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  • 1. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods James A. Taylor, Leah J. Geyer and Kenneth W. Feldman Pediatrics 2010;125;105-111; originally published online Nov 30, 2009; DOI: 10.1542/peds.2009-1195 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 2. ARTICLESUse of Supplemental Vitamin D Among InfantsBreastfed for Prolonged PeriodsAUTHORS: James A. Taylor, MD,a Leah J. Geyer, AB,a and WHAT’S KNOWN ON THIS SUBJECT: Because of the risk ofKenneth W. Feldman, MDa,b nutritional rickets, vitamin D supplementation is recommendedaDepartment of Pediatrics, University of Washington, Seattle, for all breastfed infants. There is emerging evidence of otherWashington; and bDepartment of Pediatrics, Seattle Children’s benefits of vitamin D for children.Hospital, Seattle, WashingtonKEY WORDS WHAT THIS STUDY ADDS: The results of this study providebreastfeeding, vitamin D, infants, rickets insight into the proportion of breastfed infants who receiveABBREVIATIONS vitamin D supplementation and the reasons parents choose toAAP—American Academy of Pediatrics provide the vitamin to their children.PSPRN—Puget Sound Pediatric Research NetworkOR— odds ratioCI— confidence for publication Jul 30, 2009 abstractAddress correspondence to James A. Taylor, MD, University of OBJECTIVES: To determine the rate of vitamin D supplementation inWashington, Child Health Institute, Box 354920, Seattle, WA predominantly breastfed children. To identify patient characteristics,98195. E-mail: parental beliefs, and practitioner policies associated with supplemen-PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). tation.Copyright © 2009 by the American Academy of Pediatrics METHODS: A prospective observational study was conducted in aFINANCIAL DISCLOSURE: The authors have indicated they have practice-based research network. Network pediatricians completed ano financial relationships relevant to this article to disclose. survey regarding their policy on vitamin D supplementation for breast- fed infants. Parents of children 6 to 24 months old completed a survey on the initial type of feeding given to the child, length of breastfeeding, formula supplementation, and use of multivitamins. Parents indicated their level of agreement with statements regarding vitamin D supple- mentation. RESULTS: Among 44 responding pediatricians, 36.4% indicated that they recommended vitamin D supplementation for all breastfed in- fants. A total of 2364 surveys were completed on age-eligible children; 1140 infants were breastfed for at least 6 months with little or no formula supplementation. The rate of vitamin D use for these infants was 15.9%. Use of vitamin D was significantly associated with parental agreement that their child’s pediatrician recommended supplementa- tion (odds ratio [OR]: 7.8), and that vitamins are unnecessary because breast milk has all needed nutrition (OR: 0.12). Among parents of pre- dominantly breastfed infants who indicated that their child’s doctor recommended vitamin D, 44.6% gave the supplementation to their child. Conversely, 67% of parents agreed that breast milk has all needed nutrition, and only 3% of these parents gave vitamin D to their children. CONCLUSIONS: A minority of breastfed infants received vitamin D sup- plementation. Educational efforts directed at both physicians and par- ents are needed to increase compliance with vitamin D supplementa- tion guidelines. Pediatrics 2010;125:105–111PEDIATRICS Volume 125, Number 1, January 2010 105 Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 3. Because the vitamin D content in hu- supplement, their breastfed infants. TABLE 1 Statements Regarding Vitamin D Supplementation and Rickets on theman milk may be relatively low, breast- We were particularly interested in the Practitioner Vitamin D Survey andfed infants are at risk for rickets un- role that their child’s pediatrician had Parental Survey of Infant Feedingless they are exposed to adequate in influencing this choice. Before the Practitioner vitamin D surveyamounts of sunshine to produce en- project, we postulated that approxi- In order to practice high quality medicine it is important to follow AAP practice guidelines.dogenous vitamin D or receive it from mately one third of infants who were A major limitation of the AAP recommendationother sources.1–4 For more than a de- breastfed for at least 6 months would that all breastfed infants receivecade, supplemental vitamin D has been receive supplemental vitamin D and supplemental vitamin D is that the recommendation is not evidence-based.recommended for certain infants who that a parent’s decision regarding sup- Routinely recommending vitamin D forare breastfed to prevent rickets.5 In plementation would be highly influ- breastfed babies may result in some2003, the American Academy of Pediat- enced by the recommendation of