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Diana Lee, RD, IBCLC
Once thought of as an eradicated disease, nutritional rickets, or severe vitamin D deficiency, has resurfaced as a public health issue. The AAP Section on Breastfeeding and Committee on Nutrition have issued new guidelines for vitamin D intake for prevention of rickets and vitamin D deficiency in infants.1 (see box below). Professionals working in the area of lactation should be well informed of these guidelines and be prepared to answer the obvious question: "If breastmilk is complete nutrition, then why do I need to supplement with vitamin D?" There is valid concern that women will conclude from these recommendations that breastmilk is inferior and might either shorten their length of breastfeeding or not start breastfeeding at all.
Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake
A clinical report issued in April 2003 by the AAP recommends a supplement of 200 IU Vitamin D per day beginning within the first 2 months of life for the following:
All breastfed infants unless they are weaned to at least 500 mL per day of vitamin D-fortified formula or milk.
All non-breastfed infants who are ingesting less than 500 mL per day of vitamin D-fortified formula or milk.
Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.
The fact remains that breastmilk is the optimum source of infant nutrition. Human milk is uniquely superior for infant feeding and is species-specific; all substitute feeding options differ markedly from it. The breastfed infant is the reference or normative model against
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which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.2 It is important for health professionals to know the basis for these recommendations and understand the nutritional, social and environmental dynamics that contribute to vitamin D deficiency.
The National Academy of Sciences Food and Nutrition Board recommends 200 IU as the adequate intake (AI) of vitamin D for all infants.3 Human milk typically contains a vitamin D concentration of 25 IU/L or less. 4-6 Therefore, the recommended adequate intake of vitamin D cannot be met with human milk alone. The biologically normal means of obtaining sufficient vitamin D is through sunlight exposure. However, there is growing concern about sunlight exposure and risk of skin cancer. In addition, regular sunscreen use recommended by cancer experts markedly reduces vitamin D production in the skin. The new AAP policy statement on vitamin D was developed due to the following:
1. The results of the North Carolina
study on rickets in breastfed African
American infants (Kreiter et al. 2000);7
2. The Healthy People 2010 goal of
75% of infants breastfed for the first 6
months of life (US DHHS, 2000);
3. The uncertainty about how much sun
exposure is required for each infant as
well as how air pollution and latitude
affect sun exposure;
4. The growing concern about UV
exposure in childhood and its
relationship to skin cancer in later
years;
5. The uncertainty about the amount of
sunlight needed for people with darker
skin pigmentation;
6. The fact that vitamin D is not a
nutrient, but a precursor of steroid
hormones, that is not naturally present
in any infant food, including human
milk, in quantities that will meet
individual needs.
continued on page 3
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Published by: SDCBC
Sponsored by: Regional Perinatal System
Editors:
Diana Lee, RD, IBCLC
Angela Tenenini, BS
Jo Ann Shaw, RD, IBCLC
Nancy Wight, MD, FAAP,IBCLC
Leslie Wynn, RN, PHN
Designed by:
Creative Impacts
www.creative-impacts.com
Inquiries can be sent to:
San Diego County Breastfeeding Coalition
Children's Hospital
3020 Children's Way, MC 5073
San Diego, CA 92123-4282
sdcbc@breastfeeding.org
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