Signifying the importance of vitamin D and the consequences of its deficiency in pregnant women.

1. TABLE OF CONTENTS
CHAPTER 01: INTRODUCTION.................................................................................................4
CHAPTER 02: LITERATURE REVIEW....................................................................................... 7
CHAPTER 03: OVERVIEW OF METHODOLOGY AND FINDINGS......................................... 11
CHAPTER 04: DISCUSSION OF THE THEMES ARISING FROM THE REVIEW..................... 14
CHAPTER 05: REFERENCES................................................................................................... 25
CHAPTER 06: APPENDIX........................................................................................................ 28

2. ABSTRACT
Vitamin D deficiency is alarmingly low in worldwide population that is the fundamental
reason for numerous skeletal and non-skeletal diseases like rickets, schizophrenia, body ache,
small-for-gestational, diabetes and much more. Considering the rising rate of vitamin D
deficiency trends by the healthcare centres, a research was conducted to unravel the source of
the problem and develop solutions to eradicate the illness from its root. During the research,
it was found that females who are pregnant are at greater possibility of vitamin D
insufficiency than the non-pregnant females. Due to this, neonates and infants born of
vitamin D deficit women are also predisposed to vitamin D deficiency. Moreover, pregnant
women lacking sufficient vitamin D concentration in their bodies suffer from preterm birth,
caesarean section, body ache and preterm labour. If lactating mothers lack necessary levels of
vitamin D, the breast milk also lacks the required nutrition for their kids. Healthcare centres
in United States, United Kingdom and other European countries are advising mothers to give
oral supplements to breastfed infants or to switch to formula based milk. As the law of nature
has always made mother’s breast milk the entire and sole feed for the infants, this deficiency
had raised concerns for medical researchers. Through numerous researches held in United
Kingdom, America and various European countries, it was found that 20-100% women
across the globe are victims of vitamin D insufficiency. In studies conducted,
recommendations for pregnant women and infants were discovered to be optimal at
75nmol/L. If women take oral supplements and maintain their vitamin D levels, then their
breast milk will be sufficient for their infants and there is no need for the infants to take any
oral supplements or switch to formula based milk at all. The primary resources were selected
from United States, United Kingdom and European States keeping in mind that they follow
the same clinical health standards as the ones followed in UK. The study papers were selected
from Google Scholar and EBSCOhost health research database using the keywords vitamin D
insufficiency in adults, vitamin D intake methods, vitamin D fluctuating levels in three
trimesters of pregnancy, vitamin D need in newly born babies, vitamin D and lactating
mothers with consequent health of postnatal, vitamin D levels in breastfeeding women and
neonates and efforts needed to maintain breastfeeding as main source of nutrition for
neonates instead of resorting to formula based milk as a substitute. The essay introduces the

3. topic in Chapter1 of Introduction. Then it moves on to the literature review in Chapter 2
where some of the previous work of researchers on vitamin D is explained briefly. The
chapter 3 discusses the aims of the research essay and previous researchers’ contribution was
mentioned to develop an inference implying the importance of vitamin D in pregnant women
and children. Then in Chapter 4, Discussion of the Themes Arising from the Review were
explored in detail by referring to the studies conducted worldwide and the results they found
to further strengthen the argument that with optimal vitamin D levels in pregnant and
lactating women, infants shall be provided the desired amount of daily vitamin D
consumption through mother serum in placenta and through breast milk successfully.

4. CHAPTER 01: INTRODUCTION
Vitamin D is treasured for the indispensable part it plays in the growth of calcium
homeostasis and bone fitness ever since 1921. In this essay, the primary need and importance
for vitamin D supplements for pregnant females and infants is explored. As the vitamin D
deficit levels in the populace increases leaving a vast percentage of them disabled physically
or mentally, there is a dire need to focus on the contributing factors to resulting in vitamin D
deficiency so that they can be tackled and prevented before they cause the damage.
Vitamin D provides protection for bone and muscle health (Public Health England, 2016)
(PHE). The development of healthy bones requires calcium, but the shortage of vitamin D
affects the absorption of calcium which, as a result, is actively prevented. Hence, it is more
likely to cause bone deformities and a severe condition such as Rickets (Moran, 2013;
Gluckman, et al., 2015). Due to deficiency of sunlight during the months of autumn and
winter in the United Kingdom (UK), PHE recommends that population as a whole should
take a supplement of 10 micrograms of vitamin D with a balanced diet that contains natural
or fortified vitamin D.
The diversity of risks related with vitamin D deficit especially in pregnant women and new
born infants include Pre-elampsia in pregnant mothers and low birth weight, neonatal
hypocalcaemia and tetany in the infants. More than ninety per cent of vitamin D comes from
the sun; direct sunlight to the skin allows the body to produce vitamin D, which is crucial for
the absorption of calcium and phosphate (Moran, 2013). Current practice in health visiting
when advising nursing mothers about vitamin D is that exclusively breastfeeding baby should
take supplements of vitamin D, however, if the baby is fully formula fed they do not need to
be given the supplements as the formula itself is fortified with vitamin D. As a student health
visitor, it sounds contradicting that on one hand it is advised that breastfeeding is the best
source of nutrition for the baby and on the other hand it does not contain the essential vitamin
the baby needs. This thought triggered for an answer to enable evidence based practice, as it
allows rationalising professional integrity and accountability when determining best practice
(Aveyard, 2014). As (Aveyard, 2014) highlights questions arising from practice which will
eventually allow the practitioners to feed back into practice, hence the following question
arose “What factors are associated with lack of vitamin D in pregnant mothers and infants?”

5. Since it is a rising problem in the current pregnant women, it is alarmingly troublesome due
to deteriorating health rate of pregnant women and delivery of premature babies. This essay
focuses on the health problems faced by the pregnant women, new born babies and women
after delivery of babies. Moreover, the essay discusses in detail the usage and need of vitamin
D in humans generally, in women during the days they are pregnant, in lactating women and
babies post-delivery for at least four months on physical health such as muscles, bones, and
limbs. It hopes to emphasize on the prominence of regular vitamin D consumption in various
forms and explores the various forms in which vitamin D can be consumed. It is a vital step
towards developing the importance on vitamin D consumption as it is primarily not taken into
consideration in daily nutritional intake hence the low vitamin levels in the population. The
long-lasting effects of vitamin D deficiency are irreversible. Therefore, raising awareness is
necessary to ensure health of pregnant women, lactating mothers and new-born babies.
Despite the importance of vitamin D being the topic of discussion of many previous
researches, there is no precedent relating to the entirety of the dimensions related to the
process of childbirth and its relationship with vitamin D along with its impact on physical
health. Therefore, efforts will be made on producing a thorough research and developing an
argument for the essence of vitamin D and the vitality of it throughout pregnancy and
childhood.
The aim of the review was to look at studies conducted in the United Kingdom about the
dynamics related with lack of vitamin D in pregnant mothers and infants. However,
throughout the search of the literatures it was identified that there were not many studies
conducted in the UK, most of the studies were either reviews or articles on the subject,
therefore, this literature review will look at studies from the United States, New Zealand, and
Europe as health care provisions are similar to Britain.
Firstly, the essay shall reflect on historical background of vitamin D’s importance and then,
the state of the art ideas shall be inferred in chapter 2, namely ‘overview of methodology and
findings’. After that in chapter 3 called ‘discussions of themes arising from the review’, all
the findings in chapter 2 will be explored and reviewed in further detail. Furthermore, an
analytical deduction will be made on the current levels in pregnant and lactating mothers and
the effects of that on the newly born child and whether the presumed importance of Vitamin
D and its current sources are enough considering the nutrition levels required for healthy
growth.

6. Primary search has been done on vitamin D deficit levels in adults, vitamin D intake
methods, vitamin D fluctuating amounts in three trimesters of pregnancy, vitamin D need in
new-born babies, vitamin D and lactating mothers including the consequent health of
postnatal, vitamin D levels breastfeeding women and neonates and their relationship, and
efforts needed to maintain breastfeeding as the main source of nutrition for neonates instead
of resorting to formula milk entirely.

