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Subject:
From:
Emily Haessler <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Wed, 2 Apr 2003 09:02:04 -0500
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Can't we all agree to call it that:  a sunlight deficiency not a breastmilk
deficiency! Why not recommend banning the "baby buckets" to prevent it!

-----Original Message-----
From: Cynthia Good Mojab [mailto:[log in to unmask]]
Sent: Tuesday, April 01, 2003 5:46 PM
To: [log in to unmask]
Subject: Vitamin D supplementation, sunlight deficiency, and
breastfeeding (long)


Dear colleagues:

I am glad to see vitamin D supplementation of breastfed infants being
discussed here on Lactnet. It is an issue I have been studying for over two
years. Anyone with questions on this issue is likely to find relevant
research in my two articles:

Good Mojab, C. Sunlight deficiency: A review of the literature. Mothering.
March-April 2003; 117:52-55; 57-63.
Good Mojab, C. Sunlight deficiency and breastfeeding. Breastfeeding
Abstracts. 2002; 22(1):3-4.

Here are some replies to some of the general questions/comments made on the
topic so far:

1. How much sunlight exposure is needed to prevent vitamin D deficiency in
breastfed infants?

The amount of sunlight exposure needed to prevent vitamin D deficiency
depends on such factors as skin pigmentation, latitude, degree of skin
exposure, season, time of day, amount of pollution, degree of use of
sunscreen, altitude, weather, the vitamin D status of the lactating mother,
and the current status of vitamin D stores in the infant's body.
Recommendations do and should, therefore, vary around the world, taking
into account local conditions and practices.

"The skin has a large capacity to produce vitamin D. Exposure of the entire
adult body to the smallest amount of UVB radiation that produces transient,
just perceptible skin reddening is comparable to taking an oral dose of
10,000 to 25,000 IU of vitamin D. 8,9 Therefore, sufficient levels of
vitamin D can be developed from partial exposure of the body to sunlight
well before sunburn occurs." (Good Mojab 2003)

"Exclusively breastfed Caucasian infants under six months of age (39 N;
Cincinnati, Ohio) are expect to achieve adequate vitamin D status when
exposed to sunlight for 30 minutes per week (diaper only) or two hours per
week (fully clothed without a hat). 34 The sunlight exposure of darkly
pigmented infants is poorly understood. 35 Studies of the influence of skin
pigmentation on the cutaneous production of vitamin D in adults have shown
conflicting results. 36, 37 However, a study by Brazerol and colleagues
showed that darkly and lightly pigmented adults were equally capable of
producing vitamin D when episodes of UVB exposure occurred periodically
over time (biweekly for six weeks in their study).38" (Good Mojab 2003)

"There is no global consensus on whether or how to screen infants,
children, or pregnant women for vitamin D deficiency or on how to best
prevent vitamin D deficiency in breastfed infants and children.
Recommendations for preventing vitamin D deficiency in breastfed infants
include universal supplementation, supplementation of at-risk breastfed
infants, and habitual small doses of sunshine; some regions with plentiful
sunshine have not yet developed recommendations.28, 29, 30, 31, 32...The
determination of the exact amount of regular, brief, and nonerythemal
sunlight exposure needed just to produce sufficient vitamin D in specific
infants and children depends on many factors." (Good Mojab 2002)

2. What is the prevalence of rickets among breastfed infants?

"There are currently no national data on the prevalence of rickets in the
US,77 though case reports and descriptive studies clearly indicate that
rickets is not a disease of the past....Rickets in breastfed infants has
been documented among at-risk populations in northern Europe, North
America, and former Soviet countries since the 1970s.78 In some developing
countries it remains a serious health problem.79-82 Overt rickets is more
common in children 6 to 36 months of age than in infants under 6 months of
age.83-86 Findings of bone deformities suggestive of rickets are very rare
in full-term or premature neonates.87" (Good Mojab 2003)

3. Is breastmilk deficient in vitamin D?

No. This point of view is a cultural artifact. Just the phrase "vitamin D
deficiency" illustrates how much we have missed the point, as "vitamin D"
was misclassified as a vitamin and subsequently found to be a hormone that
 is not contained in most foods. What we are really talking about is
sunlight deficiency.

"Vitamin D is actually not a vitamin at all, but a steroid hormone produced
in the body after direct exposure of the skin to ultraviolet B (UVB)
radiation in sunlight." (Good Mojab 2003)

"The direct, casual exposure of skin to sunlight is the most common and the
biologically normal way that human beings attain sufficient levels of
vitamin D...Because only a few foods naturally contain significant levels
of vitamin D (e.g., the oils and livers of some fatty fish), it would be
unusual for people to obtain adequate vitamin D from diet alone without
supplementation or enrichment.7"(Good Mojab 2003)

"The natural sources of vitamin D for nurslings are primarily the stores
they develop prenatally (for newborns) and the vitamin D they produce with
exposure of their skin to sunlight; a smaller additional contribution is
from human milk.15, 16 The concentration of fat-soluble vitamin D in human
milk varies from 5 to 136 IU/L, depending on how is activity is measured
and on maternal vitamin D status during lactation.17-19 This concentration
provides less than the 200 to 400 IU per day commonly recommended for
infants under one year of age.20 However, human milk shouldn't be
considered 'deficient' in vitamin D, because the biologically normal means
of obtaining sufficient vitamin D in humans is via sunlight exposure, not
diet.21-23" (Good Mojab 2003)

4. Is the statement "Exclusively breastfed infants are at increased risk of
vitamin D deficiency and rickets. This is because human milk contains only
small amounts of vitamin D, insufficient to prevent rickets." accurate?