their mothers electing to formula feed instead. Some of my breastfed patients will likelyrics (AAP) recommended that all child’s pediatrician. develop rickets if they don’t receivebreastfed infants receive at least 200 supplemental vitamin D.IU/day of supplemental vitamin D; METHODS Parental survey of infant feeding I think that giving vitamins to babies and youngin 2008, the recommendation was A prospective observational study was children is important for their overallchanged to at least 400 IU/day.2,6 conducted by the Puget Sound Pediat- health.Estimates of physician adherence to ric Research Network (PSPRN), a re- Vitamins may be needed to prevent rickets or other bone diseases in some babies.the AAP recommendations regarding gional practice-based network of pri- It is inconvenient to give vitamins to youngvitamin D supplementation vary. A mary care pediatric practices in the babies.1999 survey of North Carolina pediatri- Seattle, Washington, area. For this When my baby was less than 6 months old, he/she didn’t need any extra vitaminscians found that 44.6% recommended project, 44 PSPRN practitioners from 7 because the breast milk or formula thatthe supplement for all breastfed in- private practice offices and 1 inner- he/she took had everything my baby needed.fants, and 38.6% recommended it for city pediatric clinic participated. The If babies are out in the sunlight and fresh air they don’t need extra vitamins.some infants.7 These results are simi- study consisted of 2 surveys, including My child’s doctor recommended that I give mylar to a study of Las Vegas, Nevada, a practitioner vitamin D survey and an baby vitamins.pediatricians in which 48% recom- infant-feeding survey completed bymended vitamin D for breastfed in- parents. Survey data were collectedfants.8 Recently, it was reported that between July 2006 and June 2008. responses to statements by pedia-89% of responding pediatricians in the Before collecting data on infants, the tricians who indicated that they rec-US military recommended supplemen- practitioner vitamin D survey was dis- ommended vitamin D for all breastfedtation for all, or some, infants fed hu- tributed to 44 PSPRN pediatricians. The infants were compared with the re-man milk.9 More important, however, pediatricians were asked about their sponses of those who had some otherthere have been few data on whether current recommendation regarding vi- practice regarding supplementation.these recommendations influence pa- tamin D supplementation for breastfed Likert-scale responses were trans-rental behavior and how many breast- infants. Possible responses included formed to an ordinal scale for the anal-fed infants actually receive supple- recommend vitamin D for all breastfed ysis. Regression analysis was used tomental vitamin D. In a study on the patients; recommend for “high-risk” chil- assess differences; generalized esti-prevalence of hypovitaminosis D in dren; discuss pros and cons of supple- mating equation techniques were usedyoung children in the Boston, Massa- mentation with parents; and do not rou- to account for the clustering of pedia-chusetts, area, Gordon et al10 reported tinely discuss vitamin D with parents. tricians in different practices.11that only 2% of breastfed infants re- Pediatricians were asked to indicate The infant-feeding survey was distrib-ceived supplemental vitamin D. their level of agreement with 4 state- uted to parents of children 6 to 24We conducted a study to determine the ments regarding supplemental vitamin months old at the time of an office visitrate of supplemental vitamin D usage D by using a 6-point Likert scale, with to a PSPRN practice. This survey wasamong a group of infants from the Se- possible responses to each statement anonymous; no identifying health in-attle, Washington, area who were pre- ranging from “completely agree” to formation was collected. Surveys weredominantly breastfed for at least the “completely disagree.” The statements available in both English and Spanishfirst 6 months of life. We were inter- on vitamin D usage are shown in Table 1. and were distributed by a research as-ested in identifying the reasons par- For the analysis of data in the prac- sistant who visited practices on a reg-ents choose to supplement, or to not titioner vitamin D surveys, the ularly scheduled basis. Surveys were106 TAYLOR et al Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 4. ARTICLESalso distributed to parents by office mula daily during the first 6 months of garding supplementation and use ofstaff in participating practices during life and “never” or “almost never” re- vitamin D in study patients was as-multiple data-collection periods that ceived 16 oz of formula in 1 day. Be- sessed. Parental agreement withranged from 1 to 3 months. cause commercial formula contains statements regarding vitamin D useFor the infant-feeding survey, parents 400 IU/L,12 