Vitamin D Supplementation

NeoNotes Journal Club
Andrew B. Kairalla MD, Editor

Vitamin D Supplementation

Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake. Gartner LM, Greer FR, and Section on Breastfeeding and Committee on Nutrition. PEDIATRICS (April 2003) 111 : 908-910.

Rickets in infants attributable to inadequate vitamin D intakeand decreased exposure to sunlight continues to be reportedin the United States . It is recommended that all infants, includingthose who are exclusively breastfed, have a minimum intake of200 IU of vitamin D per day beginning during the first 2 monthsof life. In addition, it is recommended that an intake of 200IU of vitamin D per day be continued throughout childhood andadolescence, because adequate sunlight exposure is not easilydetermined for a given individual. These new vitamin D intakeguidelines for healthy infants and children are based on therecommendations of the National Academy of Sciences.

Comment: The primary source of vitamin D synthesis in humans comes from exposure to the ultraviolet B fraction of sunlight. I suspect that the fact that we are seeing cases of clinical rickets in our infants and children reflects that they spend too much time indoors or perhaps they use too much sunscreen. Since our dermatology colleagues tell us that sun exposure should be avoided, we are left with the need to supplement vitamin D in our diets. All commercially available infant formulas in the United States as well as Vitamin D- fortified cow’s milk contain adequate Vitamin D to satisfy this requirement as long as daily intake exceeds 500 ml/day. Human milk contains only about 25 units of Vitamin D per liter, so exclusively breast fed babies will need additional vitamin D supplementation. This supplementation can easily be provided to infants using available infant multivitamin preparations that contain 400 units of vitamin D per ml. ABK.

Additional Comments:

Date: 10 Apr 2003
Time: 17:36:50

The summary of the article suggests providing a vitamin D supplement to infants sometime in the first 2 months--why not from day one? Certainly the fetus would be getting a good supply of vitamin D and calcium/phosphorus if it remained unborn. Also, it matters which form of vitamin D is given. Most supplements, including ADEK that we give to infants with cholestasis, contain ergocalciferol from plant sources. With this form of vitamin D, UV light is necessary for effectiveness. I doubt whether anyone these days gets enough sunlight for our needs. Cholecalciferol, from animal sources, does not require UV light to be effective. I believe we should supplement human beings from birth till death with cholecalciferol for improved bone density and stronger bodies, especially premature infants and even more so those with cholestasis.

UserName:    Bruce Ogden, MD
Institution: Utah Valley Regional Medical Center
telephone:   801-357-7707
email:       uvbogden@ihc.com

Date: 19 May 2003
Time: 02:23:50

The only problem with starting vitamin supplement at birth is that it may make mother think that breast milk is not a perfect food and lacks other nutritionals too. Research has shown that those mothers were told to hold breast feeding, for even brief period, stopped breast feeding much earlier. It will be important to stress and discuss in detail that it is changed environmental factors ( too little outdoor and sunscreens) rather than breast milk quality necessitated Vitamin D supplementation. The children with dark skin living in unsafe neighborhood (staying mostly inside) are at maximum risk. These children are also found to have highest incidence of having TV in their bedrooms making it even worse.

UserName:    Bikramjit S Sangha MD
Institution: Kaiser Permanente - Los Angeles
telephone:   323-783-1659
email:       bikramjit.s.sangha@kp.org

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