The breastfeeding mother: Breast milk as a biomarker?

Posted on June 25, 2012 by John Cannell, MD

It just never made sense to me, 40 years ago, when my professors at UNC School of Medicine casually announced human breast milk contained no vitamin D.
“How can that be? How can that possibly be? That makes no sense,” I thought. “Was primitive man supposed to give their infants vitamin D pills that didn’t even exist?”
I have written before about biomarkers, such as:

• How high does your vitamin D level have to be to maximally suppress parathyroid hormone?
• How high does your vitamin D level have to be to maximally improve calcium absorption?
•  How high does your vitamin D level have to be to prevent abnormal bones?

The answer to these questions varies from 20 ng/ml to 40 ng/ml, depending on what study you decide to quote. But what about breast milk as a biomarker? Infants need vitamin D for strong bones and general development. Without vitamin D, the infant can develop rickets. In the 21^st century, this is treatable in a clinic. In the wild, the tribe may have left a screaming baby with soft bones at the wayside.

How high does the breastfeeding mom’s vitamin D level need to be for her infant to get natural vitamin D levels? This level is a biomarker because it gives us insight on how high vitamin D levels were for species survival. If the breastfeeding mom couldn’t supply vitamin D to the infant, our species may not have survived. Whatever vitamin D level that might be, that would be the level humans evolved to have.
Professors Wagner and Hollis and colleagues did an elegant randomized controlled trial 6 years ago that we have covered before, but it should be covered often. They simply gave two different doses of vitamin D to nursing mothers and measured the vitamin D levels of their infants and mothers. They used a small sample of breast feeding women, giving half the women a prenatal vitamin (containing 400 IU) and the other half a prenatal vitamin plus an extra 6,000 IU/day of vitamin D.
The suckling infants of the mothers given only the prenatal were also given 300 IU of vitamin D directly (it would have been unethical to deprive any of the infants of vitamin D). They noted no side effects with any dose, but the 6,000 IU/day arm of the study answered my 40-year-old question.
Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med. 2006 Summer;1(2):59-70.
The 6,000 IU/day dose of vitamin D did three things.

1. It gave the mothers natural vitamin D levels (50 ng/ml or close to).
2. It transformed breast milk into a rich source of vitamin D.
3. It gave suckling infants natural blood levels of vitamin D (45 ng/ml).

Given this, if you are now breast-feeding and not taking vitamin D, then I hope you are giving your infant at least 400 IU of vitamin D per day as the American Academy of Pediatrics (AAP) recommends. If you want your infant to start getting their vitamin D from your breast milk, I recommend the following steps:

1. Take a loading dose of 10,000 IU/day for a month.
2. After one month on 10,000 IU/day, stop supplementing your infant with vitamin D as your breast milk should now be filled with vitamin D.
3. Take 6,000 IU/day maintenance dose thereafter, except on days you get full body sun exposure.

However — and this is important — when the breastfeeding stops, you need to start supplementing your child again, as the AAP recommends, unless the child is in the sun enough to have adequate levels, and very few are.
I’d like to reiterate, can you think of a better biomarker for how much vitamin D humans need?

• “How much vitamin D do human breast–feeding mothers have to take to transform their breast milk into an adequate source of vitamin D for their infants?”

This is a great biomarker question, one essential to the survival of our species. The answer is 50 ng/ml, which can be achieved by 6,000 IU/day for breastfeeding mothers.
Further reading:

• Taylor SN, Wagner CL, Hollis BW. Vitamin D supplementation during lactation to support infant and mother. J Am Coll Nutr. 2008 Dec;27(6):690-701. Review.

About John Cannell, MD

Dr. John Cannell is founder of the Vitamin D Council. He has written many peer-reviewed papers on vitamin D and speaks frequently across the United States on the subject. Dr. Cannell holds an M.D. and has served the medical field as a general practitioner, itinerant emergency physician, and psychiatrist.

View all posts by John Cannell, MD →

 

http://blog.vitamindcouncil.org/2012/06/25/the-breastfeeding-mother-breast-milk-as-a-biomarker/ 

What is Hypophosphatasia (HPP)?

Hypophosphatasia is an inherited metabolic (chemical) bone disease that results from low levels of an enzyme called alkaline phosphatase (ALP). Enzymes are proteins that act in the body's chemical reactions by breaking down other chemicals. ALP is normally present in large amounts in bone and liver. In hypophosphatasia, abnormalities in the gene that makes ALP lead to production of inactive ALP. Subsequently, several chemicals - including phosphoethanolamine, pyridoxal 5'-phosphate (a form of vitamin B6) and inorganic pyrophosphate - accumulate in the body and are found in large amounts in the blood and urine of people with Hypophosphatasia. It appears that the accumulation of inorganic pyrophosphate is the cause of the characteristic defective calcification of bones in infants and children (rickets) and in adults (osteomalacia).

Nevertheless, the severity of hypophosphatasia is remarkably variable from patient-to-patient. The most severely affected fail to form a skeleton in the womb and are stillborn. The most mildly affected patients may show only low levels of ALP in the blood, yet never suffer bony problems.

In general, patients are categorized as having "perinatal", "childhood" or "adult" hypophosphatasia depending on the severity of the disease, which in turn is reflected by the age at which bony manifestations are first detected. Odontohypophosphatasia refers to children and adults who have only dental, but not skeletal, problems (premature loss of teeth).

