Nursing and Vitamin D

The American Academy of Pediatrics (AAP) acknowledges that breast milk is the gold standard in infant nutrition, but nevertheless recommends supplementing all infants — formula- or breastfed — with a daily dose of 400 IU of vitamin D. Two things about this mystify me. First, the implication that human milk is universally low in vitamin D doesn’t seem plausible; after all, the human race survived for millennia without the benefit of store-bought supplements. Second, research increasingly suggests that the vitamin D intake recommendations are set quite low (for both adults and children), making the determination that 400 IU per day is appropriate for infants somewhat random.

If the 400 IU of vitamin D recommended by the AAP is low by an increasing body of research, how much vitamin D is appropriate for a breastfeeding infant? This is a little hard to say. Some studies suggest a dose several times that recommended by the AAP (Hypponen et al 2001; Pittard et al 1991). However, there’s the concern of toxicity, since it’s possible to take too much of the vitamin. Currently, the National Institutes of Health (NIH) has the tolerable upper limit set at 1000 IU for babies under 6 months of age, but even this number may be conservative, since the Hypponen study found a protective effect of vitamin D against type 1 diabetes at twice that dose. My analysis, after looking at the data, is that 400 IU of supplementation is probably a little low, but there’s limited evidence that supports going over 1000 IU.

However, it may not be necessary to supplement a nursing infant at all, under the right conditions. You don’t need to consume vitamin D; assuming you get enough sun exposure, you can make it yourself (this route is appropriate for adults and older children, but not for babies, as infants shouldn’t be exposed to direct sunlight). This is a good thing, because there aren’t a wide variety of foods that contain the vitamin. It takes a light-skinned individual only about 10-15 minutes per day to make adequate vitamin D, though sunscreen negatively impacts production. Also, lower-intensity sunlight (such as at higher latitudes) isn’t sufficient to produce the vitamin. Still, an increase in time spent indoors means that many nursing mothers today aren’t getting the sunlight our ancestors did. It’s not that human milk is universally low in vitamin D, it’s that most women simply don’t spend enough time in the sun. If you work or exercise outdoors — year-round — in Phoenix, AZ, you probably don’t need to supplement your nursing infant with vitamin D. If you live in Buffalo, NY, you probably do.

It seems intuitive that a breastfeeding mother who is receiving enough vitamin D from sun exposure and/or food should be able to pass adequate quantities of vitamin D into her milk, making supplementing unnecessary. Several studies support this, including an older study by Hollis et al, and one published more recently by Taylor et al. The Taylor study, in particular, found good results with very high vitamin D intake by nursing mothers, noting that maternal consumption of 6400 IU of vitamin D a day provided for nursing infant vitamin D needs and appeared safe for both mother and baby. This is somewhat above the 4000 IU per day set as the tolerable upper limit by the NIH, though a study by Hathcock et al notes no adverse effects up to 10,000 IU per day.

Science Bottom Line:* Evidence supports nursing mothers taking supplemental vitamin D in quantities of around 4000-6400 IU per day. There doesn’t appear to be any need to supplement a nursing infant with adequate maternal vitamin D intake.

 

Do you or did you supplement your nursing baby with vitamin D? Leave a comment below.

 

References:

Hathcock et al. Risk assessment for vitamin D. Am J Clin Nutr. 2007 85:6–18.

Hollis et al. Vitamin D requirements during lactation: high-­‐dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1752S-­‐8S.

Hyppönen et al. Intake of vitamin D and risk of type 1 diabetes: a birth-­‐cohort study. Lancet. 2001 358:1500–1503.

Pittard et al. How much vitamin D for neonates? Am J Dis Child. 1991 145:1147– 1149.

Taylor et al. Vitamin D Supplementation during Lactation to Support Infant and Mother. J Am Coll Nutr. 2008 Dec;27(6):690-­‐701.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

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17 Comments (+add yours?)

  1. Nicole
    Oct 23, 2011 @ 22:45:59

    I take between 5,000 and 7,000 IUs per day (depending on whether I remember to take my fish oil pills that also contain vitamin D) and supplement my one-year-old with 400-800 IUs per day. The prescription dose for vitamin D deficiency is 50,000 IUs per week; I know because I had to take that for a number of a months. Contemporary studies are suggesting most people have regardless of where they live, due to sunscreen use and lifestyle changes that keep us inside most of the day most of the year. I was swayed by studies that showed that breastfeeding infants of mothers taking 4,000 IUs per day were not deficient, while mothers taking only 1,000-2,000 IUs per day didn’t provide enough in their breastmilk.

    Reply

    • SquintMom
      Oct 24, 2011 @ 01:49:28

      Thanks for your comment! I totally agree that most people, regardless of where they live, should probably take vitamin D (unless you, for instance, live in Phoenix and bike commute to work, year-round, without sunscreen!). I agree with you that the studies are quite compelling!

      Reply

  2. BAE
    Oct 23, 2011 @ 22:55:20

    My baby’s doc recommended it, so I got the supplement and tried to give it. He sputtered and choked and gagged every time I tried to give it so I stopped. When I reported this back to the pediatrician he said that it was probably ok for now, but to add it to foods once he was on solids.

    Reply

    • SquintMom
      Oct 24, 2011 @ 01:53:05

      We had the same trouble (and no wonder; have you ever tasted that stuff!?)! Actually, it was W’s response to the vitamin D supplement that caused me to look into the research (that, and I simply couldn’t bring myself to believe that breast milk couldn’t be made into an ideal food if mama got the nutrients she needed). I found the evidence for mama-supplementation very compelling.