7. CHAPTER 02: LITERATURE REVIEW
The effect of Vitamin D in pregnant women in Asia on the growth of fetus was determined
by Brooke at al., (1980). There were two groups of women made. One group was given
ergocalceferol in their diet in their last trimester. The other group was treated by placebo. It
was observed that all the mothers in the Vitamin D treated group gained faster weight in their
last trimester. Thus it was concluded that the addition of Vitamin D in the diet of women
promotes the healthy growth of their infants and helps in the proper ossification of the skulls
of them.
A study by Hypponen et al., (2001) suggests that the intake of vitamin D in the diets of
pregnant women reduces significantly the risk of diabetes type-I in their infants. An
experimental group of children was made and kept under observation. The children in the
experimental group were all in their first year of life. Another control group was made that
included the children of the same age. The experimental group was supplemented with
vitamin D in their diet. The control group did not receive the supplementation. The results
were obtained that showed that the children in the experimental group had decreases risk of
diabetes type-I and rickets development for the next years of their life. The children in the
control group showed affinity for the development of rickets and diabetes type-I in the later
years of their life.
A study by O’Dell et al., (2002) pays attention towards the prevalence of Hypovitaminosis D
in White and African American women that reached a reproductive age. Hypovitaminosis D
is defined as the deficiency of vitamin D in blood serum. This deficiency was observed to be
present in the women of reproductive age because their diet lacked vitamin D in their life
earlier. They did not take any vitamin D supplements. All those women had less body mass
index value. These women were diagnosed with the less ability to conceive and nourish their
fetus. All those women were recommended a suitable dose of vitamin D to be incorporated in
their regular diet.
MD et al., (2002) studied the relationship of vitamin D deficiency in the milk of lactating
mothers and its impacts on the skeleton of their newborns. The adequate level of Serum 25-

8. hydroxyvitamin D (250HD) is necessary in the milk of mothers for the right growth of their
young ones. When the level dropped from the critical values, the development of bones was
observed to be halted and the mineralization of bones was discovered. Thus vitamin D was
found to play a ital. role in the strong development of skeleton in young ones who are
dependent on the milk of their mother.
Pettifor (2004) determined the critical role of vitamin D and calcium deficiency in nutritional
rickets. Nutritional rickets is the leading public health concern in Nigeria, Yemen,
Bangladesh and Ethiopia. Nutritional rickets was fought by sunlight and vitamin D
supplementation in diet of such infected people. The infants were observed to be the main
victim of vitamin D deficiency because of the lack of vitamin D in the breast milk of their
mothers. The diet low in calcium promotes the catabolism of vitamin D more and thus leads
to the nutritional rickets. This condition can be fought effectively by the appropriate
supplementation of vitamin D and calcium in the diets of people suffering from it.
While everyone was studying the role of vitamin D in bone tissue development, Mc Grath et
al., (2004) studied the role of vitamin D in schizophrenia development. Two group (control
and experimental) were made. The experimental group was supplemented with vitamin D in
appropriate level in their diet. All those individuals in the experimental group were observed
to have a reduced risk of schizophrenia that is a psychotic disorder. The less supplementation
of vitamin D in the diet poses a threat of schizophrenia in individuals in their earlier or later
life. The study concludes that the early steps to avoid hypovitamosis D in the childhood leads
to the reduced risk of schizophrenia in the later life of an individual.
Mannion et al., (2006) studied the effect of reduced milk consumption in the pregnant
women. According to medical science, some proteins in milk might cause an allergy to the
pregnant women so they are advised not to take milk in their diet while they are pregnant.
Milk houses the vitamin D, protein, riboflavin and calcium in it. If the intake of milk is
discontinued along with no intake of vitamin D and other supplements in the diet of such
pregnant women, the child born to such women have a health risk that is posed to them by
their lower milk as the vitamin D in milk promotes their growth.
Bodnar et al., (2007) studied the relationship between the deficiency of vitamin D and
Preeclampsia. They found out that the deficiency of vitamin D in the diet leads to the high
risks of preeclampsia. The molecular and endocrinological basis of relationship of vitamin D
to preeclampsia has yet not been known. For this study two groups – control and

9. experimental were made. The experimental group of pregnant mothers was supplemented
vitamin D in their diet while the control group of pregnant mothers lacked vitamin D
supplementation in their diet. The newborns of them were assessed for preeclampsia. The risk
of preeclampsia was less in the newborns whose mothers were properly supplemented with
vitamin D in their diets.
A study by Bodnar et al., (2007) was concerned with the vitamin D status in the diets of
White and Black pregnant mothers and their neonates in Northern United States. It was
explored that the insufficiency of vitamin D in the diet of women and their neonates was the
leading cause of skeleton deformation, diabetes type-I, schizophrenia, preeclampsia and other
complex of problems. By only a proper supplementation of vitamin D in the diet, all these
medical threats can be conveniently fought.
Misra et al., (2008) discussed the management of vitamin D deficiency in children. This
study reviewed the current knowledge of vitamin D deficiency and recommendations to fight
this problem. The study recommends the use of all natural and synthetic sources from where
one can obtain the vitamin D in his diet. The study also found out the sources that optimize
the synthesis of vitamin D and its intake. The Drug and Therapeutics Committee of the
Lawson Wilkins Pediatric Endocrine Society played an active role in all the findings of this
study.
Wagner et al., (2008) studied on the ways to prevent the vitamin D deficiency and rickets in
children, infants and adolescents. They found out that the insufficient levels of vitamin D in
the diet of infants promote rickets in them. There is a limited number of natural sources of
vitamin D. The sunlight is an alternative and effective source of vitamin D but the sunlight as
a source inhabits a problem too. The problem is that the adequate levels of sunlight are yet
not determined for a person and the excess of sunlight promotes the proliferation of cancer
cells in skin. After their study, their conclusion stated that the children including infants and
adolescents require 400 IU of vitamin D on daily basis in their diet. The vitamin D
supplementation in diet promotes the innate immunity that helps fighting the cancer and
diabetes.
Mithal et al., (2009) studied the global status of vitamin D and hypovitaminosis D
determinants. They studied the prevalence of vitamin D deficiency across the globe. The
common determinants of hypovitaminosis D and vitamin D deficiency were determined by
them. The main regions included in the study were Europe, Asia, Africa, Middle East,

10. Oceania, North and Latin America. Middle East and South Asia were the regions where the
vitamin D deficiency was the most prevalent due to the less exposure of sunlight and dietary
habits. Vitamin D deficiency was reported to be the re-emerging problem globally and is
posing a serious health threat.
A study by Merewood et al., (2009) targets the relationship between the deficient levels of
vitamin D and their primary caesarian section. It was discovered that the mothers lacking
vitamin D in their diet has a highest vulnerability to death during normal child birth. The
molecular role of vitamin D behind these deaths is yet not established. The research
establishes a direct relationship between the low serum levels of 25-hydroxyvitamin D
[25(OH)D] in the pregnant women and their primary cesarean section.
Miyake et al., (2009) studied the effect of consumption of vitamin D, calcium and other dairy
products by pregnant women on the infants between 16 to 24 months in terms of eczema and
wheeze development. They studied 763 Japanese pregnant women. They recorded their
vitamin D intake in their diet. They reached a conclusion that a higher intake of vitamin D,
calcium and other dairy products by pregnant women reduces the risks of wheeze and eczema
development in infants. The consumption of 4.309 µg/day of vitamin D by the mothers can
significantly reduce the eczema and wheeze development in infants.
Holick et al., (2011) developed a clinical practice guideline for the endocrine society by
evaluation of the treatment and prevention of deficiency of vitamin D. they established that
the level of serum 25-hydroxyvitamin D should be measured in all those patients who are
suspected to be suffering from vitamin D deficiency at first. If there is a diagnosis of the
vitamin D deficiency in them, they should be treated by vitamin D supplementation.
Important vitamin D supplementation includes vitamin D2 and D3. They are considered an
effective source to combat vitamin D deficiency. The vitamin D deficiency also initiates the
cardiovascular and noncalcemic disorders.
Allen et al., (2013) studied the relationship of vitamin D deficiency and various allergies. He
studied the food allergies in children to egg, peanuts, nuts, shrimp or seasame by the skin
prick testing. All those children possessing the allergen gene in their genome, there was
initiation of the allergy to their respective allergen food. The serum 25-hydroxyvitamin D
level was measured in all those children by tandem mass spectrometry and liquid
chromatography. It was found that all those allergic children have lower level of vitamin D in
their serum. Similar skin pricking tests were conducted on children that were previously not