The x-ray changes are quite distinct to the trained eye. Similarly, the diagnosis of hypophosphatasia is largely substantiated by measuring ALP in the blood (a routine test) that is low in hypophosphatasia. However, it is important that the doctors use appropriate age ranges for normals when interpreting an ALP level.

Prevalence

It has been estimated that severe forms of hypophosphatasia occur in approximately one per 100,000 live births. The more mild childhood and adult forms are probably somewhat more common. About one out of every 200 individuals in the United States may be a carrier for hypophosphatasia

Prognosis

The outcome following a diagnosis of hypophosphatasia is very variable. In general, the earlier the diagnosis is made the more severe the skeletal manifestations. Cases with severe, not mild, deformity at birth almost always have a lethal outcome within days or weeks. When the diagnosis is made before six months of age, some infants have a downhill and fatal course, others survive and may even do well. When diagnosed during childhood, there can by presence or absence of skeletal deformity from underlying rickets, but premature loss of teeth (less than five years of age) is the most common manifestation. Adults may be troubled by recurrent fractures in their feet and painful, partial fractures in their thigh bones.

Symptoms

Depending on the severity of the skeletal disease, there may be deformity of the limbs and chest. Pneumonia can result if chest distortion is severe. Recurrent fractures can occur. Teeth may be lost prematurely, have wide pulp (inside) chambers, and thereby be predisposed to cavities.

Inheritance Factors

The severe perinatal and infantile forms of hypophosphatasia are inherited as autosomal recessive conditions. The patient receives one defective gene from each parent. Some more mild (childhood or adult) hypophosphatasia cases are also inherited this way. Other mild adult and odonto hypophosphatasia cases seem to be inherited in an autosomal dominant pattern (the patient gets just one defective gene, not two, transmitted from one of his/her parents). In this form, mild hypophosphatasia can occur from generation-to-generation. The perinatal form of hypophosphatasia can often be detected during pregnancy by ultrasound and by measuring ALP activity in chorionic villus samples from amniocentesis.

Individuals with hypophosphatasia and parents of children with hypophosphatasia are encouraged to seek genetic counseling to explain the likelihood and severity of hypophosphatasia recurring in their families.

Treatments

As yet, there is no cure for hypophosphatasia and no proven medical therapy. Some medications are being evaluated. Treatment is generally directed towards preventing or correcting the symptoms or complications.

Expert dental care and physical therapy are recommended. An orthopaedic procedure called "rodding" may be especially helpful for adults with painful partial fractures in their thigh bones. Severely affected infants may manifest increased levels of calcium in their blood that may be treated with calcitonin and certain diuretics. Doctors should avoid the temptation to give calcium supplements or vitamin D unless there is clear-cut deficiency.

Contributing Medical Specialist
Michael P. Whyte. M.D.
Medical Director
Center for Metabolic Bone Disease and Molecular Research
Shriners Hospital
St. Louis, Missouri

A change of mood towards drugging kids

OPINION: What on earth has a five-year-old got to feel depressed about?

That was our initial reaction to stunning revelations that children as young as five are receiving counselling, and in some cases drugs, to combat the apparent early onset of mental health issues.

The Fairfax Media story published last week also revealed that 3240 New Zealand children between the ages of 10 and 19 were given anti-psychotic medication last year, a spike of close to 50 per cent over the previous four years.

Many of our readers would have been similarly horrified that such young children would be prescribed mood- stabilising drugs, let alone have the mental problems to require such seemingly radical intervention.

But a little research reveals this is not the only country in which its youngest members need the support of drugs to lighten the mood.

The United States has also experienced a sharp increase in the use of anti- psychotic drugs for children.

One study revealed that one in five children visiting a psychiatrist was prescribed mood-stabilising medicine.

Not surprising for a nation where over- medication appears to be the default position and its victims include celebrities such as Heath Ledger, Whitney Houston and Michael Jackson.

But another study highlighted a factor of even greater concern. It noted that while prescriptions were on the increase, "literature on effects on children is poor".

It went on to say that "studies are few, methodology is flawed, limiting the conclusions to be drawn". And that younger patients were less able to "articulate symptoms", which meant there was "more scope for confusion and diagnosis".

A major concern when the medical professional is contemplating administering heavy-duty drugs for impressionable minds.

That dearth of quality research to support the medical profession's largesse was highlighted in another online report, which said the "impact of depression and its treatment on the brain in adolescents is understudied".

That is not to say that such treatments are automatically bad or not warranted. This country has a sad and shocking record when it comes to youth suicide, which indicates that mental illness can become evident well before the person is introduced to the daily grind and vicious cycle that adulthood can represent.

But what is clear is a lack of certainty around how young minds can be affected by an early introduction to anti-psychotic and mood-stabilising drugs. And a growing tendency for over-anxious parents and care-givers to over-dramatise and over- correct their child's possibly aberrant behaviour.

It is worth noting that in America, the sharpest rises in mental health drug use has been in its white communities.

Presumably, for ethnic groups, medication for their youth is either culturally unacceptable or simply too expensive.

And no doubt they will be the richer for that.

- © Fairfax NZ News

http://www.stuff.co.nz/taranaki-daily-news/opinion/6683248/A-change-of-mood-towards-drugging-kids

CPS does not maintain a clean environment

The title says it all. These were taken during a visit with my son. These are the toys provided in the visitation rooms for child protective services. These toys are dirty day in and day out. It is my personal opinion that the State is committing negligence by allowing such filth, and that they should put far more effort into maintaining a healthy environment. If you are going to be Hypocritical, and if your agency is going to accuse healthy families of abuse and neglect, then the agency needs to look at itself too. Based off of what I have seen, the State isn't looking towards the best interest of children.

