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Mon, 6 Dec 2010 10:23:05 -0600
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Excellent analysis of the Vitamin D controversy.  I am APPALLED that this is discouraging people who are extremely deficient according to lab tests from taking remedial Vitamin D.  I can testify also that getting my own D levels up has given me my eyesight back!  And staved off my autoimmune disease.  I wonder who benefits from this preliminary report?  The dairy industry? 

-----Original Message-----
From: Lactation Information and Discussion [mailto:[log in to unmask]] On Behalf Of Diana Cassar-Uhl
Sent: Friday, December 03, 2010 2:43 AM
Subject: pushing the envelope on supplements/vitamin D for Susan

Hello Susan (and all),

First, I'd like to thank you for your outstanding guest post on Nancy Mohrbacher's blog on iron supplementation.  I've been sharing it far and wide and an so thankful for such a clearly stated, intelligent response to the nonsensical AAP recommendation on iron.

Now, I read your question about vitamin D more than 12 hours ago and have been itchy to give you some information ever since!  I will probably forget something so please feel free to ask me any questions you have.  Vitamin D supplementation has been a topic close to my heart (or should I say under my skin?  haha) for a few years now, so I have become very comfortable with this ongoing study regarding vitamin D supplementation in pregnant women:

Here is the link to the study description itself:
http://clinicaltrials.gov/ct2/show/NCT00292591

And here is one "readable" summary of the study and its preliminary
findings:
http://www.rxlist.com/script/main/art.asp?articlekey=116003

If you "Google around," you will find more by Dr. Carol Wagner, et.  
al.  It is all worth reading, as is the book version (Hale) that was released this year: "New Insights Into Vitamin D During Pregnancy, Lactation, and Early Infancy."

In short, vitamin D was historically believed to only be necessary for bone health.  More recently, researchers are discovering it does a whole lot more in our bodies and the intake/blood levels necessary for bone health are not adequate for meeting our other needs for vitamin D.
The problem/controversy, which was reflected in the IOM report on vitamin D DRI released this week, is that "there is not enough conclusive data" to connect intake and blood levels of vitamin D (or, conversely, vitamin D deficiency) with the prevention of (or development of) these other conditions.

However, what we do have is this:  we, as a population, are avoiding the sun, in an effort to prevent skin cancer.  As well, many of us live too far north for the sun's rays to be worth a whole lot most of the year.  I'll just say that we here in New York could strip down naked and go take an afternoon nap in the snow in February and not make vitamin D.  However, in July, 20 minutes, mostly uncovered, can result in 20,000 - 30,000 IU of vitamin D being produced.  (Or it might not, depending on various factors, but that's more than we need to discuss right here and now.)  Our levels of circulating 25-OH(D) are, in many, many cases, too low to prevent osteomalacia/bone loss ... but sometimes, high enough to protect our bones but too low to support these "other things" vitamin D is supposed to be involved in (but there's "not enough conclusive data" on).

As for being afraid of high levels of vitamin D, it is theoretically possible to supplement too much, but according to Wagner et. al. (who is citing, I believe Vieth?  I can dig for the reference if you want but hopefully I've pointed you in the right direction), doses of higher than 10,000 IU/day for extended periods would have to be taken in order to approach toxicity.

Babies are being born to mothers who are, themselves deficient in vitamin D.  That's why our milk doesn't confer the 400 IU recommended for daily intake for infants (which is based on the level necessary to prevent rickets).  The work referenced above found that maternal supplementation of 4000 IU/day  during pregnancy (which you probably recognize as the newly released "upper limit"), followed by 6400 IU/ day during lactation (uh oh!  That's more than the government says we're supposed to take!!) is necessary to put 400 IU/day into our babies, based on average volume of milk consumed, maternal supplement amounts corresponding to vitamin D levels in the milk ... it also considers that, for a mother's milk to be replete in vitamin D, the level of circulating 25-OH(D) in her blood needs to be nearly twice the currently accepted (but still debated) target value for sufficiency, which is 32 ng/mL (if you google around, you'll note that many doctors and others suggest 40 as a minimum, a study of male surfers living in Hawaii found that their (unsupplemented) levels ranged in the mid-50's to the low 60's ... suggestive that we should all be where humans outdoors near the equator are?).  A mother's level would need to be >50 in order for her milk to provide the necessary D for her baby.