11. known for any allergy. The skin pricking with multiple allergic substances did not show any
reaction. Upon liquid chromatography and tandem mass spectrometry of the vitamin D levels
in the serum of such children, it was established that all those children possess adequate
vitamin D levels. All those children did not have eczema as the vitamin D reduces its risks.
Hence their study concluded that the deficiency of vitamin D promotes certain kinds of
allergies in children.
CHAPTER 03: OVERVIEW OF METHODOLOGY AND FINDINGS
The aim of this essay is to delve deep into sufficient levels of vitamin D in pregnant mother
and children, explore the impact of vitamin D deficit and the need to battle the factors
contributing to the deficiency in vitamin D from the roots and develop a strong inference of
continuing breastfeeding instead of using formula milk as a substitute. Furthermore, the need
for oral supplementation to infants has to be minimized by making lactating mothers strong
enough to fend children from vitamin D deficit related diseases. To amount for a viable
research essay, all the resources have been retrieved from 2010-2018 in order to come up
with state-of-the-art solutions for the problem at hand. The research strategy focuses on
library search using EBSCOhost and Google Scholar using the key search terms Vitamin D
and breastfeeding, Healthy implication, postnatal, neonate, pregnancy and vitamin D.
Vitamin D is cherished for its imperative part in biological (Calcium phosphorus)
homeostasis and skeletal fitness ever since 1920s (Kennel, 2010). (Woolcott, et al., 2016)
identified that optimal vitamin D levels have been known to reduce probability of
“gestational diabetes, preeclampsia, bacterial vaginosis, preterm birth, small for gestational
age infants, and later child health outcomes of low bone density, asthma and type I diabetes.”
Its deficiency has adverse effects on skeletal and non-skeletal muscles including pregnant
women as concentration levels less than 50nmol/L are known to lead to dangerous perinatal
circumstances (Woolcott, et al., 2016). In another research conducted by Lundqvist et al.,
(2016), around one-third women were detected with 25(OH) vitamin D levels lower than
50nmol/L. Lower 25(OH) D concentration has been identified as a contributing factor of
osteoporosis and prostate cancer (Bodnar, et al., 2010). Another life-risking condition
associated through vitamin D deficit was revealed in a research that led doctors to believe
that lower vitamin D levels in mothers have a direct correlation with earlier childbirths than

12. the due delivery time (Moon 2015, Harvey 2014, Dregil 2016). Other researchers have found
sufficient evidences to assume that there is a risk of respiratory infections in babies along
with baby’s small body size and bone mineralization (Krieger, et al., 2018).
Since ancient times, breastfeeding has been endorsed for healthy nutritional boost in
breastfed infants. However, a research proves that purely breastfed babies are prone to rickets
than formula fed children (Wagner, 2015). Rickets is known as a deformation caused by lack
of mineral that stubs the “growth of plate, increased bone deformities, biochemical
abnormalities, impaired growth, and seizures” (Wheeler, et al., 2016). According to Goldacre
et al., (2014), nutritional rickets is related with vitamin D deficit in diet and inadequate
disclosure to daylight which reduces vitamin D production in the skin, and due to increased
incidences of rickets, the Chief Medical Officer made a case in England to supplement all
under 5 children with vitamin D to prevent incidences of rickets in 2013 (Professor Dame
Sally C Davies, 2013). Bodnar et al (2010) also highlighted the aforementioned diseases and
dwelled on about predisposition for schizophrenia during pregnancy. Due to studies
conducted in Canada, Australia and New Zealand, common factors were discovered which
led to vitamin D deficit in children such as vitamin D scarcity in mothers during the times
they are pregnant, season of birth and exclusive breastfeeding. Tetany is a condition marked
by intermittent muscular spasms, and it is caused by calcium deficiency (Gluckman, et al.,
2015).
Due to unclear suggestion of the measurement of vitamin D, however in the United Kingdom
(UK), America (USA) and in Europe the performance of a 25-hydoroxyvitamin D (250HD)
test can be performed, which allows to determine whether a person is deficient or has
insufficient amount of vitamin D in the body (Cancer Research UK, 2010). According to
(Cancer Research UK, 2010), there is no standard optimal level of vitamin D level in the
body, however, anything below 25nmol/l is suggested to be deficient, and anything in the
region of 50nmol/l is sufficient, while 70-80nmol/l is assumed to exist optimal.
As Vitamin D absence goes unnoticed in masses, it does not get diagnosed hence remains
untreated. Moreover, the assumed treatment of oral dietary consumption of vitamin D
resources is not the optimal solution designed for all vitamin D deficit people as it does not
guarantee regain of optimum vitamin D levels in the compromised person (Kennel, 2010).
(Emmerson, et al., 2017) found out in a research conducted on white skinned women for 2
years that 67% breastfed infants have vitamin D deficiency compared to 2% in formula fed

13. infants which shows that entirely breastfed children are prone to higher vitamin D deficiency
than formula fed one.
Then the questions arise, why are women advised to breast feed kids as much as they can
while it is being revealed that formula fed kids are healthier? What is the change in lactation
period in women in recent age that has caused their infants to face vitamin D deficiency? Do
pregnant women require more vitamin D levels than average adults? What are the ways to
combat the arising issue of vitamin D deficiency in new-born babies? How can vitamin D
deficiency be detected and cured before severe deficiency destroys the probability of healthy
life for children before they are even born? How can we detect vitamin D insufficiency in
pregnant women and what measures can be taken to enhance vitamin D levels during
pregnancy? Moreover, how can children with alarmingly low levels of vitamin D get treated
to regulate the vitamin D levels back to the desired one? Is there a risk involved of high
vitamin D levels leading to vitamin D induced toxicity? Considering the fact that black skin
contains pigments that is not receptive to sunrays, what other options do black pregnant
women have to make up for the reduced hormones released through sun baths? What health
hazards are pregnant women with low vitamin D levels succumbed to after they deliver their
baby?

14. CHAPTER 04: DISCUSSION OF THE THEMES ARISING FROM THE
REVIEW
Deficiencies
Vitamin D levels have been the centre of attention of health researchers since decades but
recently, it has been found to be the leading cause of high numbers of body deformations in
newly born babies. Holick (2011) estimates around 20-100% US, Canadian and European
have vitamin D deficit while women who are pregnant or in the process lactation tend to lie at
greater risk of being deficit in vitamin D. Naturally vitamin occurs in biological atmospheres
in two structures namely Vitamin D2 and Vitamin D3. Both are equivalent in their benefits but
are acquired through different resources. Oral supplements are usually used to acquire
ergocalciferol (D2) while major source of cholecalciferol (D3) is taken from exposing skin to

15. ultraviolet radiation (UVB) in sunlight, taking oral supplements, digesting food sources like
milk, oily fish, soy and yogurt etc. Usually food items account for 50-200 IU/serving.
Vitamin D Resources
It is generally assumed that the finest method to obtain vitamin D is by drinking milk, having
fish or even consuming supplements. Despite the fact that these do serve as nutritional homes
of vitamin D, but undeviating disclosure to the sun is essentially the preeminent technique to
enthral this essential vitamin.
Melanin is an ingredient that controls the complexion of an individual’s skin of how light or
dark your skin colour is, and the proportion of quantity of melanin is integral as the increase
in quantity of melanin in your body determines the darkness of your skin colour. Melanin
becomes unconstrained after an individual is uncovered to daylight. The greater the quantity
of sunshine a person receives; the greater the amount of melanin is released in our skin. It’s
supposed that approximately 90 percent to 95 percent of utmost people’s vitamin D derives
from normal daylight disclosure. The quantity of melanin you partake in your skin affects the
aggregate of vitamin D you can yield, so the fairer your skin, the more effortlessly you can
produce vitamin D.
Melanin is transfigured into functional vitamin D due to the cholesterol levels to be
disseminated all through the body. Due to this reason for several people, a minor to adequate
intensification in cholesterol levels can be evidently noted in the winter months when there is
less disclosure to sunlight, as it’s communal to expend much more time indoors.
Apart from sufficient productive causes such as oily fish, the vitamin D quantity of majority
of the food items is between 50 and 200 IU per plateful although this fluctuates around the
world depending on their packaging and distribution. A foremost source of vitamin D deficit
lies in the fact that mostly adults live indoors and are not exposed to sufficient extents of
daylight that releases Vitamin D3. Using sunscreen creams also reduces the chances of
vitamin synthesis by 90%. Dark-skinned women are generally deficit in vitamin D due to the
dark skin that is naturally protecting them from sun. Dark skinned women need to be basked
in sunshine around three to five times longer than the white-skinned pregnant women.
Furthermore, obese women are predisposed to vitamin D deficiency as BMI has an inverse
proportion to vitamin D concentration in the body. Therefore, obese mothers need to take
more vitamin D than thinner women.