the infants who were de- was dichotomized; responses of “com-of age-eligible children provided the fined as being predominantly breast- pletely agree” or “agree” were com-current age of their child and were fed received 100 IU of vitamin D from pared with all other responses forasked the initial type of feeding for him formula on a routine basis and never each item. Similarly, the response toor her (breast milk or infant formula). or almost never received 200 IU daily. the item in the infant-feeding survey in On the basis of the recommendation which parents were asked how im-Parents of those infants who were ini- for 200 IU of supplemental vitamin D portant their child’s pediatrician’stially breastfed were asked how long daily that was in place when the study recommendation was regarding sup-their child received human milk, how data were collected,2 none of these plemental vitamin D was dichotomizedmuch formula their child received on a predominantly breastfed, unsupple- by comparing responses of “very im-routine basis, and how often the child portant” or “important” to otherreceived 16 oz of formula in a single mented study children received 50% (possible responses included of the recommended vitamin D dose“never or almost never,” “a few days from infant formula on a daily basis Each individual characteristic or beliefeach week,” “almost every day,” or and virtually never received all of the was compared with the use of vitamin“every day,”). Parents were asked recommended dose from this source. D in predominantly breastfed study pa-whether their child routinely received The rate of supplemental vitamin D use tients. Those characteristics and be- in the children who were predomi- liefs statistically associated with vita-a multivitamin (all containing vitamin min D use in univariate analyses,D) during the first 6 months of life. The nantly breastfed for at least 6 months defined as an odds ratio (OR) with aparent was also asked to provide the was calculated. The rate of breast- 95% CI that did not include 1.0, werename of his or her child’s pediatrician feeding, prolonged breastfeeding, included in a multivariate model toduring the child’s first 6 months of life and vitamin D use was also com- identify factors independently associ-and to indicate how important this puted for children from different ra- ated with vitamin D use in breastfedphysician’s recommendation was re- cial and ethnic groups; 95% confi- children.garding the decision of whether to give dence intervals (CIs) around pointhis or her infant vitamins; responses estimates were calculated. Finally, during the study period, therewere categorized with a 5-point Likert was increasing publicity regarding vi- Characteristics and parental beliefs tamin D deficiency in children andscale that ranged from “very impor- associated with supplemental vitamin adults.13,14 To protect the anonymity oftant” to “very unimportant.” Parents D use in children who were predomi- study children and their parents, wewere also asked to provide the race nantly breastfed for at least 6 months did not collect data on the date thatand ethnicity of their child. were assessed with the use of logistic infant surveys were completed (theseSix statements regarding vitamin D regression. Generalized estimating dates corresponded to dates of physi-supplementation were listed on the equation techniques were used in cian visits, which is considered to besurvey. As with the practitioner survey, these analyses to account for the clus- identifiable health information).15 How-parents indicated their level of agree- tering of patients in different prac- ever, information on the surveys wasment with each statement by using a tices.11 Characteristics assessed in- entered into databases as they were6-point Likert scale. The statements on cluded race, ethnicity, and age. Data on collected. To assess the effects of sec-the infant-feeding survey are listed in the infant-feeding surveys regarding ular trends in vitamin D use during theFig 1. the child’s pediatrician during the first study period (2006 –2008), we catego-Much of the analysis of data in the 6 months of life were linked to re- rized study patients into tertiles on theinfant-feeding surveys was focused on sponses on the practitioner vitamin D basis of the chronological order ofthose children who were predomi- surveys. On the basis of this linkage, when their data were entered into thenantly breastfed for at least the first 6 the association between having a pedi- study databases.months of life. Children were consid- atrician who recommended vitamin D The study was approved by the Seattleered to be predominantly breastfed if for all breastfed infants versus having Children’s Hospital’s institutional re-they routinely received 8 oz of for- a provider who had another policy re- view board.PEDIATRICS Volume 125, Number 1, January 2010 107 Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 5. RESULTS 2433 completed surveys -69 surveys on children <6 mo or >25 mo oldA total of 44 PSPRN pediatricians com- 2364 surveys on eligible children (97.2%)pleted the practitioner vitamin D sur-vey. At the time that the survey wascompleted, 16 pediatricians (36.4%) in-dicated that they routinely recom- 1945 initially breastfed (82.6%) 411 formula fed (17.4%) 8 missingmended supplemental vitamin D for allof their breastfed patients. Fourteenrespondents (31.8%) recommended 1456 infants breastfed for ≥6 mo (75%)supplemental vitamin D for breastfed 4 missinginfants who were at high risk for de-veloping rickets. Six pediatricians - 287 infants who took ≥8 oz/d formula on(13.6%) responded that they discussed routine basis and/or 16 oz formula a fewthe pros and cons of supplementation d/wk or more (20.1%) -29 with missing datawith parents of breastfed infants, and8 (18.2%) indicated that they did notroutinely discuss vitamin D supple- 1140 infants predominatelymentation with parents. breastfed for ≥6 mo (58.6% of those initially breastfed)Physicians who did not recommend vi-tamin D for all breastfed infants had FIGURE 1 Survey completion and breastfeeding practices in study children.significantly higher levels of agree-ment with the statement, “A major lim-itation of the AAP recommendation TABLE 2 Rate of Initial Breastfeeding Among Study Infants of Different Racial and/or Ethnic Groups and Rates of Being Predominately Breastfed for at Least 6 Monthsthat all breastfed infants receive sup- Race/Ethnicity No.a % Initially % Predominantlyplemental vitamin D is that the recom- Breastfed Breastfed for 6 momendation is not evidence based,” Black 120 62.5 24.2than pediatricians who recommended American Indian/Alaskan Native 42 88.1 52.4vitamin D for all breastfed infants (39 Asian/Pacific Islander 427 81.5 44.8total responses; P .011). Those prac- White 1695 85.1 52.4 Hispanic ethnicityb 232 73.7 41.0titioners who were not universally rec- a Data on children whose parents indicated that they were of multiple races are included in more than 1 race category.ommending vitamin D also had higher b Includes children from all racial groups.levels of agreement than those whouniversally recommended supplemen-tation for breastfed children with the breastfeeding practices of their chil- As shown in Fig 1, surveys were com-statement indicating that recommend- dren are summarized in Fig 1. Among pleted by parents of 1140 children whoing supplementation might lead some the 2364 eligible children whose par- were predominantly breastfed for atmothers to choose to not breastfeed ents completed surveys, 1945 (82.6% least the first 6 months of life. The resttheir infants (P .042). There were no [95% CI: 81.0%– 84.1%]) were mainly of the analysis was focused on thesesignificant differences in levels of fed with human milk during their first 1140 study infants and toddlers. Over-agreement for the statement regard- month of life. The race and ethnicity of all, 181 of 1139 of these childrening the importance of following AAP eligible children are shown in Table 2 (15.9% [95% CI: 13.8%–18.1%]) wereguidelines and the statement regard- along with the rates of initial breast- routinely given supplemental vitamin Ding the possibility of rickets in breast- feeding and the proportion who were during the first 6 months of life. Infor-fed children who were not supple- predominantly fed human milk for at mation on vitamin D use for 1 child wasmented between those pediatricians least 6 months. The mean age of the missing. Use of supplemental vitaminwho routinely recommended vitamin D infants and toddlers at the time their D in predominantly breastfed infantsand those who had another policy re- parents completed the survey was 12.1 varied according to race, with val-garding supplementation. months (SD: 4.8 months); 25% were ues ranging from 14.2% (95% CI:Data on completion of the infant- aged 8 months or younger, and 25% 11.9%–16.6%) among white children tofeeding survey by parents and on were aged 16 months or older. 27.1% (95% CI: 20.9%–34.0%) among108 TAYLOR et al Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 6. ARTICLESTABLE 3 Univariate Association Between Vitamin D Use and Patient Characteristics, Parental tamin D supplementation and that vita- Beliefs, and Policy of the Child’s Pediatrician Among Study Children Who Were Predominantly Breastfed for at Least the First 6 Months of Life mins are important for a child’s over- Variable ORa 95% CI No.b all health were the only variables thatWhite 0.63 0.44–0.90 1089 were positively and significantly asso-Nonwhite race and/or Hispanic ethnicityc 1.67 1.22–2.27 1089 ciated with the use of vitamin D. Con-Black 1.12 0.49–2.62 1089 versely, parental agreement that sup-Asian/Pacific Islander 2.02 1.43–2.87 1089Hispanic ethnicity 0.93 0.56–1.54 1084 plementation is unnecessary