Are Innocent Parents Being Prosecuted for Killing Their Babies?

Are Innocent Parents Being Prosecuted for Killing Their Babies?

The doctor who came up with “shaken-baby syndrome” thinks so.

By Emily Bazelon|Posted Wednesday, March 14, 2012, at 4:19 PM ET

Could larger medical conditions be responsible for baby deaths that were blamed on shaken-baby syndrome?

By Michael Blackburn/Thinkstock Images.

In 1971, pediatrician Norman Guthkelch helped come up with the medical diagnosis of shaken-baby syndrome. Guthkelch and another pediatrician each wrote a paper proposing that unexplained bleeding in the brain of infants could occur because of whiplash—via shaking—without causing a visible neck injury and without direct impact to the head. That diagnosis became the basis for “do not shake” campaigns and, over the years, hundreds of criminal prosecutions for child abuse.

Now Guthkelch is worried that medical examiners and prosecutors have been too quick to turn to the shaken-baby diagnosis—and that innocent people may be in prison as a result. He called me to express that concern after I wrote about some questionable shaken-baby prosecutions for the New York Times Magazine last year. Guthkelch told Joseph Shapiro of NPR about an Arizona case he found particularly troubling after reviewing it for the defense. “I think I used the expression in my report, ‘I wouldn’t hang a cat on the evidence of shaking, as presented,’ ” he said.

Guthkelch, who is 96, was talking about the conviction of Drayton Witt, who was an 18-year-old when he was charged with shaking his 4-month-old son, Steven, to death in 2000. Based on the standard medical theory of the time, the case looked like a classic case of abusive shaking to doctors who treated Steven in the hospital as well as to the medical examiner who conducted the autopsy. Later at trial, these doctors testified against Witt, who was convicted of second-degree murder and sentenced to 20 years.

But now the case doesn’t look so clear-cut. It may, instead, be an example of doctors applying an outdated method of diagnosis—one that ignored Steven’s troubled medical history and thus missed an alternate explanation for his death. It’s not just Guthkelch who is raising the alarm: The medical examiner who testified against Witt, pathologist A.L. Mosley, has recanted his position at trial. Mosley now believes that Steven died of natural causes. Which raises a couple of questions: Is Drayton Witt serving time for a crime he did not commit? Will prosecutors in Arizona continue to argue that his conviction should stand?

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Steven Witt’s health problems started at birth. He was born with the umbilical cord wrapped around his neck, and he had trouble breathing. He got better and went home, but a few weeks later, his mother, who lived with Drayton Witt and later married him, brought the baby to the doctor because he’d been feverish and vomiting for three days. A few weeks later, Steven was sick again, with a fever and an upper respiratory infection. From then on, his mother was in frequent touch with the pediatrician.

A few days before Steven turned 4 months old, his mother took him to the emergency room because of what was by then his familiar fever, congestion, and vomiting. The doctors thought he had pneumonia, and they prescribed an antibiotic. After Steven took his first dose, his left eye couldn’t focus, he refused the bottle, and he lay limp. The next morning, he threw up and started shaking. Witt came home from work, and he and Steven’s mother rushed the baby to the hospital.

In the ER, Steven had a grand mal seizure. He spent the next six days in the hospital, with a fever and pupils that weren’t dilating normally. The doctors weren’t sure what was wrong, but tests showed more massive seizures, even though Steven was taking anti-seizure medication. His mother told the doctors that Steven had lost head control and couldn’t track with his eyes as he could before. Still, they sent the baby home with his parents before the week was up, on May 7, with antibiotics and the anti-seizure drug Phenobarbital.

According to Witt’s defense, Steven was never again a normal, healthy baby. Sometimes, his eyes twitched back and forth. He threw up repeatedly. His mother called the pediatrician and the hospital; his grandmother worried about his health; and a neighbor who was a nurse noticed the baby’s recurring problems. Steven’s mother brought him back to the pediatrician on May 26 because he’d again had a fever for days and had been projectile vomiting. She was told to continue the antibiotics and Phenobarbital, and she and the baby were sent home.

On June 1, Witt took care of Steven during the day while his mother went to work. Shortly after 8 p.m., Witt told Steven’s mother over the phone that he thought the baby was having another seizure because his eyes weren’t normal. They agreed that Witt would pick her up at work and they would drive to the hospital. On the way, Steven had a major seizure, and Witt tried to resuscitate his son. At the hospital, it took 32 minutes to get Steven’s heart started again. He was also seriously dehydrated—because of the vomiting, he’d been unable to keep down food or liquids.

Drayton Witt and his wife

Courtesy of the Arizona Justice Project

And yet despite the baby’s long medical saga, Witt was almost immediately suspected of abuse. The social worker from child protective services who talked to Witt and his wife at 4 a.m. on June 2 wrote in her notes that the couple had no specific explanation for the baby’s “severe head trauma.” After Steven’s death on the afternoon of June 2, Dr. Mosley, who knew that the doctors at the hospital thought he’d been killed by shaken baby syndrome, concluded that the death was a homicide caused by “shaken/impact syndrome.” Mosley noted that Steven had no neck injury, no bruising or fractures, no external signs of abuse. But none of that mattered. At Witt’s trial, Mosley testified against him, along with several other doctors. Because of the state of the science at the time, Witt had just one doctor in his corner, who only partially rebutted the shaken-baby theory.

