Hi Laura and fellow Lactnetters,
I would suggest checking out the website for the Vitamin D council
http://www.vitamindcouncil.org. This month's newsletter is focused on
Vitamin D in pediatrics, so you may want to take a look at that too.
I am in the (slow) process of reviewing the latest Vitamin D studies as well
as the recommendations put out by the Vitamin D council, so here is what I
have learned so far by reading reviews (not the actual studies themselves)
and by discussing with other dietitians.
The vitamin D council emphasizes the importance of testing for deficiency.
After checking with some colleagues, the test appears to be covered by
insurance companies in the USA. They, however, do have recommendations on
supplementation if one decides not to go that route. They also state that if
the mother is not deficient in VitD, then the amount in breastmilk is
adequate. What they observe, though is that the common use of sunscreens as
well as the lack of sunlight exposure in certain climates limit vitamin D
production in the skin. They claim that 10-15 minutes of sun exposure can
produce plenty of VitD, but skin color and age also are important variables.
Therefore, they have recommendations for supplementation that is much higher
than AAP or the National Academy of Sciences. They claim that the high doses
will not cause toxicity. The Council also states that vit D deficiency can
be secondary causes of many chronic and acute diseases. Another thing they
state is that Vitamin A supplementation can be toxic(given it's in the
retinol form, not its precursor like Beta Carotene) and can interfere with
vitamin D metabolism. Which would make them contraindicate the vi-sol
supplements commonly prescribed.
I suspect that the AAP statement on Vitamin D was made in response to some
cases of rickets in breastfed babies and this was more of a public
health-type response, i.e. submitting a guideline that will work for an
entire population as a preventive measure, instead of doing any screening
such as vitamin D testing. Generally, recommendations are made for
populations, not subgroups, so that is why there was the general
recommendation to prescribe a multivitamin to breastfed infants. It is
really up to the practitioner to make the proper judgement for their
patient. They also went by the dietary reference intake amounts put out by
the National Academy of Sciences. Recent evidence appears that the NAS
recommendations are insufficient and outdated. As it appears there is a
greater body of evidence supporting higher doses (as well as its safety) in
addition to widespread VitD deficiency (though not as severe as rickets),
that would be the motivating factor of increasing the supplementation. Also,
it appears that the AAP is not willing to promote sun exposure due to the
concern and evidence toward skin cancer. So the safest route for them is
supplementation.
I have yet to get my hands on this article and read it myself, but August's
edition of Pediatrics has an article called Vitamin D Deficiency in Children
and Its Management: Review of Current Knowledge and Recommendations.
(Pediatrics; Aug2008, Vol. 122 Issue 2, p398-417, 20p, 8 charts, 2
diagrams). I am interested in learning what this article says. If anyone has
read it please share your insights.
So given what I have learned so far, I have come to these initial
conclusions:
- Vitamin D in breastmilk is adequate if the mother has adequate vitamin
D levels.
- Breastfed babies should only supplement if tests show they are
sufficient in Vitamin D
- People who live in certain areas where there is little sun to skin
exposure during the winter, should consider screening or supplementation.
Checking vitamin D levels first would be advisable, as well as follow up.
Oh and then there is the whole issue of the proper vitamin D test
(screening) and the proper supplements...)
My thoughts are not yet set in stone. I have definitely not critically
reviewed all the studies out there like the AAP and other groups have. And
I'd like to add that I am not a huge proponent of supplementation in
general. However, I do think there is a place for it and as evidence appears
to support it, I will consider it as well. I hope others on this list can
contribute so that we can provide the best care.
All the best,
Renata Mangrum, MPH, RD.
http://nurturingnotes.blogspot.com
http://infantfeedinghistory.blogspot.com
http://www.linkedin.com/in/renatamangrum
On Mon, Oct 13, 2008 at 8:21 AM, Laura Miller, RN <[log in to unmask]>wrote:
> First, I'd like to just introduce myself. I am an RN in CT and pursueing
> my
> IBCLC in 2009. I am very interested in PP and hope to gain some insight
> from
> the group. Looking forward to discussions.
>
> This morning on the Today Show, NBC, there was a segment about new
> recommendations to supplement not only breastfeeding infants, but toddlers
> and older children with 400iu of VitD daily.
>
> This has been a long time discussion for me. In my studies I was been
> taught
> to encourage women to get outside and expose their' babies to the sun. I
> was taught that with adequate exposure, babies do not need supplement and
> that giving the supplement was implying to the mother that somehow her
> breastmilk was not adequate. I was always confused by the AAP position on
> supplementing. I really researched and found that yes, the synthesis of
> Vitamin D exposure would be adequate allowing their' location in respect to
> the equator, season they are born, etc. I am still confused. I also found
> in
> some studies that women who are already taking a prenatal vitamin while
> breastfeeding have increased amount of VitD than women who are not, so this
> is the information I give to my patients.
>
> Many of the local pediatricians put their' babies on Trivisol, which is
> full of
> everything, not just VitD. My recommendations for mothers it to continue
> taking prenatal vitamins and be sure to expose their' infants to at least
> 30
> minutes of direct sunlight daily, in warm months, on a blanket, in a
> diaper. I
> also give them articles to forward to their' pediatrician for discussion.
>
> What are your recommendations? Should babies be supplemented? I'm
> getting mixed opinions from IBCLC's around the world.
>
> Thank you,
> Laura Miller, RN
>
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