16. These vitamins are only extracted from food origins when they are ingested. During
digestion, liver metabolizes D2 and D3 into 25(OH)D known as the calcidiol. This is then
changed to 25(OH)D2 and 25(OH)D3 and become calcitriol 1,25(OH)2D in kidneys which are
then utilized by endocrine and autocrine actions in cells. Vitamin D deficiency, also known as
hypovitaminosis D, causes obstruction in absorption of calcium through intestinal tracks that
contributes to bone loss. Optimal vitamin D levels in men are found to be 30ng/mL to
40ng/mL for optimal absorption of calcium. Vitamin D deficiency tempers the calcium
absorption rate to only 15% while only 60% of phosphorus is absorbed (Holick, 2011).
Lapillonne (2010) hypothesized and proved that mother’s serum contains vitamin D in the
structure of 25(OH)D that is directly connected to the consumption of vitamin D rich food
and body exposure to sun. As the foetus relies upon the mother’s nutritional feed, calcium
and 25(OH)D passes through the placental vein. Even after birth, the child’s only source of
nutrition is breast milk through which 25(OH)D passes easily (Lapillonne, 2010).
The reason that vitamin D is measured in the body in the form of 25(OH)D is because the
half-life of 2-3 weeks and is known as the best indicator as vitamin D is found in lymph
system in this form.
Vitamin D is accessible in the commercial market in the forms such as ergo-calciferol,
cholecalciferol, and calcitriol. Ergocalciferol and cholecalciferol, formerly considered as
similar in affect, might escalate the growth of vitamin D levels to erratic amounts. Recent
evidences recommend that cholecalciferol surges calcidiol concentrations two to threefold
extra as compared to ergocalciferol.
Deficiencies
Lack of sufficient level of vitamin D has been known to hyperparathyroidism (HPT). This is
coupled with decapitation of intestinal calcium absorption that is vital for metabolic functions
of the body. One of the physical signs that body exhibits during vitamin D deficiency is
fragile bones with low mineral bone density that cause frequent bone fractures. Moreover,
fragile bodies that are susceptible to fall frequently should get their vitamin D levels instantly
checked. For diagnostic measures of detecting vitamin D deficiency, X-rays are conducted,
clinical evaluations are made on deformed skeletal body, biopsy is done and several
biochemical tests are conducted like plasma alkaline phosphatase activity (Lapillonne, 2010).
Bone mineral density causes osteopenia and osteoporosis. As adults have already formed

17. their bodies, the vitamin deficiency is exhibited in terms of body ache and pains in muscles
and bones. Elderly people having vitamin D deficit are more prone to falling while kids with
vitamin D deficit end up having restricted body movement like difficulty in walking and
standing.
After birth, children depend on their mother’s daily feed of breast milk or sunlight exposure
to meet their daily requirement of vitamin D. However, due to lack of sunshine in the
country, both the woman and her child continue to lack the obligatory level of vitamin D.
This results in a very little quantity of vitamin D in the breast milk. It remains insufficient for
the child who cannot procure vitamin D from any other source. Therefore, the child remains
at a superior danger of vitamin D deficit. Even while roaming in a diaper, the child must bath
in sunshine for at least 30 minutes every day to maintain the necessary intake of vitamin D.
Deficiency and Requirement of Pregnant Women
(Bodnar, et al., 2010) states, “Maternal vitamin D deficiency is a major health problem.” The
primary timespan in which vitamin D deficit in pregnant mothers affects the babies is during
pregnancy as all vital parts are being fundamentally developed during that growth age. It can
depict adverse consequences as vitamin D is used in brain growth, skeletal development and
non-skeletal muscles. The known repurcussions of vitamin D insufficiency like subordinate
hyperparathyroidism, osteomalacia and hypocalcemia are found in all adults including
pregnant women. These conditions are not worsened due to pregnancy (Lapillonne, 2010).
Some of the research experiments conducted have highlighted the correlation of vitamin D
deficiency to insulin resistant, gestational diabetes and preeclampsia in pregnant women.
Pregnant women’s daily vitamin level requirement is the same as any adult requirement
however; it changes drastically between women of different ethnicities due to difference in
skin colour and availability of melanin that blocks the sun rays. In countries like United
Kingdom where the sunrays are low on average in comparison to the tropical areas, women
are deprived from an enriching source of cholecalciferol (D3) that aggravates the condition
from dark skinned women who usually block out that sun. Dark skinned women are known to
be predisposed to vitamin D deficiency. Furthermore, there are differences in vitamin D level
of pregnant women depending on their living conditions, season and physical activity as it is
subjected to the amount of sunshine they receive.

18. Vitamin D (D3) levels are lower in light of a figurative comparison between pregnant and
non-pregnant women. A study has revealed that those women who tend to take 10-15 µg/d of
vitamin D have 27% less chance of preeclampsia than the women who do not take
supplements of vitamin D. In another research, pregnant women with consumption of <37.5
nmol/L of vitamin D were more susceptible to having a caesarean division than women with
37.5 nmol/L or higher by four times (Lapillonne, 2010). Moreover, vitamin D deficiency has
accounted for ‘preterm labour, gestational diabetes and preterm birth’ (Pludowski et al.
2013). According to studies conducted by NIHCD and Thrasher Research Fund, women were
given 2000 and 4000 IU/day of vitamin D3 from 12-16 weeks of gestation that showed
improved results of pregnancy after analysing improved levels of (Pludowski et al. 2013).
In order to understand the needs of pregnant women in every country, the whole population
should be taken into consideration with respect to their daily activities. Since United
Kingdom has a similar living standard to that of Europe and the United States, papers from
only these regions were considered for credibility and reliability. 25(OH)D levels do not
really variate in the first trimester in comparison to the other non-pregnant women but
slowly, it gets decreased by the ending term of pregnancy i.e. the third trimester (Krieger, et
al., 2018). This decrease in vitamin D level is accounted for by the increase in plasma
parathyroid hormones. During the duration of the delivery of the baby, the vitamin D
concentration in the baby’s body is more or less the same to that of the mother as the cord
blood is the sole provider of the food (Krieger, et al., 2018).
Organ and skeleton development of the baby happens in the foremost and the second-most
trimester of the gravidity. Then, in the third trimester the baby starts to grow and needs the
reserves of calcium from mother. As calcium absorption is aided by the vitamin D levels in
the woman’s body, her kidney and placenta starts producing 1,25(OH)2D. This helps in
receptive binding of vitamin D protein concentrations. Such high levels then accelerate and
enhance the intestinal calcium absorption.
Lactating Mothers
It is thoroughly believed that the perfect source of nourishment for the baby, since ancient
times, is breast milk. It is the general assumption that the breast milk is enough for the
nursing infant as breast milk contain the antibodies that help the infant fight off the diseases
of the new world. However, recent researched show that breast milk is not enough to combat