Twelve years later, lawyers from the Arizona Justice Project have gone to court asking for a hearing for Witt. They want the state courts to reopen the case and order a new trial, based on the way the scientific understanding of shaken-baby syndrome has shifted. The mainstream position still holds that it is possible to shake a baby to death. But many doctors now allow that a history of illness like Steven’s can account for the subdural and retinal bleeding, and brain swelling, that used to be blamed exclusively on shaken-baby syndrome.

It’s Steven’s medical history that distresses Norman Guthkelch. “This was always a sickly baby,” he told me when I reached him over the phone. “I was taught to start by considering the non-criminal explanation, and this little guy was in sufficient trouble without any need to postulate someone had shaken him.” Mosley has joined Guthkelch in asking the Arizona courts to revisit Witt’s conviction. “There is now no longer consensus in the medical community that the findings I reported in my autopsy report are reliable proof of SBS [shaken baby syndrome] or child abuse,” Mosley told the court. “Steven had a complicated medical history, including unexplained neurological problems. He had no outward signs of abuse. If I were to testify today, I would state that I believe Steven’s death was likely the result of a natural disease process, not SBS.”

Drayton Witt reminds me of Shirley Ree Smith, a grandmother accused of shaking her baby to death in California in 1996. Both may well have been convicted based on past medical assumptions that may not stand up to present scrutiny. That may also be true of some people sent to prison more recently. I still wonder about the conviction of Trudy Munoz Rueda, a daycare provider whom I wrote about in the Times Magazine. Another is a former New York daycare provider named Alma Calderaro. When she was convicted of assault and child endangerment in 2009, and sentenced to eight and half years in prison, Calderaro’s lawyer did not call a single medical expert to testify on her behalf. Now on appeal, three doctors are saying that the baby who collapsed in Calderaro’s care had subdural bleeding that was chronic and that this condition, rather than shaking, probably caused her injuries. Prosecutors have until mid-April to respond.

By calling attention to these cases, I don’t mean to suggest that every defendant convicted of harming a baby who has the symptoms associated with shaken-baby syndrome is innocent. I’ve learned from my reporting that these cases are incredibly fact-specific. In a pending prosecution in Queens that has gotten a lot of attention, the baby who died, Annie Li, had serious bone fractures as well as internal bleeding. The lawyer for Li’s father, who has been charged with manslaughter and second-degree murder, says that while the test results aren’t in yet, a congenital bone condition may be to blame for the fractures. We’ll see.

Meanwhile, the district attorney who prosecuted Drayton Witt hasn’t responded to his petition for a hearing and a new trial. As these cases move through the courts, they are testing prosecutors’ and judges’ willingness to undo old verdicts. That’s never an easy step to take. But sometimes it’s the only one that is just.

http://www.slate.com/articles/news_and_politics/crime/2012/03/when_babies_die_are_doctors_too_quick_to_blame_it_on_shaken_baby_syndrome_.single.html 

Missouri House Wants to Penalize the Innocent.

Missouri House Wants to Increase Prison Time for Shaken Baby Cases

-->

By: KOLR10 News

Updated: March 8, 2012

(Jefferson City, MO)--Lawmakers in the Missouri House are looking at ways to stiffen penalties for those who hurt or kill a baby by shaking them.

The Associated Press reports the House has endorsed a measure that would expand Missouri's child abuse law.

The bill's sponsor says the current law makes it hard to prosecute people when a child dies from Shaken Baby Syndrome.

The bill would make it a crime to "recklessly cause head injuries" to any child.

Currently, abusers face up to seven years in prison.
This measure would raise prison time up to fifteen years, if the child is younger than two years old.

"Child abuse is despicable, and I have little sympathy for those who inflict it, especially in cases resulting in the death of the infant. However, the diagnosis of Shaken Baby Syndrome (aka Abusive Head Trauma) has been increasingly under fire of the past several years, with many, many doctors now coming forward to state their concerns about how the diagnosis is being misused to convict the innocent. I'm not sure which is more despicable: sending an innocent, grieving parent to prison when their infant dies of natural causes, or the child abuse itself. In fact, even the man who created the diagnosis, A. Norman Guthkelch, is now "horrified" by the way his diagnosis has been perverted and over-diagnosed to the point that perhaps hundreds of innocent people are sent to prison every year. http://www.npr.org/2011/06/29/137471992/rethinking-shaken-baby-syndrome Furthermore, Dr. Waney Squier, one of the top infant neuropathologists in the world has stated that she feels that perhaps HALF OR MORE of Shaken Baby http://www.dailymail.co.uk/femail/article-1382290/At-half-parents-tried-shaken-baby-syndrome-wrongly-convicted-expert-warns.html The UK and Canada have both begun to recognize the horrible mistakes that this faulty diagnosis have caused, but the United States is lagging far behind. And now we want to increase the penalty for crimes that may not even be real? This is madness. Professor Deborah Tuerkheimer recently wrote a paper on the problems regarding the prosecution of Shaken Baby Syndrome from a legal standpoint. In her opinion as well, some day we are going to have to come to terms with an injustice that we have never before faced in our legal system, and it will be monumental, as this diagnosis is eventually proven to be junk science. http://lawreview.wustl.edu/inprint/87/1/dtuerkheimer.pdf

Jeremy P. March 8, 2012 at 9:51 am"

Free, But Not Cleared: Ernie Lopez Comes Home

After nearly nine years in prison, Ernie Lopez has returned home to Amarillo, Texas, where a throng of family members and supporters celebrated his release.

