Patient Presentation
A 5-day-old female came to clinic for their routine health supervision visit after birth. The baby was a term infant born to a 31 year old G1P1 female without problems during the pregnancy or delivery. The baby was breastfed and was doing well. The infant was not jaundiced and was eliminating well.
The pertinent physical exam showed a 3.148 kg infant (25% overall, down 5% from birthweight), length 50 cm (50%), head circumference 35 cm (50%). There was mild facial jaundice without icterus (transcutaneous bilirubin was 6.9 mg/dL) and the rest of the examination was normal.
The diagnosis of a healthy female was made. The pediatrician discussed anticipatory guidance and recommended the family obtain some Vitamin D to supplement the baby. The mother said that she was Vitamin D deficient and was already taking some supplements. She wanted to know that if she kept taking her own supplement and also gave the baby Vitamin D would that give the baby too much Vitamin D. The pediatrician said that he wasn’t sure, but that the easiest thing to do was to just switch the mother to taking her own supplement of 6400 IU of Vitamin D daily and then that would help the mother and would be the recommended dosage for the baby.
Discussion
Vitamin D is an important vitamin for bone formation and mineral homeostasis. Hypocalcemia, hypophosphatemia, osteomalacia, rickets and tetany can all result because of Vitamin D deficiency. Deficiency is caused by inadequate dietary intakes of Vitamin D, inadequate exposure to sunlight or patients with fat malabsorption or renal disease. Even in high sun exposure areas of the world, Vitamin D deficiency can occur because of inadequate exposure due to clothing or cultural practices. Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure also. Adequate sunlight exposure for infants is considered 30 minutes/week clothed in a diaper only, or 2 hours/week fully clothed but without a hat.
25-hydroxy Vitamin D (25(OH)D or calcidiol) is the best indicator of Vitamin D status. More than 15 ng/mL is considered adequate Vitamin D serum levels. For a review of the production of Vitamin D, click here. For a review of how much Vitamin D is in different foods, click here.
Human breast milk is low in Vitamin D. Therefore all infants who are exclusively breastfed need supplementation. Infants with darker pigmentation or living in northern climates with less sunlight are particularly susceptible to Vitamin D deficiency. This supplementation can be stopped if the infant is taking at least 1 liter or quart/day of formula or Vitamin D fortified whole milk. Children taking less than 1 liter/day of Vitamin D fortified milk should also receive supplementation of 400 IU/day. Note that soy milk may or may not be Vitamin D fortified. Breastfeeding women who wish to take their own supplement are recommended to take at least 6400 IU.
Learning Point
A meta-analysis and systematic review of a “…dose-response analysis on the relation[ship] between circulating 24-hydroxy vitamin D … and maternal [v]itamin D supplementation in mother-infant dyads…”” was conducted in 2022. They found that “maternal [v]itamin D supplement dosages were associated with circulating 24(OH)D concentrations in breastfeeding women in a nonlinear fashion.” In contrast, “A linear relation was observed between maternal [v]itamin D supplementation dosage and the infants’ circulating 25(OH)D concentrations. Each additional 1000 IU of maternal [v]itamin D intake was accompanied by a 2.7 ng/mL increase in serum 25(OH)D concentration in their nursing infants.” They also found that “[l]ong-term maternal supplementation with vitamin D at a high dose (>6000IU/d) effectively corrected vitamin D deficiency in both mothers and infants.” As many mothers are Vitamin D deficient, this appears to be a good treatment for both mother and baby.
Questions for Further Discussion
1. What are the recommendation for supplementing iron to infants and young children?
2. How much calcium is recommended for different ages of the pediatric population?
3. What are the recommendations for supplementing late pre-term infants?
Related Cases
- Disease: Vitamin D Supplementation | Vitamins
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: General Pediatrics | Neonatology | Nutrition / Dietetics
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Vitamin D Deficiency and Vitamin D.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Rios-Leyvraz M, Yao Q. Calcium, zinc, and vitamin D in breast milk: a systematic review and meta-analysis. Int Breastfeed J. 2023;18:27. doi:10.1186/s13006-023-00564-2
Niramitmahapanya S, Kaoiean S, Sangtawesin V, Patanaprapan A, Bordeerat NK, Deerochanawong C. Correlation of 25-Hydroxyvitamin D Levels in Serum vs. Breastmilk in Vitamin D-Supplementation Breastfeeding Women during Lactation: Randomized Double Blinded Control Trial. J Med Assoc Thail Chotmaihet Thangphaet. 2017;100 Suppl 1:S165-171.
Kazemain E, Ansari S, Davoodi SH, et al. The Effect of Maternal Vitamin D Supplementation on Vitamin D Status of Exclusively Breastfeeding Mothers and Their Nursing Infants: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Adv Nutr. 2022;13(2):568-585. doi:10.1093/advances/nmab126
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 