      Reply

  3. Jessica
    Oct 23, 2011 @ 23:11:09

    I’m so glad I saw the link to this on Kellymom’s FB post! My 2-week-old’s pediatrician just recommended vitamin D for my baby, and I exclusively BF. I wanted to say, “Hey, what makes my milk less than sufficient?”, but I didn’t think of it in time. 😉

    Reply

    • SquintMom
      Oct 24, 2011 @ 01:55:05

      While I’d never advise someone to go against their pediatrician’s recommendation, I certainly think it would be worth taking research that shows good outcomes if mama takes supplements (such as the Taylor et al study) to the doc to get his/her opinion on taking that route. Best of luck to you with your newborn!

      Reply

  4. kristin
    Oct 24, 2011 @ 02:17:33

    Good read

    Reply

  5. Genia Stephen
    Oct 24, 2011 @ 13:16:47

    Great summary of the research. Some of the comments make me wonder though if people are hearing your point that the supplementation guidelines are not suggesting that breast milk is deficient (although they certainly read that way!). This is not the same as the iron supplementation issue. While high circulating maternal levels may provide enough in breast milk, and so one may conclude that maternal diet is the controlling factor. This is a lifestyle issue – not a nutritional issue. Calling Vitamin D a vitamin is part of the problem. It’s not, traditionally speaking, a vitamin. Babies, from an evolutionary perspective, would have synthesized their own vitamin D. Dependency on maternal stores would have been far less. Cold climate, reduction of ozone leading to need for sunscreen, industrial revolution and indoor lifestyle are all recent human developments. Breast milk is not deficient. – but nor can it be expected to compensate for all the checks and balances we humans mess with. There are still big gaps in the research for sure. I believe we need to heeding the preventative medicine warning here – our lifestyles have become so problematic that not even breast milk can com

    Reply

  6. Genia Stephen
    Oct 24, 2011 @ 13:21:47

    Ahhh..I pressed submit by accident. I was saying… Not even breast milk can compensate. Pretty scary! And in case I sound all judgmental like, I just like to confess that all typos and inadvertent submissions are due to my typing this on my iPhone while in the bath and eating a decadent brownie. Seriously. I wish I were kidding.

    Reply

  7. uncanny
    Oct 24, 2011 @ 20:53:26

    I take 1400 IU a day (1000 + 400 in my prenatal). I give the boy 400 IU for now, and once we finish this bottle he’s moving up to 600 IU because those drops were cheaper than the “baby” dose. He’s 5 months now and I’ve supplemented most days since birth. We live in Canada – there is no way anyone gets enough sun from about October – April.

    Reply

  8. uncanny
    Oct 24, 2011 @ 20:55:56

    Oh, and regarding the spluttering: Carlson D drops. One drop on a nipple or pacifier, no mess no fuss no taste. Wonderful product if a mom does want to supplement the infant directly.

    Reply

    • SquintMom
      Oct 24, 2011 @ 21:33:32

      I have a similar product, called DDrops, that has no taste. One drop instead of a dropper-ful. Great stuff.

      Reply

  9. LeeAnn
    Nov 04, 2011 @ 04:25:57

    I had my levels tested and based on information from a recent paper published in Breastfeeding Medicine by Linda Haggerty felt confident that since my 25(OH)D level was 55 that my son (now 6 months) was getting enough via breastmilk.

    Now we are heading into winter in the Upper Midwest and though my supplementation stays the same (2000 IU plus 400 in a multi vitamin, plus whatever I’m getting from milk, cereal, etc) I wonder if it wouldn’t be prudent to start him on drops. I’m unlikely to be able to convince my PCP to keep testing my serum levels every few months, and anyway, who wants to worry about that? Like you said, another 400 IU isn’t going to hurt. I’m still somewhat on the fence about it though because most days I’m doing good just to take my own vitamins!

    Reply

    • SquintMom
      Nov 06, 2011 @ 17:10:27

      The Upper Midwest is definitely a region in which your winter vitamin D synthesis will be pretty low! I have a hard time remembering to supplement myself as well (much less my baby), so one of the things I’ve done to try to remember her vitamins is that I use D Drops (you only need a single drop), and I leave the bottle near the chair I normally nurse her in. I see it every time we nurse.

      Reply

  10. Cloud
    Nov 06, 2011 @ 22:43:39

    Hi! followed a link over… We supplement, and we live in sunny San Diego! We also wear sunscreen every day, because we are all quite fair.

    A while back, I wrote a post about some recent research that provides evidence of the mechanism by which vitamin D supports immune function:
    http://www.wandering-scientist.com/2010/03/mechanism-for-effects-of-vitamin-d-on.html

    As I said in that post, I think “supports immune function” is a pretty irresistible proposition for most people whose kids are in day care….

    Reply

  11. Trackback: When Is The Best Time To Introduce Solids? | SquintMom.com
  12. JR
    Mar 31, 2012 @ 16:20:40

    Found your very interesting blog and am reading it. Although my breastfeeding days are long past, it’s worth noting that I recently was told by my doctor that I have a SEVERE vitamin D deficiency, and possibly have for years. No one ever checked before. I have a few mitigating factors but given this strange development in my life, I wouldn’t be immediately skeptical of this new round of AAP advice.

    Reply

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