Hugging his daughter Nikki and brother Eddie late last week, Lopez seemed overwhelmed and relieved.

Watch Ernie Lopez, Released on PBS. See more from FRONTLINE.

A jury in 2003 convicted Lopez — who was profiled by ProPublica, FRONTLINE and NPR last year – of sexually assaulting six-month-old Isis Vas, whom he was babysitting. The girl died shortly after the alleged attack.

But in the years since Lopez was sentenced to 60 years behind bars, new evidence has surfaced suggesting Vas died of natural causes – a severe blood disorder called Disseminated Intravascular Coagulation, which can cause bleeding throughout the body.  Lopez’s appellate lawyers, led by Seattle attorney Heather Kirkwood, have amassed a team of medical specialists who have challenged the notion that Lopez sexually assaulted the child and fatally injured her brain.

Lopez, 41, has always maintained his innocence.

In January, the Texas Court of Criminal Appeals overturned Lopez’s conviction, saying that his original legal team had provided him with ineffective assistance during his trial by “failing to call medical experts” to dispute the prosecution’s theory that Lopez had attacked the baby.  The court – the highest criminal court in Texas – didn’t absolve Lopez, but said there was a “reasonable probability” that he would have been acquitted had his attorneys countered the medical evidence arrayed against him.

For more on this story, watch our film The Child Cases. Also take a look at reporting from our partners at ProPublica and NPR, including this slideshow of Ernie Lopez’s first hours of freedom.

Lopez’s story reflects a broader controversy. Increasing numbers of doctors and other experts are questioning the reliability of the science used to prosecute cases of fatal child abuse and sexual assault. In Canada and the U.S. at least 23 people who were wrongly accused of killing children based on flawed or biased work by forensic pathologists have been cleared over the last 15 years.

The Texas court’s ruling set the stage for Lopez to be released Friday on a $10,000 bond. His release order bars him from initiating contact with children, though he is allowed to spend time with his three children. It also requires him to wear an electronic monitoring anklet and to abide by a 10 p.m. to 6 a.m. curfew.

At his parents’ home on the outskirts of Amarillo, Lopez celebrated the events and holidays he missed during his long confinement. The family even put up a Christmas tree.

Watch Ernie Lopez Arrives Home on PBS. See more from FRONTLINE.

While Lopez was overjoyed to be reunited with his family and friends, Potter County District Attorney Randall Sims has signaled his intent to retry Lopez on sexual assault charges.

Sims recently declined to talk about the details of the case with ProPublica, FRONTLINE and NPR, but throughout the appeals process, prosecutors have maintained that Lopez assaulted Vas, and have enlisted an array of medical professionals to support that contention.

Lopez’s lawyers said they expect their client to face trial again this fall. Since his release, Lopez has reveled in his freedom and grappled with the reality that it may be only temporary.

Watch The Free World on PBS. See more from FRONTLINE.

http://www.pbs.org/wgbh/pages/frontline/criminal-justice/the-child-cases/free-but-not-cleared-ernie-lopez-comes-home/

Adherence to Vitamin D Recommendations Among US Infants

http://pediatrics.aappublications.org/content/125/4/627.full

Adherence to Vitamin D Recommendations Among US Infants

1. Cria G. Perrine, PhD^a,^b, 
2. Andrea J. Sharma, PhD, MPH^b,
3. Maria Elena D. Jefferds, PhD^b, 
4. Mary K. Serdula, MD^b,
5. Kelley S. Scanlon, PhD, RD^b

+Author Affiliations

1. ^aEpidemic Intelligence Service, Office of Workforce and Career Development, and
2. ^bDivision of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia

 

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ABSTRACT

OBJECTIVES: In November 2008, the American Academy of Pediatrics (AAP) doubled the recommended daily intake of vitamin D for infants and children, from 200 IU/day (2003 recommendation) to 400 IU/day. We aimed to assess the prevalence of infants meeting the AAP recommended intake of vitamin D during their first year of life.

METHODS: Using data from the Infant Feeding Practices Study II, conducted from 2005 to 2007, we estimated the percentage of infants who met vitamin D recommendations at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months (n = 1952–1633).

RESULTS: The use of oral vitamin D supplements was low, regardless of whether infants were consuming breast milk or formula, ranging from 1% to 13%, varying by age. Among infants who consumed breast milk but no formula, only 5% to 13% met either recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation. Among those who consumed formula but no breast milk, 81% to 98% met the 2003 recommendation, but only 20% to 37% would have met the 2008 recommendation.

CONCLUSIONS: Our findings suggest that most US infants are not consuming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should encourage parents of infants who are either breastfed or consuming <1 L/day of infant formula to give their infants an oral vitamin D supplement.

Key Words:

• American Academy of Pediatrics
 
• vitamin D
 
• Infant Feeding Practices Study II
• supplement

WHAT'S KNOWN ON THIS SUBJECT:

There have been few data on the prevalence of US infants meeting AAP vitamin D recommendations.

WHAT THIS STUDY ADDS:

We estimated the prevalence of breastfed, formula-fed, and mixed-fed infants who met the 2003 and 2008 AAP vitamin D recommendations. Most infants, not just those who are breastfed, will need to receive an oral vitamin D supplement to meet the 2008 AAP recommendation.