Now, delving a bit further, we learn that it takes months to bring a level of vitamin D up in a body.  It could take even longer if the  
body has any absorption issues (known or unknown) or other factors.   
These are months of exclusive breastfeeding (we hope!).  Therefore, the recommendation, bearing in mind that most mothers definitely do not have the levels of vitamin D in their bodies to adequately fortify their milk to meet the needs of their babies, is to supplement the babies, beginning within the first few days of birth.

A mother can and should request a vitamin D check; perhaps she's a lifeguard in Florida and has enough vitamin D ... she can decide not to supplement her baby.  Or perhaps her level is higher than average, but not terrific ... that mother may decide to offer a supplement every other day or a few times a week, based on what she knows about her own body.

As for the supplements themselves, they're available in D-only preparations, as drops.  One drop offers the 400 IU.  It can be placed on the mother's nipple before baby latches on to nurse, or it can be given directly to baby but yes, care must be taken to give only the drop, not more because it is so concentrated.  Parents have to request the D-only and be counseled to avoid the Tri-Vi or Poly-Vi preparations out there, because those contain vitamins that can  
interfere with the absorption of nutrients from mother's milk.   
Doctors who have been prescribing the multi-vitamin preparations and are therefore familiar and comfortable with them also need to be educated about the D-only supplements.

While I stand to gain absolutely nothing from vitamin D advocacy, I have taken it on as a personal mission because I've seen the difference it makes in my own life.  My mother, at the time of her diagnosis of breast cancer, had an immeasurably low level of 25-OH(D) and her oncologist immediately began supplementing her with 50,000 IU twice weekly, then once weekly, then bi-weekly, now she takes it once a month.  (One connection for which there's "not enough conclusive data" is that between vitamin D and breast cancer.  As the daughter of a survivor, allow me to state that I'm not taking any chances by waiting for a government agency to accept what other studies have
established.)  Correcting a vitamin D deficiency in my own body has been a major part of the improved health and well-being I've experienced in 2010 (the other major factor being identification and management of a gluten intolerance ... which was contributing to the vitamin D deficiency).  I am currently taking, with a doctor's approval and monitoring, 7000 IU/day.  My children are 8, 6, and
(almost) 3; the youngest still nurses 2-3 times a day and I think she's the only one who got any vitamin D at all from me.  I didn't supplement them as babies at all, because I believed my milk provided everything.  Now I understand that my milk does provide everything when I'm living as I was created to live ... but I'm clearly not doing that!  I'm thankful our bodies adapt and so much does come out fine even under less than perfect circumstances (for example, the nutritional heft of the milk of a severely malnourished mother is far superior to what one might expect ... miraculous!) but I am learning that, in the case of vitamin D, a lot of work needs to be done.  I believe we (public health we) should be targeting the mothers and supplementing us adults, but until the medical profession accepts this, we're lagging severely behind and cheating our babies.

I understand I've cited the body of work (please, google to find everything, or better yet, find the book) of exactly ONE research group, but to me, the studies themselves are so well-done and indisputable, I feel very comfortable passing along the information that has been reported from them.

I hope this helps and if you have any questions, I'd be delighted to try and answer them for you.  Like I mentioned, I've spent nearly 2 years living with this information and I've experienced firsthand the effects of replenishing a vitamin D deficiency, and I'm outraged by the IOM report from earlier this week.

Diana Cassar-Uhl, IBCLC and LLLL in upstate NY (studying for GRE and applying to MPH programs when I'm not being mamma, helping mammas, or playing clarinet)

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