get is 1000 IU/day.
When infants reach a body weight of greater than 1500 g, vitamin D intake should be around 400 IU. The maximum they can get is 1000 IU/day.
Infants with cholestasis, other malabsorptive disorders, or renal disease should be considered for special assessment, sometimes warranting 25(OH)D levels over 50 ng/ml.