19. low vitamin D levels. Due to the lone source of the baby’s food, i.e. the breast milk, the baby
grows a deficiency in vitamin D that restricts physical and mental growth. Currently, breast
milk only covers ten per cent of the suggested intake of vitamin D for the babies. A study
conducted in Germany highlighted that the vitamin D deficit has a high correlation with
winter and spring months, in cases of pregnant mothers, higher BMI and indoor residence
(Gellert, et al., 2017). In the same study, it was deduced that breastfeeding women were four
times prone to vitamin deficiency than non-pregnant women. Only 32% of the women of the
German population took supplements for vitamin D and that too was on an average of 156
IU/day that is extremely low considering the recommended IU of 400-1000 IU per day. This
shows a trend of women facing pregnancy issues and opting for caesarean section due to
complications caused by vitamin D deficiency. According to other studies, women in Sweden
with less than 50nmol/l were 22% in winters due to short daytime and low sun exposure
while it was 15% in summer time. In China, US and Mexico, 43% women face vitamin
insufficiency. Therefore, there newly born babies will be more vulnerable to vitamin D
deficiency caused problems. During lactation period, the level of 25(OH)D further decreases
from the time of their pregnancy as around 77% women had been checked so far in Germany
to face this issue. It might also be caused due to increased BMI after pregnancy. Low bone
density leads to rickets and is only one of the body deformation diseases among the list of
illnesses that deficiency of vitamin D is a factor of (Hollis et al., 2015). In lactating women,
when they are transferring around 20% of their vitamin D to their babies through their breast
milk, a higher intake of vitamin D must be maintained (Pludowski et al. 2013). In a research
conducted by Hollis et al. (2015) and Wagner (), a relationship was formed where it was
deduced that if a deficit is found in the mother’s vitamin D level, so will her breast milk and
for that reason, her child will lack vitamin D as well. Contrariwise, breast milk can be
improved by intake of supplements of vitamin D by the mother orally or by exposing the skin
of the mother to the sun. According to Hollis et al. (2015), currently, mother’s breast milk
contributes to only half (or even lower) i.e. <12.5nmol/L of the required vitamin D level of
the baby’s daily intake. Despite American Academy of Paediatrics’ (AAP) recommendation
for oral intake of vitamin D to breastfed babies, it is rarely taken into consideration. If a
lactating mother intakes 6400 IU vitamin D3 per day, her breast milk will be entirely
sufficient for her infant without further need of oral supplementation to the baby.
As babies after birth grow at the fastest rate in their entire lifespan, their bodies grow and the
bones need calcium to do so. For maximum calcium absorption through intestinal tracts,

20. infants also need vitamin D. This is the reason lactating women are advised to take proper
nutrition during breastfeeding months. For adequate amount of calcium in the breast feed
milk, multivitamins should be taken containing no less than 400 IU of vitamin D coupled
with 1000 IU/day of vitamin D. This amounts for a total of 1400-1500 IU/day that has to be
taken by mother for the sake of the child and herself.
Deficiency and Requirements in Children
Infant birth weight and size is used as a method to correlate mother’s vitamin D deficiency to
that of infants’ reduced growth that used to produce inconsistent findings due to the fact that
infants grow at a remarkable speed hence the prediction of any correlation deemed
unsuccessful in some case (Bodnar, et al., 2010). The past findings also produced inconsistent
results as the growth of the baby was usually analysed in the third trimester when the baby’s
growth rate is the maximum (Bodnar, et al., 2010). In neonates and infants, vitamin D deficit
is directly related to that of mothers as their major source of nutrition is their mothers first
through placenta before birth and then through the milk from the breasts of their mothers
after they are born. The vitamin D absence in kids is turned to rickets in a very short period
especially in those infants that have weak bone density and face malnutrition. A number of
recent researches contribute to the detailed statistics that vitamin D also contributes to non-
skeletal problems and vitamin D scarcity can cause an increased risk factor in developing
abnormalities in fetus. Brain development requires vitamin D. Therefore, brain growth is
reduced under vitamin D deficiency leading to reduced nerve growth, lesser number of genes
for neurotransmission and underdeveloped neuronal structure which plays the fundamental
role in developing schizophrenic predisposition in infants (Lapillonne, 2010). Moreover,
vitamin D ensures protection against developing type 1 diabetes in children. Mothers who
take constant vitamin D supplementation have been recorded to have given birth to children
less prone to type I diabetes. Vitamin D enhances immune system. Therefore, those mothers
who tend to have reported to contain truncated vitamin D levels usually put their foetuses at
risk of asthma or allergic rhinitis.
In a study conducted by (Hollis, et al., 2015), both African American females and their kids
were found at a higher danger of vitamin D shortage due to less receptive skin to UV rays.

21. This leads to severe vitamin D deficit at a level of 2.5nmol/L in infants despite a month long
breastfeeding period.
In struggles to accomplish and sustain the objective of the desired vitamin levels, the AAP
endorses that all the children of varying ages have a duty to be provided with a minute
regular dosage of 400 globally recognized units of vitamin D to avert the symptoms and
danger of rickets and to conserve vitamin D intensities at > 20 ng/mL (50 nmol/L) (Misra et
al. 2008). Term infants ought to be augmented with 400 to 800 units regularly to rationalize
the unsatisfactory transference of motherly vitamin D reserves and confirm calcidiol
concentrations of > 20 ng/mL (50 nmol/L) (Misra et al. 2008). Preterm infants are
additionally probable to be vitamin D scarce as their trans placental transference from their
mom was a petite period, hospitalization following towards an insignificant aggregate of UV-
mediated vitamin D development, and perhaps inferior vitamin D reserves as a poorer fat
mass (Abrams 2013). To cater this population, the AAP issued a descriptive analysis in 2013
on necessities of vitamin D and calcium of entirely fed preterm infants. Even though there are
no clinical concluding reports in this populace, the AAP acclaims 200 to 400 international
units/day of vitamin D supplementation in extremely little birth weight babies (<1500 g) and
400 international units/day of vitamin D supplementation in infants weighing > 1500 g. This
is practical to contemplate growing this quantity to 1000 units per day in > 1500 g infants, as
it is the recognized greater unobjectionable dosage for hale and hearty full-term infants. The
calcidiol concentration objective in the preterm populace residues is equivalent to the full-
term infants (>20 ng/mL). The IOM, in 2010, delivered strategies that augmented the
suggested dietary requirement of vitamin D to 600 international units regularly for fit
children 1 to 18 years of age, which has been resonated by the Endocrine Society.
Steps for vitamin D improvement
Holick (2011) acclaimed a regular prescription of 400 IU/d of vitamin D for 0 to 1 year olds
while children older than 1-year old till they are 18 years old need 600IU/d of vitamin D for
healthy bone structure as it is a speedy growth age. To bring the 25(OH)D intensities in the
blood above 75nmol/l, a regular dosage of 1000 IU/d of vitamin D is recommended. To
maintain a recommended 25(OH)D level of 75nmol/l for both preganant and lactating
women, no less than 1500-2000 IU/d of vitamin D intake is mandatory. In case of vitamin D
deficiency in neonates from 0 to 1 year olds, a daily intake of 2000 IU/d for a duration of 6
weeks or a lump sum amount of 50,000 IU just once a week for a period of 6 weeks is

22. recommended in the form of D2 and D3. Then, the continuation of normal dosage from 400-
1000 IU/d has to be followed. In another study, a mother’s 150,000 IU intake of vitamin D
once showed a considerable result in the infants’ vitamin D levels.
Next, several researches suggest that a balanced sunlight exposure. Mostly, a disclosure of 5-
10 minutes of contact of arms, hands, face and legs twice or thrice in a week proves to be
helpful as well. Nonetheless, the unsurpassed and easiest way to categorically certify that
satisfactory amount of vitamin D is being taken is by the intake of simple supplementation. In
supplementing, there are two options from which will be able to take in the arrangements of
vitamin D. Ergocalciferol is the vegan arrangement of vitamin D and cholecalciferol is the
form solely derived from animals, ordinarily acquired from liver oil and lanolin from fish and
sheep respectively. The utmost edible and effective form for the body is cholecalciferol form,
but for vegetarians, ergocalciferol is preferable. As quality is important so it is recommended
in researches that Nordic Naturals Vitamin D3 (1000 IU per soft gel) in the ordinarily
acceptable form cholecalciferol is the finest consumed form.
The carter oil is organic, extra virgin olive oil and they are very easy to swallow as they come
in small, soft gels. Nordic Naturals Prenatal DHA with additional vitamin D3 (400 IU per 2
soft gels) is mostly recommended. It supplies two most essential ingredients for pregnant
mothers subsidized by a well-established, dependable corporation that pledges ideal
cleanliness, eminence and brilliance.
After observation of clinical trials and present studies, it has been inferred and deduced that
women who are pregnant in near northern latitude should receive extra antenatal care. Proper
dieting plans should be made to make up for the lost sunshine and women at the menace of
extremely truncated deficit of vitamin D ought to be prescribed higher IU/day of vitamin D
intake than normal of 400 IU/day of vitamin D that is the prescribed level for average adult.
Apart from supplements, food enriched with vitamin D should be adopted in daily life meals.
Vitamin D is mostly found in perch, trout, mackerel, tuna, wild salmon, herring, walleye, and
halibut. Moreover, pregnant women should opt for eggs, liver, mushrooms and fortified milk
and dairy products. Group studies from around the world have been known to discuss food
items recommended during pregnancy. However, due to lack of guidance from midwives or
other mothers, pregnant women live an unguided life and end up with lack of necessary
nutrition including vitamin D.

