Ann Fam Med 2017;15:68-70. https://doi.org/10.1370/afm.2016.
Puja J. Umaretiya, MD1,3 Sara S. Oberhelman, MD2 Elizabeth W. Cozine, MD2 Julie A. Maxson, BA2 Stephanie M. Quigg2 Tom D. Thacher, MD2
1Mayo Medical School, Rochester, Minnesota
2Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
3Boston Children's Hospital, Boston, Massachusetts
Conflicts of interest: Dr Thacher is a consultant for Biomedical Systems, Inc, and has received a speaking honorarium from Sandoz. The other authors report none.
CORRESPOND1NG AUTHOR: Tom D. Thacher, MD Department of Family Medicine Mayo Clinic Rochester 200 First St SW Rochester, MN 55905 thacher.thomas at mayo.edu
Vitamin D supplementation (OR sunshine) is required for breastfed babies as there is extremly little vitamin D in most breastmilk
The following are MINIMUM IUs for healthy, full term babies and healthy, normal-weight mothers
The doses for the infant MUST increase as the infant weight increases
|Daily||or Weekly||or Monthly|
Daily dosing is better than weekly, which is much better than monthly
- Note: check for allergic reaction first (in infant or mother) with a small dose (say 1,000 IU) and wait for 3 days
- Note: If the mother did not already have a high level of vitamin D, it would normally take 2-4 months before there would be enough Vitamin D in her breastmilk to aid her infant
Recommend a loading dose of vitamin D for the mother = 50,000 IU daily for a week
See also VitaminDWiki
- Breastfeeding mothers and Vitamin D: supplement only themselves usually, 4 out of 10 used monthly rather than daily – Jan 2017
- 1900 IU provides some increase in Vitamin D in both mother and breast milk – Aug 2017
- Newborn Vitamin D - single dose is better than daily – RCT Sept 2016
- Monthly 120,000 IU of Vitamin D during lactation worked well - May 2016
- Breastfeeding mother getting 6400 IU of Vitamin D is similar to infant getting 400 IU – RCT Sept 2015
- Children getting 60,000 IU monthly got to vitamin D level of 33 ng – Sept 2015
- 800 IU vitamin D for infant and 2000 IU for mother is good, not great – RCT Dec 2013
- Nepalese infants who sunbathe, etc. have much higher levels of vitamin D than their mothers – Dec 2016
- 800 IU of vitamin D got most white Danish children to 20 nanograms – RCT Oct 2016
- Only 1 in 5 toddlers get recommended minimum vitamin D – Sept 2016
- Mother got 100,000 IU of vitamin D monthly, breastfeeding infant got a little – RCT Aug 2016
- Take vitamin D3 daily or weekly which has the following graph
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
596 items in the category Infant/Child See also
- breastfed 962 items as of Sept 2017
- "BIRTH DEFECTS" 172 items as of July 2016
- Stunting OR “low birth weight” OR LBW OR preemie OR preemies OR preterm 1940 items as of Oct 2018
- "SUDDEN INFANT DEATH" OR SIDS 177 items as of Nov 2018
- Overview of Rickets and Vitamin D
- Youth category listing has
145 items along with related searches
Daily vitamin D supplementation is recommended for breastfed infants, but alternative methods include enriching breast milk with vitamin D through maternal supplementation or intermittent high-dose vitamin D. We determined maternal preferences for vitamin D supplementation in 140 mothers with exclusively breastfed infants, and 44 who used both breast and formula milk. Only 101 (55%) supplemented their infants with vitamin D. One hundred sixty (88%) preferred supplementing themselves rather than their infants, and 102 (57%) preferred daily to monthly supplementation. Safety was most important in choosing a method of supplementation. Taking maternal preferences into consideration may improve adequate intakes of vitamin D in breastfed infants.
Vitamin D deficiency has become a global public health concern. Nutritional rickets is the most established consequence, and an increasing incidence of rickets has been observed in developed countries.1,2 In one study up to 18% of US children were vitamin D deficient, and 1% had severe deficiency.3
Breastfed infants are vulnerable to vitamin D deficiency because of the low concentration of vitamin D in breast milk. The American Academy of Pediatrics (AAP) recommends supplementation of breastfed, partially breastfed, and bottle-fed infants with vitamin D at 400 IU/d, beginning in the first few days of life.4 Adherence to this recommendation, however, is poor.5
Several studies have explored alternative methods of supplementation. Breast milk can be enriched with vitamin D through daily or intermittent high-dose maternal supplementation to meet infants' vitamin D requirements.6,7 Alternatively, oral vitamin D, 50,000 IU every 2 months, can be given to healthy infants with routine vaccinations to prevent vitamin D deficiency.8
Little is known about maternal preferences for different methods of vitamin D supplementation. Our aim was to assess maternal practices and preferences for vitamin D supplementation of their infants in primary care.
Mothers seeking care with infants for either 2-month or 4-month well- child visits were surveyed regarding vitamin D supplementation. Eligible mothers were aged 18 years and older, spoke English, and had an infant aged between 6 weeks and 5 months that was receiving primary care at Mayo Clinic in Rochester, Minnesota. Practices included 1 urban site, 2 suburban sites, and 1 rural site.