becauseChild’s age 1.00 0.97–1.03 1139 breast milk has all needed nutritionParent agrees: vitamins important for overall health 5.22 3.45–7.90 1101 and that giving vitamins is inconve-Parent agrees: vitamins needed to prevent rickets/other diseases 2.77 1.93–3.98 1020Practitioner survey: child’s doctor recommends vitamin D for all 3.88 2.23–6.73 926 nient were both significantly associ- breastfed infants ated with not using vitamin D. Addi-Parent agrees: child’s doctor recommended vitamin D 19.52 10.61–35.93 1083 tional models that included all racialParent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.07 0.04–0.13 1109Parent agrees: giving vitamins inconvenient 0.59 0.42–0.84 1087 variable terms and/or data on theParent agrees: vitamins not needed if infant is out in sunlight 0.29 0.17–0.49 1074 child’s pediatrician’s recommendationChild’s doctor’s recommendation regarding vitamin D important in 2.88 1.65–5.03 1037 regarding supplementation were ana- parent’s decision about vitamin D supplementationa lyzed. The results of every analysis OR was calculated by using logistic regression after accounting for clustering of children into different practices.b No. indicates number of valid responses to each item. were similar. Parental agreement thatc Of the study children, 335 of 1090 (30.7%) were nonwhite race and/or Hispanic ethnicity; information on vitamin D vitamin D was recommended by thesupplementation was collected for 1089 of these children. child’s physician (adjusted ORs rang- ing from 7.76 to 8.93 in different analy-Asian/Pacific Islander children. A total tritional rickets are nonwhite and/or ses) and agreement that vitamins areof 29 black patients were predomi- Hispanic,16 only 1 race variable (non- good for overall infant health (ad-nantly breastfed for at least 6 months; white race and/or Hispanic ethnicity, justed ORs: 1.98 –2.23) were signifi-6 of these children (20.7%) received or non-Hispanic white race) was in- cantly associated with providing sup-supplemental vitamin D. The rate of vi- cluded in the model. In addition, be- plementation; agreement that breasttamin D usage among Hispanic chil- cause 213 predominantly breastfed milk had all needed nutrition (adjusteddren who were breastfed for at least 6 study children had an initial primary ORs: 0.10 – 0.12) and agreement thatmonths without significant formula care provider who was not a member giving vitamins is inconvenient (ad-supplementation was 15.8% (95% CI: of PSPRN and did not complete the justed ORs: 0.45– 0 .46) were statisti-9.1%–24.7%). practitioner survey, data on the child’s cally associated with not giving vita-The univariate association between vi- pediatrician’s vitamin D recommenda- min D.tamin D use in predominantly breast- tion policy were not included in the When asked to identify their child’sfed children and several variables, in- larger model. The results of the multi- main doctor during the first 6 monthscluding race, ethnicity, age, parental variate analysis are shown in Table 4. of life, parents of 927 patients listed abeliefs, and the policy of the child’s pe- Of the variables assessed in the full PSPRN pediatrician who had com-diatrician regarding supplementation, model, parental agreement that the pleted the practitioner vitamin D sur-are summarized in Table 3. In the child’s pediatrician recommended vi- vey (81.3% of those infants who wereunadjusted analyses, most of the vari-ables assessed were statistically asso-ciated with supplementation. To iden- TABLE 4 Multivariate Analysis to Identify Patient Characteristics, Parent Beliefs, and Providertify characteristics and beliefs that Policies Associated With Vitamin D Supplementation in Predominantly Breastfed Infantswere independently associated with vi- Variable ORa 95% CItamin D use in breastfed infants, an Nonwhite race and/or Hispanic ethnicity 1.29 0.81–2.06analysis including those variables sig- Parent agrees: vitamins important for overall health 1.98 1.17–3.34 Parent agrees: vitamins needed to prevent rickets/other diseases 1.37 0.81–2.31nificantly associated with supplemen- Parent agrees: child’s doctor recommended vitamin D 7.76 4.11–14.64tation in univariate comparisons was Parent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.12 0.07–0.23conducted. Because of both the over- Parent agrees: giving vitamins inconvenient 0.45 0.26–0.76 Parent agrees: vitamins not needed if infant is out in sunlight 0.94 0.42–2.10lap between several racial and ethnic Child’s doctor’s recommendation regarding vitamin D important in 1.83 0.77–4.39groups and evidence that 90% of decision about vitamin D supplementationchildren in the United States with nu- a OR calculated using logistic regression after accounting for clustering of children into different practices.PEDIATRICS Volume 125, Number 1, January 2010 109 Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 7. predominantly