The role of vitamin D in calcium and phosphorus homeostasis and bone metabolism has been well established; however, the presence of vitamin D receptors in many cell types suggests that vitamin D has other physiologic functions.¹ For example, vitamin D deficiency has been associated with respiratory infections, type 1 diabetes, cardiovascular diseases, and cancer in later life,^1,–,3 which emphasizes the importance of vitamin D nutrition throughout the life span. In children, nutritional rickets typically occurs in severe cases of vitamin D deficiency, causing softening and weakening of the bones, and is associated with impaired growth, developmental delays, lethargy, and hypocalcemic seizures.⁴

In addition to being obtained through the diet, vitamin D is synthesized endogenously in the skin after exposure to ultraviolet light. The American Academy of Pediatrics (AAP) advises that children younger than 6 months be kept out of the sun altogether and that those aged 6 months or older wear protective clothing and sunscreen to minimize sun exposure.⁵ Some researchers recommend short episodes of sun exposure as a way of obtaining vitamin D; however, the safety of this method for infants with regard to future skin cancer is not known.^6,7 In addition, one's ability to produce vitamin D is affected by latitude, season, sunscreen use, skin pigmentation, and air pollution, which make sun exposure an unreliable source of vitamin D. Thus, infants need to obtain vitamin D either primarily or entirely from their diet. In 1997, the Institute of Medicine (IOM) recommended that 200 IU/day be considered “adequate intake” of vitamin D for infants, although it did not have sufficient information to determine a recommended dietary allowance.⁸ In 2003, the AAP released vitamin D–consumption guidelines in line with those of the IOM and recommended that all children begin consuming 200 IU/day of vitamin D during their first 2 months of life.⁴

Although there currently is no national surveillance of nutritional rickets in the United States, cases of rickets among hospital patients continue to be reported.^9,10 The prevalence of poor vitamin D status among US infants also remains high by most measures, although data on infant vitamin D status can be difficult to interpret because of a lack of consensus on optimal vitamin D levels or on what constitutes vitamin D deficiency. Depending on the definitions used, vitamin D deficiency has been reported in 10% to 65% and insufficiency in 40% to 56% of US neonates, infants, and toddlers,^11,–,13 which suggests that vitamin D levels may not be optimal in these groups. Given the growing evidence that the level of vitamin D consumption it recommended in 2003 may not be sufficient, in November 2008 the AAP released a new recommendation that all children receive 400 IU/day of vitamin D from their first few days of life through adolescence.¹⁴ The IOM is also reviewing its current recommendations for vitamin D consumption and plans to release a report on the findings of this review in May 2010.

Although breast milk is the best single source of food for infants,¹⁵ it only contains <25 to 78 IU/L of vitamin D¹⁴ and, thus, is insufficient, by itself, to provide adequate levels of vitamin D for infants. Foods that are good sources of vitamin D include oily fish, egg yolks, and fortified foods such as infant formula and milk.¹⁶ Most infants, however, will not consistently consume these foods during their first year of life unless they are primarily fed infant formula. All infants require a supplemental source of vitamin D from an oral vitamin D supplement, fortified infant formula, or both.

Our objective for this analysis was to estimate the prevalence of adherence to both the 2003 and 2008 AAP vitamin D recommendations among infants during their first year of life. Because infants' level of vitamin D consumption would likely differ by the extent to which they were formula fed, we produced separate prevalence estimates for infants who were breastfed, formula fed, and “mixed fed” (both breastfed and formula fed).

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METHODS

We analyzed data from the Infant Feeding Practices Study II (IFPS II), a longitudinal survey of US mothers of healthy singletons, followed from late pregnancy through the first year of their infant's life, which was conducted from 2005 through 2007 by the US Food and Drug Administration in collaboration with the Centers for Disease Control and Prevention.¹⁷ The sample was drawn from a consumer-opinion mail panel that was nationally distributed but not nationally representative. Women were recruited in their third trimester of pregnancy; mothers at least 18 years of age, mothers and infants without medical conditions that would affect feeding, and infants who were born after at least 35 weeks' gestation and weighed at least 5 lb were included in the study. Extensive details of the IFPS II methodology, the IFPS II sample, and a comparison of the IFPS sample with a nationally representative sample of women from the National Survey of Family Growth (NSFG) have been published previously.¹⁸ Generally, IFPS II participants were older and more educated, had a higher income and fewer children, were breastfed longer, and were more likely to be white than those in the NSFG sample.

Each IFPS II participant was mailed 1 prenatal and 10 postnatal questionnaires at approximately monthly intervals that asked about various infant feeding and care practices. We analyzed data collected about infants at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months as if the data were from separate cross-sectional surveys; sample sizes ranged from 1952 mothers of infants at 3 months to 1633 mothers of infants at 10.5 months. Regarding supplement use, mothers were asked on each monthly questionnaire, “Which of the following was your baby given in vitamin or mineral drops or pills at least 3 days a week during the past 2 weeks? If your baby was given drops or pills that contained more than 1 of the items listed, please mark each of the separate items.” If the mother checked the box for vitamin D, the infant was categorized as having received an oral vitamin D supplement. Thus, our estimate of vitamin D supplementation was not of daily administration, but of a minimum of 3 days per week.