23. Summary
The need for pregnant women to take vitamin D supplements or stay exposed to sun is vital
to their own health and to that of their infants. Mothers are solely responsible for their child’s
health and immense care should be taken to regulate their child’s nutritional feed whether
during pregnancy or after immediate childbirth. The hunch that law of nature cannot be as
cruel as to have such low vitamin D levels in lactating mothers that the child would develop
rickets turned out to be true. It is only because of self-negligence and lack of supervised food
intake that caused lack of nutrition and hence, the increasing rate of body deformation from a
single nutrient; vitamin D. Vitamin D is one of the major nutrients needed for physiological
and psychological wellbeing of the children as well as the mother who goes through an
intensive growth period where she provides for the baby through mother serum and placenta
and then through breast milk during the lactating stage. Some might assume that vitamin D
toxicity will occur if vitamin D is taken constantly at such high levels. A universally
acknowledged truth is that high vitamin D levels cause hypercalciuria, hypercalcemia and
renal stones. However, a study was conducted where 10,000 IU vitamin D per day was
consumed for 1.5 years but not a single case of renal stones came forth (Hollis et al. 2015). In
accordance to the precedent, Hollis et al. (2015) also did not come across any such event that
could associate vitamin D consumption of 6400 UI/day to hypercalciuria or renal stones.
4.1 - CONCLUSION
Vitamin D is significant for skeletal and non-skeletal fitness. It is a firm fact now that there
are numerous individuals who have considerably less levels of vitamin D than the presently
commended levels for optimum healthiness. Globally, vitamin D is primarily acquired by
disclosure to UVB energy in the form of daylight and cutaneous vitamin D manufacture. The
significant factors of variations in latitude, cultural lifestyles, season, evading from constant
sun contact, and sunscreen defence can all bound vitamin D construction. Gastrointestinal,
hepatic, and renal disease can be associated to low vitamin D levels, but hypovitaminosis D
most frequently outcomes from insufficient dosage of vitamin D. Hypovitaminosis D due to
shortage of UVB disclosure is not effortlessly modified by nutritional dosage separately in
the absenteeism of supplementation. Food ramparts with vitamin D rely on invalid
commendations for daily AI. Supplementation with 800 to 1000 IU/d of vitamin D or 50,000

24. IU monthly is innocuous for utmost people and it safeguards levels of vitamin D within the
optimum range. This consumption is within the presently suggested benign upper acceptable
limit for vitamin D of 2000 IU/d for those aged 1 year and older. There has been no
substantial difference accounted for daily dosage of vitamin D for pregnant women as it is the
same as required by other adults. The endorsed dosage of vitamin D for babies is 400IU/d till
they are 1-year old. Recommended vitamin levels for all is 75nmol/l. People with lower than
35 to 30 nmol/l are described to have vitamin D deficit and need immediate raise of vitamin
D supplements of 50,000 IU one time a week for six weeks.
The essay focused on the downsides of vitamin D dearth, especially establishing the
importance of it in neonates and pregnant women. The suggested amounts were discussed for
healthy levels of vitamin D and for healthy physical and psychological growth of children.
The need of breastfeeding was established and further reliance on formula milk was
diminished. Additionally, the need to provide oral supplements to infants were also logically
tackled by strengthening the vitamin D levels in breast feed milk. Moreover, there should be
an increased appreciation for absorption of sunshine by the skin to uphold the durable levels
of vitamin D in the body. UV rays are healthy for the skin and cause synthesis of vitamin D
that can help with the lack of vitamin D (D3) in the body. Outdoor activities shall be a
nourishing act for the children as well as the adults as there are not many food items
enriching in vitamin D. Even the assumed richness of vitamin D in fish is not enough to
amount for the daily need of vitamins by children and adults alike, especially pregnant
women. Women should not solely rely on their food for complete nutritional gain daily. It is
vital to take vitamin supplements to stay healthy even before getting pregnant as it would
guarantee a healthier pregnancy term, avoid caesarean section and the probability of preterm
birth. Not only that, optimal vitamin D levels will ensure a healthy child is born with strong
bones and muscular strength. Vitamin D deficiency causes irreversible damage to health
which can be easily prevented if supplements are taken on a daily basis according to the
recommended dosage.
Future studies can be done on detecting child growth rate via ultrasounds and prescribing a
suitable vitamin D dosage to pregnant women before childbirth so that child development
stage can be as nutritious as possible. Furthermore, a standard level of vitamin D requirement
is needed to regulate daily intake of children and adults according to their needs. Moreover,
further research can be done to check other implications of physiological and psychological

25. of vitamin D deficiency in prenatal and infant stage to develop effective countermeasures and
establish nationwide awareness by national health centres to overcome the lack of vitamin D
levels from 20-100% in population down to the minimum. Additionally, other ways to
combat low vitamin levels in lactating women’s breast milk should be deduced apart from
taking vitamin D supplements that can immediately supply the nutrition needed by the baby
instead of relying on directly supplementing babies through artificial methods like vitamin D
based formula milk or other supplements.
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Allen, K., 2013. Faculty of 1000 evaluation for Vitamin D insufficiency is associated with
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Andıran, N., Yordam, N. & Özön, A., 2002. Risk factors for vitamin d deficiency in breast-
fed newborns and their mothers. Nutrition, 18(1), pp.47–50
Anon, 2015. The High Prevalence of Hypovitaminosis D in China. Medicine, 94(11), p.1
Benjasupattananun, P. & Phipatanakul, W., 2011. Dairy Food, Calcium and Vitamin D Intake
in Pregnancy, and Wheeze and Eczema in Infants. Pediatrics, 128(Supplement 3)

26. Bodnar, L. M. et al., 2010. Maternal Serum 25-Hydroxyvitamin D Concentrations Are
Associated with Small-for-Gestational Age Births in White Women. [Online]
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Bodnar, L.M. et al., 2007. High Prevalence of Vitamin D Insufficiency in Black and White
Pregnant Women Residing in the Northern United States and Their Neonates. The
Journal of Nutrition, 137(2), pp.447–452
De-Regil LM, Palacios C, Lombardo LK, et al. (2016) Vitamin D supplementation for
women during pregnancy. Cochrane Database Syst Rev, issue 1, CD008873
Dungan, J., 2008. Maternal Vitamin D Deficiency Increases the Risk of
Preeclampsia. Yearbook of Obstetrics, Gynecology and Womens Health, 2008,
pp.73–75
Emmerson, A. J. B. et al., 2017. Vitamin D status of White pregnant women and infants at
birth and 4 months in North West England: A cohort study.
Gellert, S., Strohle, A. & Hahn, A., 2017. Breastfeeding woman are at higher risk of vitamin
D deficiency than non-breastfeedn women - insight from the German VitaMinFemin
Study
Harvey NC, Holroyd C, Ntani G, et al. (2014) Vitamin D supplementation in pregnancy: a
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Hollis, B. W. et al., 2015. Maternal Versus Infant Vitamin D Supplementation During
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CHAPTER 06: APPENDIX
Authors Country and
Year of
Publication
Study
Aims and
Objectives
Sample
Characteristics
Research
Design
Data
Collection
Data
Analysis
Findings Limitations
study
1. (Abrams
2013)
USA, 2013 Qualitative Vitamin
D
should
be
provide
d at 200
to 400
IU/day
both
during
hospitali
zation