No. It is as inaccurate as saying something like: "breathing increases the
risk of lung cancer." While statistically true (people who don't breathe
are not going to die of lung cancer), it fails to acknowledge that certain
things are happening *while breathing* that increase the incidence of lung
cancer: the inhalation of cigarette smoke to be specific. Breathing is
biologically normal. Intentionally and repeatedly breathing cigarette smoke
is not. Breastfeeding is biologically normal. Inadequate sun exposure is
not. Exclusively breastfed infants who are inadequately exposed to sunlight
are at increased risk of vitamin D deficiency and rickets. Exclusively
breastfed infants who are adequately exposed to sunlight are not at
increased risk of vitamin D deficiency and rickets. Sunlight deficiency, a
biologically abnormal situation, is the problem.

"Anyone with inadequate exposure to UVB radiation in sunlight is at risk
for vitamin D deficiency. Risk factors for nurslings and their mothers
overlap and interact. They include indoor confinement during the day (e.g.,
due to exclusively indoor daycare, unsafe neighborhoods, custom),39 living
at higher latitudes (essentially no vitamin D is produced with sun exposure
from November to February in Boston [42 N] and from mid-October to
mid-April in Edmonton, Canada [52 N],40, 41 darker skin pigmentation, 42-45
sunscreen use,49-51 seasonal variations resulting in less ultraviolet
radiation (e.g., late winter and early spring in the Northern
Hemisphere),52, 53 covering much or all of the body when outside (e.g., due
to custom, fear of skin cancer, cold climate),54-57 increased birth order
(e.g., a mother's sixth child has a higher risk of vitamin D deficiency
than does her first child), 58-59 the replacement of human milk with foods
low in calcium, 60-64 the replacement of human milk with foods that reduce
calcium absorption (e.g., grains and some green leaves containing phylates,
oxalates, tannates, and phosphates; cereals grown in soil high in
strontium), 65-67 and exposure to lead (due to lead's inhibition of vitamin
D synthesis).68,69" (Good Mojab 2003)

"...sunlight exposure for many people around the world has been reduced by
industrialization, urbanization, migration, concern about skin cancer, and
social inequities." (Good Mojab 2003)

5. Does the water soluble form of vitamin D prevent rickets?

No, the water soluble form of vitamin D has not been shown to have
antirachitic activity. It certainly has some other biochemical role, but it
does not prevent vitamin D deficiency or rickets.

6. How long do a neonates prenatal stores of vitamin D last without
exposure to sunlight?

"The neonate's stores of vitamin D depend on maternal vitamin D status
during pregnancy.24, 25 A study of exclusively breastfed infants in
Tampere, Finland (61 N), in winter showed that, without UVB exposure or
vitamin D supplementation, vitamin D stores of fetal origin were depleted
by eight weeks of age.26 Although vitamin D-depleted infants had serum
levels at which rickets can occur, none had active or biochemical rickets."
(Good Mojab 2003)

Let me be clear that 1) prophylactic vitamin D supplementation is
demonstrably useful for infants who are at risk of vitamin D deficiency and
2) no known risks of supplementation exist with 200 to 400 IU per day.
Still, I believe that there is a great potential for harm from
recommendations that all US breastfed infants be supplemented with vitamin
D when only some are at risk, not the least is via the marketing of vitamin
supplements produced by formula companies who violate the WHO/UNICEF
International Code of Marketing of Breast-milk Substitutes. In addition...

"Many potential risks of vitamin D supplementation, however, haven't been
investigated. No one knows whether vitamin D supplementation has any
deleterious physiological effects on the infant, such as aspiration when
supplementation is not tolerated, harmful alterations of the infant gut, or
increased risks of infection.99...In addition, the effects of a universal
recommendation of vitamin D supplementation on breastfeeding beliefs and
behaviors (e.g., use of other supplements, premature introduction of other
foods, weaning) have not been studied....If mothers--or other
caregivers--see no difference between vitamin drops and other
supplementation or believe that human milk is inadequate because
supplements are recommended for all breastfed infants, then recommendations
of universal supplementation could indirectly serve to increase the risk of
illness and disease for many infants, including those not at risk for
vitamin D deficiency." (Good Mojab 2003)

"When rickets occurs in breastfed infants, it indicates that something is
very wrong with the context in which breastfeeding is happening, not with
breastfeeding itself. Social and environmental problems in that context
warrant assessment, further research, and amelioration. Breastfeeding is
the foundation of normal health and development, the original paradigm for
nourishing and nurturing young human beings. Health policies and healthcare
systems must first and foremost protect breastfeeding. Otherwise, they will
ultimately serve to undermine the health they seek to enhance." (Good Mojab
2003)


Mothers are going to have questions like never before about vitamin D and
breastfeeding. They deserve the chance to make an informed decision
suitable for their particular situation. Unfortunately, I can't type the
entirety of these two articles, much less the citations of all the
references I used, into a Lactnet post! So, if you've got questions, make
friends with your local reference librarian and ask her to get you copies.
As always, I welcome feedback.

I apologize for the length of this post. Vitamin D supplementation of
breastfed infants does not lend itself to quick little sound bites.

Warmly,

Cynthia

Cynthia Good Mojab, MS clinical psychology, IBCLC, RLC
Ammawell
Email: [log in to unmask]
Web site: http://home.attbi.com/~ammawell

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