On each of the postpartum surveys, mothers were also asked to estimate the average number of ounces of formula their infants consumed at each feeding (response options were 1–2, 3–4, 5–6, 7–8, and >8 oz) and the average number of feedings per day or week for both breast milk and formula. In our analyses, we used the midpoint of the formula consumption response options reported (1.5, 3.5, 5.5, 7.5, and 8.5 oz) and the average number of feedings per day to estimate average daily formula consumption, converting ounces to milliliters. We also used the reported frequency of breast milk and formula feedings to divide infants into 3 mutually exclusive feeding-practice groups: breast milk (consumed breast milk only); mixed (consumed breast milk and formula); and formula (consumed formula only). These classifications referred only to consumption of breast milk and formula; infants may also have been consuming other foods or liquids, such as water or juice. Almost no children consumed cow's milk until 10.5 months of age. Fourteen percent of infants at 10.5 months were consuming any cow's milk; for half of these infants, consumption frequency was less than once per day. When we compared the results of our analysis for all infants aged 10.5 months with results for the same group excluding those reported to have consumed any cow's milk, we found no significant differences.

The IFPS II data were collected from 2005 to 2007, at which time the 2003 AAP recommendation would have been current. We used both the 2003 and 2008 recommendations in this analysis to obtain estimates of the prevalence of infants who were meeting the 2003 recommendation and the prevalence of infants who would meet the 2008 recommendation without any behavior changes. Infants' multivitamin and vitamin D–only preparations available in the United States supply 400 IU/day; thus, infants who receive an oral vitamin D supplement would obtain enough vitamin D to meet both the 2003 and 2008 recommendations.¹⁴ Therefore, we classified infants as meeting the 2003 recommendation (which recommended beginning supplementation at 2 months of age and thus does not apply for infants younger than 2 months) if they were either receiving an oral vitamin D supplement or consuming at least 500 mL/day of vitamin D–fortified infant formula, which in the United States is fortified at a level of 400 IU/L.¹⁴ We classified infants as having met the 2008 recommendation (which applies to infants beginning within their first few days of life) if they were either receiving an oral vitamin D supplement or consuming at least 1 L/day of formula.^4,14

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RESULTS

At 1 month of age, 43% of the infants were breastfed, 32% were mixed fed, and 26% were formula fed (Table 1). With increasing age, the percentage of infants who were breastfed decreased, and the percentage who were formula fed increased; by 10.5 months of age, 27% of the infants were breastfed, 11% were mixed fed, and 62% were formula fed. Throughout the first year of life, mean formula intake ranged from 310 to 352 mL/day in the mixed-fed group, with little variation by age, and from 770 to 987 mL/day in the formula-fed group, with formula intake generally increasing with age until peaking at 4 to 6 months and then decreasing.

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TABLE 1

Percentage of Infants Fed According to Each of Three Feeding Practices by Age

Overall, only 4% to 7% of the infants were receiving an oral vitamin D supplement (Table 2), with infants 1 month of age having the lowest prevalence of supplement use. The prevalence of oral supplement use ranged from 5% to 13% in the breastfed group and from 4% to 11% in the mixed-fed group. Only 1% to 4% of the infants in the formula-fed group were receiving an oral supplement.

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TABLE 2

Percentage of Infants Who Received an Oral Vitamin D Supplement According to Feeding Practice by Age

We estimated that over the first year of life, 44% to 58% of infants met the 2003 AAP recommendation that they consume 200 IU/day of vitamin D, whereas only 11% to 25% would have met the 2008 recommendation of 400 IU/day of vitamin D (Table 3). Among breastfed infants, who must have received an oral vitamin D supplement to meet either of the AAP recommendations, only 9% to 13% were receiving enough vitamin D at 2 to 10.5 months of age to meet the 2003 or 2008 recommendation. The 2008 recommendation (but not the 2003 recommendation) applies to infants at 1 month; only 5% of 1-month-old infants who were breastfed received an oral vitamin D supplement and, thus, would have met the 2008 recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation; those who met the 2003 recommendation did so primarily through formula intake, whereas those who met the 2008 recommendation did so primarily with the use of an oral vitamin D supplement, suggesting that few mixed-fed infants consume enough formula to obtain 400 IU/day of vitamin D. More than 90% of formula-fed infants aged 2 to 7.5 months met the 2003 recommendation, as did >80% of formula-fed infants aged 9 and 10.5 months. However, only 20% to 37% of these infants would have met the new 2008 recommendation at any month of age. Because use of an oral vitamin D supplement was very low among formula-fed infants, most who were meeting the 2008 recommendation were doing so by consuming at least 1 L/day of formula. Thus, the pattern of formula-fed infants who achieved AAP 2008 recommended levels of vitamin D followed a pattern similar to that of formula intake, increasing with age until peaking at 4 to 6 months and then decreasing.

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TABLE 3

Percentage of Infants Who Met the 2003 AAP Vitamin D Recommendation and the Percentage Who Would Have Met the 2008 Recommendation According to Feeding Practice by Age

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DISCUSSION

At the time the IFPS II data were collected, the 2003 AAP recommendation was the current guideline regarding vitamin D intake for the prevention of vitamin D deficiency and rickets. Although we found that most formula-fed infants were meeting the recommendation, we also found that only approximately one-tenth of breastfed infants and one-third of mixed-fed infants were meeting it. This poor adherence to the 2003 recommendation was because of both low prevalence of oral vitamin D supplement use and most mixed-fed infants not consuming enough formula to meet the recommended consumption level of 200 IU/day. Our estimates regarding the 2008 recommendation provide a sense of the prevalence of infants among the various feeding-practice groups who would meet the new recommendation if there was no change in behavior regarding vitamin D intake. Fewer than 15% of the infants in both the breastfed and mixed-fed groups would have met the 2008 recommended level of vitamin D consumption.