We collected data regarding infant feeding practices, vitamin D supplementation, and maternal preferences for the mode of vitamin D supplementation. Response options included either supplementation of the baby or mother with vitamin D and either daily or monthly high-dose
Table 1. Maternal and Infant Characteristics
(n = 184)
A total of 601 questionnaires were mailed, 438 nonrespondents were sent a second mailing, and 31 completed the survey during well-child visits. In all, 236 mothers completed the survey. We report results for the 140 mothers with exclusively breastfed infants and 44 who used both breast and formula milk. Characteristics of the mothers and their infants are shown in Table 1.
Of the mothers, 138 (76%) were taking a multivitamin with vitamin D. Only 101 (55%) had supplemented their infants with vitamin D in the preceding week (median 5 d/wk), and 77 infants (42%) vitamin D.
Table 2. Maternal Reasons for Not Supplementing Infants With Vitamin D
Mothers rated the importance of convenience, safety, being most natural, and cost in choosing between options for vitamin D supplementation.
The survey questionnaires were distributed to the mothers in the urban site in October 2013. Questionnaires were mailed to mothers at all 4 sites in November and December 2013. A second mailing was sent to nonrespondents 30 days later. The questionnaires had no patient-identifying information and included instructions not to complete it twice.
The Mayo Clinic Institution Review Board approved the study.
received the 400 IU recommended. The proportion of infants receiving supplementation did not vary by age (P = .46). A total of 134 (73%) reported that their clinician had recommended infant vitamin D supplementation, and these mothers were more likely to supplement their infants with vitamin D (OR = 8.3; 95% CI, 3.8-18). The 11 nonwhite mothers (4.9%) were more likely to supplement infants with vitamin D than white mothers (P = .04). Mothers rated ease of administering vitamin D supplementation as 4 on a scale of 1 to 5 (with 5 being easiest), but 6 of 105 respondents (5.7%) found administration burdensome (rated 1 or 2).
The great majority of breastfeeding mothers (88.4%) preferred supplementing themselves rather than their infants with vitamin D. Most expressed a desire for a daily supplementation (57%) compared with monthly supplementation. In rating the importance of factors informing their choices, mothers rated safety highest, and cost was rated lowest. First-time mothers and those who had additional children had similar preferences and value ratings.
Regarding reasons for not supplementing infants with vitamin D (Table 2), many mothers indicated lack of knowledge about supplementation, some believed that breast milk provided infants with adequate vitamin D, and others chose not to supplement because of inconvenience or their infant's apparent dislike of the supplement.
Less than one-half the infants in this study met the AAP recommendation for vitamin D supplementation of breastfed and bottle-fed infants. More mothers took a vitamin D supplement than provided their infants with a supplement, and a minority of breastfeeding mothers adequately supplemented their infants.
Most breastfeeding mothers preferred supplementing themselves rather than their infants, and most preferred daily rather than monthly supplementation. Advantages of maternal rather than infant supplementation include increased ease of administration, simultaneous mother and infant supplementation, and avoidance of potential toxicity to the infant from dosing errors.^
High-dose maternal vitamin D supplementation (4000-6400 IU/d or a single monthly dose of 150,000 IU) can sufficiently enrich breast milk in nursing mothers, preventing vitamin D deficiency in their infants without evident toxicity.6,7 Mothers take a prenatal vitamin after delivery, so additional vitamin D could be incorporated in the maternal supplementation routine.
Our findings are limited by our study population of predominantly white mothers and might not apply to populations that are nonwhite or at a greater risk of vitamin D deficiency. Additionally, mothers who completed the questionnaire may have practices and preferences that are different from those of nonrespondents.
Promotion of breastfeeding as a complete nutritional source could be facilitated by providing adequate maternal vitamin D supplementation to breastfeeding mothers. Maternal choice of mode of supplementation may help ensure adequate vitamin D status for infants.
To read or post commentaries in response to this article, see it online at http://www.annfammed.org/content/15M/68.
- Munns CF, Shaw N, Kiely M, et al. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab. 2016;101(2):394-415.
- Thacher TD, Fischer PR, Tebben PJ, et al. Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2013;88(2):176-183.
- Mansbach JM, Ginde AA, Camargo CA Jr. Serum 25-hydroxyvitamin D levels among US children aged 1 to 11 years: do children need more vitamin D? Pediatrics. 2009;124(5):1404-1410.
- Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-1152.
- Perrine CG, Sharma AJ, Jefferds ME, Serdula MK, Scanlon KS. Adherence to vitamin D recommendations among US infants. Pediatrics. 2010;125(4):627-632.
- Oberhelman SS, Meekins ME, Fischer PR, et al. Maternal vitamin D supplementation to improve the vitamin D status of breast-fed infants: a randomized controlled trial. Mayo Clin Proc. 2013;88(12): 1378-1387.
- Hollis BW, Wagner CL, Howard CR, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics. 2015;136(4):625-634.
- Shakiba M, Sadr S, Nefei Z, Mozaffari-Khosravi H, Lotfi MH, Bema- nian MH. Combination of bolus dose vitamin D with routine vaccination in infants: a randomised trial. Singapore Med J. 2010;51 (5): 440-445.
- Ketha H, Wadams H, Lteif A, Singh RJ. Iatrogenic vitamin D toxicity in an infant—a case report and review of literature. J Steroid Bio- chem Mol Biol. 2015;148:14-18.
- Barrueto F Jr, Wang-Flores HH, Howland MA, Hoffman RS, Nelson LS. Acute vitamin D intoxication in a child. Pediatrics. 2005;116(3): e453-e456.
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