breastfed). Among this secular trend, there were no sig- tific and lay press, has likely increasedthese 927 study children, 218 (23.5%) nificant changes in the results; 4 vari- interest in providing vitamin D towere seen by a health care provider ables (agreeing that the child’s doc- breastfed infants. In our study, wewho indicated that he or she routinely tor recommended supplementation, found that vitamin D use increased sig-recommended supplemental vitamin D agreeing that vitamins are important nificantly during the final third of ourfor all breastfed infants. Parents of for overall infant health, agreeing that study period (roughly covering the pe-children whose provider universally breast milk has all needed nutrition, riod of late 2007 to mid-2008) whenrecommended vitamin D for breastfed and agreeing that giving vitamins is in- there was publicity about vitamin D.13,14infants were significantly more likely convenient) remained significantly as- However, even during this most recentto agree that the provider recom- sociated with vitamin D use. period, fewer than one quarter of themended this supplement than those of responding parents of predominantlychildren whose pediatrician had an- DISCUSSION breastfed infants reported giving vita-other policy (64.7% and 22.7%, respec- Our results indicate that only a minor- min D to their children. The same fac-tively; OR: 3.10 [95% CI: 1.95– 4.91]). ity of study children who were predom- tors (their child’s doctor’s recommen-Parents of nonwhite and/or Hispanic inantly breastfed for 6 months re- dation and a belief that breast milk haschildren were also more likely to agree ceived supplemental vitamin D. This all needed nutrition) remained signifi-that their child’s provider recom- rate of usage is explained, to a large cantly associated with a parent’s deci-mended vitamin D than those of white degree, by 2 conflicting influences. sion regarding supplementation.non-Hispanic children (44.6% and Parents who reported that their child’s27.8%, respectively; OR: 1.75 [95% CI: As expected, we found a high rate of pediatrician recommended vitamin D1.37–2.27]). Overall, 33.3% of respond- breastfeeding in this population of in- were 8 times more likely to provideing parents indicated that their child’s fants seen in primary care pediatric the supplementation than parentsprovider recommended vitamin D practices in the Seattle area. In 2002, it whose child’s pediatrician did notsupplementation. Among these par- was estimated that 71% of US children make this recommendation. However,ents, 44.6% gave the supplement to had ever been breastfed and that only one third of the parents of breast-their child versus 2.8% of those 63.2% were breastfed at 1 month of fed infants indicated that the pediatri-whose child’s provider did not rec- age. The Pacific region of the country cian recommended vitamin D. In addi-ommend vitamin D (OR: 19.52 [95% CI had the highest reported rates of tion, and perhaps the most striking10.61–35.93]). breastfeeding, with 76.4% of infants finding of this study, fewer than half from this region reportedly beingAmong the responding parents of chil- (44.6%) of the parents who respondeddren who were predominantly breast- that vitamin D was recommended by breastfed at 1 month of age.18 We foundfed for at least 6 months, 743 of 1110 their child’s pediatrician actually ad- that 82.6% of the children in our study(67.0%) agreed with the statement ministered the supplementation. This were mainly breastfed during the firstthat vitamin D supplementation is not counterintuitive result is partially ex- month of life. We also found thatrequired because breast milk has all plained by our finding that 67% of the breastfeeding among black infantsneeded nutrition. Only 3.0% of children parents believed that supplementation was more common in our populationof these parents received supplemen- is unnecessary because breast milk than nationally. However, breastfeed-tal vitamin D. has all needed nutrition. Parents who ing rates in Hispanic infants in our had this belief were 9 times less study were comparable to US rates forThere was an increase in the use of likely to give supplemental vitamin D Hispanic infants.18 Perhaps more sur-vitamin D in predominantly breastfed than those who did not agree with this prising was the finding that 1140 of theinfants during the 2-year study period.During the first third of the period, statement. 2364 infants in the study (48.2%) were10.8% of these children received sup- Initially, vitamin D supplementation breastfed with little or no formula sup-plemental vitamin D; 12.7% received was recommended for breastfed in- plementation for at least 6 months.the supplement during the middle fants as a method to prevent rickets.2 This is substantially higher than thethird and 24.0% during the last third of However, there is emerging evidence 35.1% of infants nationally who arethe study period (OR: 1.60 [95% CI: that vitamin D may play an important breastfed for at least 6 months.181.10 –2.32] for comparison between role in mitigating other disease pro- It is possible that the high rate ofthe final and first third of the study pe- cesses in children.1,17 Information breastfeeding in study children wasriod). However, after controlling for about this evidence, both in the scien- linked to the reticence of the respond-110 TAYLOR et al Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010