29. and
after
discharg
e from
the
hospital.
Infants
with
radiolog
ic
evidenc
e of
rickets
should
have
efforts
made to
maximiz
e
calcium
and
phospho
rus
intake
by using
availabl
e
commer
cial
products
and, if
needed,
direct
supplem
entation
with
these
minerals
.
2. (Bodnar, et al.,
2010)
USA, 2010 Associatio
n between
maternal
25
hydoroxyv
itamin D
concentrat
ion in
early
First time
mothers and
women with
singleton
pregnancies
were included
who delivered
small for
Nested
case
control
study
cases of a
disease
that
occur in
1198
women in
the cohort
had 124
infants
born small
for
gestational

30. pregnancy
and the
risk of
small for
gestational
age at
birth
gestational age
infants
White and
black mothers
were included
a defined
cohort
are
identified
and is
selected
from
among
those in
the
cohort
who have
not
develope
d the
disease
by the
time of
disease
occurren
ce in the
case
age.
Of those
112 had
maternal
blood
sample at
less than
22 week
gestation.
The final
sample
were 111
SGA
cases of
77 were
white and
34 were
black
3. (De-Regil, et
al., 2016)
Canada, 2016 To
examine
whether
oral
supplemen
ts with
vitamin D
alone or in
combinati
on with
calcium or
other
vitamins
and
minerals
given to
women
during
pregnancy
can safely
improve
maternal
and
We
searched
the
Cochrane
Pregnanc
y and
Childbirt
h Group's
Trials
Register
(23
February
2015),
the
Internatio
nal
Clinical
Trials
Registry
Platform
(31
January
2015),
Randomis
ed and
quasi-
randomise
d trials
with
randomisa
tion at
either
individual
or cluster
level,
evaluating
the effect
of
supplemen
tation with
vitamin D
alone or
in combin
ation with
other micr
onutrients
Two
review
authors
independ
ently i)
assessed
the
eligibility
of studies
against
the
inclusion
criteria
ii)
extracted
data from
included
studies,
and iii)
assessed
the risk
of bias of
the
New
studies
have
provide
d more
evidenc
e on the
effects
of
supplem
enting
pregnant
women
with
vitamin
D alone
or with
calcium
on
pregnan
cy
outcome
s.
Supple
menting
pregnant
women
The evide
whether
D
supplemen
should be
a part of
antenatal
all wom
improve m
and
outcomes
unclear.

31. neonatal
outcomes.
the
Network
ed
Digital
Library
of Theses
and
Dissertati
ons (28
January
2015)
and also
contacted
relevant
organisat
ions (31
January
2015).
for
women
during
pregnancy
.
included
studies.
Data
were
checked
for
accuracy.
The
quality of
the
evidence
was
assessed
using the
GRADE
approach.
with
vitamin
D in a
single or
continue
d dose
increase
s serum
25-
hydroxy
vitamin
D at
term
and may
reduce
the risk
of pre-
eclamps
ia, low
birthwei
ght and
preterm
birth.
4. (Emmerson, et
al., 2017)
England, 2017 Prevalenc
e of
vitamin D
deficiency
in white-
skinned
women
and
infants
White-skinned
pregnant
women and
infants at
gestation
between 20-28
weeks and at 4
month post
delivery
Quantitat
ive
With
further
questionn
aire to
determin
e
maternal
vitamin
D intake
and type
of
feeding,
suppleme
ntation
and sun
exposure
assessed
Clotted
whole
blood
collected
during
pregnancy
New born
cord blood
sample
taken at
birth
Blood
sample
infants at
4 month
post
delivery
before
commenci
ng solid
food.
All blood
sample
was
plasma
extracted,
frozen,
stored,
and
analysed
in
batches
after tests
for
mother
and
infants
pair had
been
obtained.
5. (Gellert, et al.,
2017)
Germany, 2017 To
determine
the
124
breastfeeding
and 124
Quantitat
ive
anthropom
etric
variables,
Vitamin
D status
measured
The data
collectio
n of
Breastfeed
infant and
children w

32. vitamin D
status in
breastfeed
ing
women
compared
to non-
pregnant
and non-
breastfeed
ing
(NPNB)
women
NPNB women
recruited
Cross-
sectional
study
skin type,
smoking
status,
holidays
within the
6 weeks of
data
collection,
in South
of
Germany
where
sunshine
is
sufficient
to produce
endogeno
us vitamin
D.
in each
participa
nt, sub
group
categoris
ed based
on their
serum 25
(OH) D
concentra
tion in
general
populatio
n as well
as
breastfee
ding
women
breastfe
eding
women
to
NPNB
women
did not
differ.
Howeve
r the
prevalen
ce of
smoking
was
higher
among
NPNB
women
than
breastfe
eding
women,
and the
mean 25
(OH)D
concentr
ation
was
lower in
breastfe
eding
women
than in
NONB
women.
part of the
therefore it
known if in
were affec
6. (Harvey,
2014)
UK, 2014 Either
assessmen
t of
vitamin D
status
(dietary
intake,
sunlight
exposure,
circulating
25(OH)-
vitamin D
concentrat
ion) or
supplemen
tation of
participant
Pregnant
women or
pregnant
women and
their
offspring.
Qualitati
ve
We
performe
d
systemati
c review
and
where
possible
combine
d study
results
using
meta-
analysis
to
estimate
the
76
studies
were
included
. There
was
consider
able
heteroge
neity
between
the
studies
and for
most
outcome
s there
The eviden
was insuffi
reliably an
question 1
relation to
biochemica
disease out

33. s with
vitamin D
or vitamin
D
containing
food e.g.
oily fish.
combine
d effect
size.
was
conflicti
ng
evidenc
e.
7. (Hollis et al.,
2015)
USA, 2015 Compare
Vitamin D
supplemen
tation of
6400 IU
per day
alone for
mother
and infant
supplemen
tation with
400 IU per
day
334 mother-
infant pair
216 still
breastfeeding
at visit 1 and
148
breastfeeding
to 4 months
And 95
breastfeeding
to 7 months
Randomi
sed
controlle
d trials
Maternal
serum
blood
measured
at
baseline
then
monthly,
and
infants
blood
measure
at
baseline
and at 4
and 7
months
3 groups
Group 1
mothers
had
400IU:
0IU:
placebo
and 1
containing
400IU;
Infantsts4
00IU
Group 2
mothers
had
2400IU:
2000IU
400 IU;
Infants
received
placebo
Group 3
mothers
had
6400IU:
6000IU:
400IU;
Infants
received
placebo
Questionn
aires and
blood
Found
African
America
n mother
had
lower
circulatin
g vitamin
than
white
subjects.
6400 IU
safely
supplied
breast
milk
with
adequat
e
vitamin
D to
satisfy
the
nursing
infants

34. sampling
on the
same day,
byy age
8. (Kennel,
2010)
USA, 2010 Recent
evidence
for the
nonskeleta
l effects of
vitamin D,
coupled
with
recognitio
n that
vitamin D
deficiency
is
common,
has
revived
interest in
this
hormone.
Vitamin D
is
produced
by skin
exposed to
ultraviolet
B
radiation
or
obtained
from
dietary
sources,
including
supplemen
ts.
Qualitati
ve
Vitamin
D
adequacy
is best
determin
ed by
measure
ment of
the 25-
hydroxyv
itamin D
concentra
tion in
the
blood.
Average
daily
vitamin
D intake
in the
populatio
n at large
and
current
dietary
reference
intake
values
are often
inadequat
e to
maintain
optimal
vitamin
D levels.
Clinicia
ns may
recomm
end
supplem
entation
but be
unsure
how to
choose
the
optimal
dose
and type
of
vitamin
D and
how to
use
testing
to
monitor
therapy.
This
review
outlines
strategie
s to
prevent,
diagnos
e, and
treat
vitamin
D
deficien
cy in
adults.
9. (Krieger, et Switzerland, To
investigate
3 rd-trimester
pregnant
A three-
centre
Demogra
phic and
Low
vitamin

35. al., 2018) 2018 the
prevalence
and
determina
nts of
vitamin D
deficiency
in 3rd
trimeseter
pregnant
women
living in
Switzerlan
d.
women living
in Switzerland
(n 305),
study was
conducted
in the
obstetric
departmen
ts of
Zurich,
Bellinzona
and
Samedan
(Switzerla
nd)
questionn
aire data
were
used to
explore
the
determin
ants of
vitamin
D
deficienc
y.
D levels
were
common
in this
sample
of
pregnant
women
and
their
newborn
s’ cord
blood.
Vitamin
D
supplem
ent
intake
was the
most
actionab
le
determi
nant of
vitamin
D status,
suggesti
ng that
vitamin
D
supplem
entation
during
pregnan
cy
should
receive
more
attention
in
clinical
practice.
10. (Lapillonne,
2010)
France, 2010 to review
the data
on the
classic
and non-
classic
actions of
vitamin D
with
Quantitiv
e
It
appears
that
vitamin
D
insuffici
ency
during
pregnan