The difference in the percentage of infants who met the 2 recommended intake levels was particularly striking among formula-fed infants. Whereas most formula-fed infants were consuming the 500 mL/day of formula required to obtain 200 IU of vitamin D, only approximately one-third were consuming the 1 L/day required to obtain 400 IU. Among this group, adherence peaked at ∼4 to 6 months, which is when many infants would begin to consume complementary foods and reduce their formula intake. The 2008 AAP guideline suggests that most infants older than 1 month will consume the 1 L/day of formula required to obtain 400 IU/day of vitamin D¹⁴; however, our results did not support this assumption and indicated instead that most infants, not just those who are breastfed, would likely need to receive an oral vitamin D supplement to consume enough vitamin D to meet the 2008 recommendation.

The very low prevalence of oral vitamin D supplementation among infants is concerning if infants are to meet current recommendations. Results from the 1999–2002 National Health and Nutrition Examination Survey showed a similarly low prevalence of vitamin D supplement use among US infants: only 8.7% of infants aged 0 to 11 months had received a vitamin D supplement in the previous 30 days.¹⁹ Pediatricians and allied health care providers are uniquely positioned to help increase the percentage of infants who receive adequate amounts of vitamin D, because parents are more likely to give their children vitamin D supplements if they are advised to do so by a health care professional.²⁰ It is unfortunate that many health care professionals are not recommending vitamin D supplements for infants.^21,–,23 Reasons that they are not doing so include beliefs that rickets is rare,²³ that infants receive sufficient sunlight,^22,23 and that breast milk has adequate levels of vitamin D.^21,–,23 Because physicians' knowledge of the AAP recommendations has been positively associated with the likelihood of their recommending vitamin D supplements,²² both health care providers and parents need to be educated about the AAP guidelines and the importance of vitamin D nutrition, including that infants should not be exposed to sunlight and, thus, need an alternate source of vitamin D.

Although the IFPS II included women from around the country, the sample was not nationally representative. Among other characteristics, women in this sample had achieved higher levels of education, had fewer children, and had breastfed longer than women in the NSFG,¹⁸ all of which may have been associated with formula and supplement use. Another limitation of our study was that all data were self-reported and required mothers to recall information about their infants' feedings over the previous 7 days and supplement use over the previous 2 weeks. Although the validity of this self-reported data is unknown, our estimates of daily formula intake among infants of IFPS II participants were consistent with, or only slightly higher than, those from other studies.^24,–,27 Other study limitations included our inability to determine the exact quantity of vitamin D that infants obtained from oral supplements and our definition of supplement use as use of a supplement on at least 3 days/week rather than more frequently. Our estimates of the prevalence of supplement use would likely have been even lower had we used a definition that required more days per week of use. These data were collected from 2005 to 2007, so our estimate of meeting the 2008 AAP recommendation assumed no change in behavior since that time. Because new vitamin D research is continually being generated, it is possible that increased media attention on vitamin D has increased the use of vitamin D supplements among infants. Despite these limitations, IFPS II was one of the largest infant-feeding studies in the United States and provides valuable data that are not available from any other data source to date, including assessment of supplement use and food intake at multiple times points during the first year of life and at as early as 1 month of life.

According to the 2008 AAP recommendation, all breastfed, mixed-fed, and formula-fed infants who consume <1 L/day of formula should receive an oral vitamin D supplement. Our findings suggest that few infants are consuming at least 1 L/day of formula; thus, many may need to receive oral vitamin D supplements to meet the 2008 AAP recommendation that they consume at least 400 IU/day. This finding should be confirmed in other studies. Parents may need support in providing supplementation for their infants. Supporting adherence in this context is challenging because of the long duration of vitamin D supplementation, the lack of tangible health effects after starting supplementation, the need for an adult to administer the daily dose, and the need for a willing infant to accept the supplement. Overall, adherence to prescriptions from health care providers is poor, even among adults, and is generally worse the longer the regimen duration is.²⁸ Pediatricians and other health care providers can support and promote daily oral vitamin D supplementation of infants by explaining to parents the purpose and benefits of vitamin D supplementation, reminding parents at each visit to give vitamin D supplements to their children, suggesting that parents develop a daily intake routine to help them remember to administer the supplement, asking parents about any adverse effects of supplementation or barriers to giving their infants supplements, and helping parents to overcome any barriers that they report.²⁹

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CONCLUSIONS

We found that most infants, not just those who are breastfed, may require an oral vitamin D supplement daily, beginning within their first few days of life, to meet the 2008 AAP recommendation that infants consume at least 400 IU/day of vitamin D.

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ACKNOWLEDGMENTS

This study was funded by the US Food and Drug Administration, Centers for Disease Control and Prevention, Office of Women's Health, National Institutes of Health, and Maternal and Child Health Bureau in the US Department of Health and Human Services.

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FOOTNOTES

• Accepted November 24, 2009.
• Address correspondence to Cria G. Perrine, PhD, 4770 Buford Hwy NE, MS K-25, Atlanta, GA 30341. E-mail: cgregory@cdc.gov
• The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
• Funded by the National Institutes of Health (NIH).
• FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
• Funded by the National Institutes of Health (NIH).
• AAP = 

  American Academy of Pediatrics • 

  IOM = 

  Institute of Medicine • 

  IFPS II = 

  Infant Feeding Practices Study II • 

  NSFG =

  National Survey of Family Growth

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