  • 8. ARTICLESing pediatricians to recommend vita- man and Svec reported among 128 fants among participating pediatri-min D in at least 2 ways. Pediatricians military pediatricians.9 cians. Our results suggest that vitaminwho did not universally recommend A potential limitation of this study is D use is strongly linked to physiciansupplementation had a belief that rec- that parents of children up to 2 years recommendations. Efforts to increaseommending vitamin D might cause old were asked to report whether vita- physician acceptance of vitamin D rec-some parents to not breastfeed their mins were given during the first 6 ommendations should lead to moreinfant. Perhaps these practitioners months of life and the reasons for this use in infants and increase compli-were wary of any intervention that choice. It is possible that some parents ance with AAP guidelines.6 However,would alter the high prevalence of did not recollect correctly. To some ex- the results of our study also suggestbreastfeeding. Conversely, pediatri- tent, our finding that significantly that there is a strong belief by parentscians may have been hesitant to bring more parents of study children whose that breast milk has all needed nu-up supplementation to parents who pediatricians universally recommend trition. To a large degree, this beliefhave strong beliefs about the nutri- vitamin D indicated that the practitio- supersedes physician recommenda-tional advantages of human milk. We ner recommended supplementation tion. Thus, to substantially increase vi-found that 68.2% of responding pedi- than those whose child’s pediatrician tamin D use in predominantly breast-atricians recommended vitamin D did not tend to validate the accuracy of fed infants, public health educationalsupplementation for some or all parental reporting on the surveys. campaigns should also directly targetbreastfed infants. Although this is parents.higher than rates found in surveys of CONCLUSIONSproviders conducted before the AAP At the time that we began this study in ACKNOWLEDGMENTrecommendation in 2003,7,8 it is 2006, there was significant resistance This study was funded by a grant fromlower than the 89% rate of recom- to the AAP recommendation for sup- the Agency for Healthcare Researchmending supplementation that Sher- plemental vitamin D for breastfed in- and Quality.REFERENCES 1. Misra M, Pacaud D, Petryk A, Collett-Solberg dren, and adolescents. Pediatrics. 2008; 2007. Available at: PF, Kappy M; Drug and Therapeutics Com- 122(5):1142–1152 2007/07/09/health/webmd/main3032600.shtml. mittee of the Lawson Wilkins Pediatric En- 7. Davenport ML, Uckun A, Calikoglu AS. Pedia- Accessed April 24, 2009 docrine Society. Vitamin D deficiency in chil- trician patterns of prescribing vitamin sup- 14. Collins AT. Kids’ low vitamin D worries doctors. dren and its management: review of plementation for infants: do they contribute June 18, 2008. Available at: http://abcnews.go. current knowledge and recommendations. to rickets? Pediatrics. 2004;113(1 pt 1): com/Health/Diet/Story?id 4982913&page 1. Pediatrics. 2008;122(2):398 – 417 179 –180 Accessed April 24, 2009 2. Gartner LM, Greer FR; American Academy of 8. Shaikh U, Alpert PT. Practices of vitamin D 15. Gunn PP, Fremont AM, Bottrell M, Shugar- Pediatrics, Section on Breastfeeding and recommendation in Las Vegas, Nevada. J man LR, Galegher J, Bikson T. The Health Committee on Nutrition. Prevention of rick- Hum Lact. 2004;20(1):56 – 61 Insurance Portability and Accountability Act ets and vitamin D deficiency: new guidelines privacy rule: a practical guide for research- for vitamin D intake. Pediatrics. 2003; 9. Sherman EM, Svec RV. Barriers to vitamin D ers. 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  • 9. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods James A. Taylor, Leah J. Geyer and Kenneth W. Feldman Pediatrics 2010;125;105-111; originally published online Nov 30, 2009; DOI: 10.1542/peds.2009-1195Updated Information including high-resolution figures, can be found at:& Services This article cites 13 articles, 10 of which you can access for free at: This article has been cited by 1 HighWire-hosted articles: sSubspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism mPermissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online: Downloaded from Provided by Stanford Univ Med Ctr on February 5, 2010