36. regards to
pregnancy
.
cy is
potential
ly
associat
ed with
increase
d risk of
preecla
mpsia,
insulin
resistanc
e and
gestatio
nal
diabetes
mellitus.
11. (Lovell, 2016) New Zealand,
2016
Do
maternal
dietary
and
vitamin D
intake and
sunlight
exposure
affect the
vitamin D
status of
Exclusivel
y
breastfed
infants?
are
dependent
on their
mothers
for
vitamin D
intake
63 term
healthy
singleton with
normal birth
weight,
exclusively
breastfed
infants age 2-3
month
Quantitat
ive
Serum
blood
sample
from
infants
were
measured
using
isotope-
dilution
liquid
chromatog
raphy-
tandem
mass
spectrome
try
Each
mothers
completed
an
interview-
administer
ed semi-
quantitativ
e food
frequency
questionna
ire
Serum
concentr
ation in
exclusiv
ely
breastfe
d infants
are
indepen
dent of
maternal
vitamin
D
intake,
therefor
e
exclusiv
e
breastfe
eding
does not
provide
adequat
e
vitamin
D for
infants
Small sam

37. 12. (Lundqvist, et
al., 2016)
Sweden, 2016 Assess
vitamin d
status in
pregnant
women in
north
Sweden
Pregnant
women,
Quantitat
ive study
Blood
sample
and
dietary
intake of
66 food
item with
questionna
ires @
week 12,
21, and 35
and after
birth at
week 12
and 29
Plasma
level of
25(OH)
was
Analysed
using
liquid
chromato
graphy
tandem-
masspect
rometry.
1/3 of
women
had 25
(OD)
vitamin
D levels
less than
50nmol/
l
Plasma
concentr
ation
was
slightly
over the
gestatio
nal
period
and
peaked
in late
pregnan
cy, and
reverted
back to
baseline
after
birth.
There
was an
increase
in
plasma
vitamin
d level
as the
pregnan
cy
progress
ed
Vitamin le
the offsprin
not measur
Not known
mothers w
breastfeed
13. (Misra et al. USA, 2008 Given the to

38. 2008) recent
spate of
reports of
vitamin D
deficiency
, there is a
need to
reexamine
our
understan
ding of
natural
and other
sources of
vitamin D,
as well as
mechanis
ms
whereby
vitamin D
synthesis
and intake
can be
optimized
perform
this task
and also
reviews
recomm
endation
s for sun
exposur
e and
vitamin
D intake
and
possible
caveats
associat
ed with
these
recomm
endation
s.
14. (Moon, 2015) UK, 2015 The
findings
are
inconsiste
nt, and
currently
there is a
lack of
data from
high-
quality
interventio
n studies
to confirm
a causal
role for
vitamin D
in these
outcomes.
there is
an
indicatio
n of
possible
benefits
of
vitamin
D
supplem
entation
during
pregnan
cy for
offsprin
g
birthwei
ght,
calcium
concentr
ations
and
bone
for none o
outcomes
current e
base con
and the a
data just
instatemen
high-quality
randomised
placebo co
trials in a r
populations
health
settings
establish
potential
and safe
vitamin
supplemen
to
particular
outcomes.

39. mass as
well as
for
reduced
maternal
pre-
eclamps
ia.
15. (Munns, 2006) Australia, 2006 A major
risk factor
for infants
is
maternal
vitamin D
deficiency
. For older
infants
and
children,
risk
factors
include
dark skin
colour,
cultural
practices,
prolonged
breastfeed
ing,
restricted
sun
exposure
and
certain
medical
conditions
.
To
prevent
vitamin D
deficiency
in infants,
pregnant
women,
especially
those who
are dark-
skinned or
veiled,
should be
screened
and
treated for
vitamin D
deficiency
, and
breastfed
infants of
dark-
skinned or
veiled
women
should be
supplemen
ted with
vitamin D
for the
first 12
months of
life.
Regular
sunlight
exposure
can
prevent
vitamin
D
deficienc
y, but the
safe
exposure
time for
children
is
unknown
. To
prevent
vitamin
D
deficienc
y, at-risk
children
should
receive
400 IU
vitamin
D daily;
if
complian
ce is
poor, an
annual
dose of
150,000
IU may
be
considere
d.
Treatme
nt of
vitamin
D
deficien
cy
involves
giving
ergocalc
iferol or
cholecal
ciferol
for 3
months
(1000
IU/day
if < 1
month
of age;
3000
IU/day
if 1-12
months
of age;
5000
IU/day
if > 12
months
of age).
High-
dose
bolus
therapy
(300,00
0-
500,000
IU)
should
be

40. consider
ed for
children
over 12
months
of age if
complia
nce or
absorpti
on
issues
are
suspecte
d.
16. (Pludowski et
al. 2013)
Poland, 2013 A review of
randomized
controlled
trials, meta-
analyses, and
other evidence
of vitamin D
action on
various health
outcomes.
Adequate
vitamin D
status
seems to
be
protective
against
musculosk
eletal
disorders
(muscle
weakness,
falls,
fractures),
infectious
diseases,
autoimmu
ne
diseases,
cardiovasc
ular
disease,
type 1 and
type 2
diabetes
mellitus,
several
types of
cancer,
neurocogn
itive
dysfunctio
n and
mental
illness,
and other
diseases,
as well as
Vitamin
D
deficien
cy/insuf
ficiency
is
associat
ed with
all-
cause
mortalit
y.

41. infertility
and
adverse
pregnancy
and birth
outcomes.
17. (Wheeler, et
al., 2016)
New Zealand,
2016
High-
Dose
Monthly
Maternal
Cholecalci
ferol
supplemen
tation
during
breastfeed
ing affects
maternal
and infant
vitamin D
status at 5
months
postpartu
m: A
Randomiz
ed
controlled
Trial
90 mother and
infants
enrolled.
Women were
enrolled from
20 week
gestation until
delivery. At 4
week
postpartum
breastfeeding
mothers were
randomly
selected
quantitati
ve
Randomis
ed double
–blind,
placebo-
controlled
trial
Randomi
sed
groups
were
chosen
15-1 of
the three
treatment
; placebo,
50,000
IU
Cholecal
ciferol
and
100.000
IU of
Cholecal
ciferol
administe
red every
month
with final
dose at
16 weeks
postpartu
m
16
weeks
supplem
entation
showed
significa
nt
change
in
maternal
serum
level,
than in
the
placebo
group.
For
infants
the
changes
did not
differ
from the
placebo
group,
however
after
adjustm
ent for
season
of birth,
vitamin
fortified
formula
intake
and
infant
skin
colour
the
levels
were
higher
than the
All three g
mothers ha
increased s
concentrat
However,
end of the
mothers ra
selected an
vitamin D
significantl
higher leve
level than
placebo

42. placebo
group
18. (Woolcott, et
al., 2016)
Switzerland,
2016
to
determine
factors
that are
associated
with
vitamin D
status of
mothers in
early
pregnancy
and
neonates.
1,635
pregnant
women from
Quebec City
and Halifax,
Canada,
2002–2010
Quantitat
ive
Vitamin D
status was
based on
the
concentrat
ion of 25-
hydroxy-
vitamin D
[25(OH)D
]
determine
d with a
chemilumi
nescence
immunoas
say in
maternal
sera
collected
at a
median of
15 weeks’
gestation
and in
neonatal
cord sera
at
delivery.
A total
of
44.8%
of
mothers
and
24.4%
of
neonates
had
25(OH)
D
concentr
ations
<50
nmol/L.
vitamin
D status
of
pregnant
women
and/or
neonates
might
be
improve
d
through
supplem
entation,
adequat
e dairy
intake, a
move
towards
a
healthy
pre-
pregnan
cy body
weight,
and
participa
tion in
physical
activity.
Controlled
are need
determine
effectivene
interventio
aimed at
factors.