Adherence to Vitamin D Recommendations Among US InfantsCria G. Perrine, Andrea J. Sharma, Maria Elena D. Jefferds, Mary K....
ARTICLESAdherence to Vitamin D Recommendations Among USInfantsAUTHORS: Cria G. Perrine, PhD,a,b Andrea J. Sharma, PhD,    ...
The role of vitamin D in calcium and         gin consuming 200 IU/day of vitamin D         to both the 2003 and 2008 AAP v...
ARTICLESlyzed data collected about infants at         TABLE 1 Percentage of Infants Fed According to Each of Three Feeding...
TABLE 2 Percentage of Infants Who Received an Oral Vitamin D Supplement According to Feeding                              ...
ARTICLESconsume complementary foods and               light and, thus, need an alternate           year of life and at as ...
daily, beginning within their first few               ACKNOWLEDGMENTS                                       of Women’s Heal...
Adherence to Vitamin D Recommendations Among US Infants Cria G. Perrine, Andrea J. Sharma, Maria Elena D. Jefferds, Mary K...
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Vita D Perrine Cg Ea At Adherence To Vit D Recommendations Among Us Infants Pediatrics 2010 125 627 632[1]

  1. 1. Adherence to Vitamin D Recommendations Among US InfantsCria G. Perrine, Andrea J. Sharma, Maria Elena D. Jefferds, Mary K. Serdula and Kelley S. Scanlon Pediatrics 2010;125;627-632; originally published online Mar 22, 2010; DOI: 10.1542/peds.2009-2571The online version of this article, along with updated information and services, is located on the World Wide Web at: is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  2. 2. ARTICLESAdherence to Vitamin D Recommendations Among USInfantsAUTHORS: Cria G. Perrine, PhD,a,b Andrea J. Sharma, PhD, WHAT’S KNOWN ON THIS SUBJECT: There have been few data onMPH,b Maria Elena D. Jefferds, PhD,b Mary K. Serdula, the prevalence of US infants meeting AAP vitamin DMD,b and Kelley S. Scanlon, PhD, RDb recommendations.aEpidemic Intelligence Service, Office of Workforce and CareerDevelopment, and bDivision of Nutrition, Physical Activity, and WHAT THIS STUDY ADDS: We estimated the prevalence ofObesity, Centers for Disease Control and Prevention, Atlanta, breastfed, formula-fed, and mixed-fed infants who met the 2003Georgia and 2008 AAP vitamin D recommendations. Most infants, not justKEY WORDS those who are breastfed, will need to receive an oral vitamin DAmerican Academy of Pediatrics, vitamin D, Infant FeedingPractices Study II, supplement supplement to meet the 2008 AAP recommendation.ABBREVIATIONSAAP—American Academy of PediatricsIOM—Institute of MedicineIFPS II—Infant Feeding Practices Study IINSFG—National Survey of Family Growth abstractThe findings and conclusions in this report are those of theauthors and do not necessarily represent the official position of OBJECTIVES: In November 2008, the American Academy of Pediatricsthe Centers for Disease Control and Prevention. (AAP) doubled the recommended daily intake of vitamin D for infantsFunded by the National Institutes of Health (NIH). and children, from 200 IU/day (2003 recommendation) to 400 IU/ We aimed to assess the prevalence of infants meeting the AAP recom-doi:10.1542/peds.2009-2571 mended intake of vitamin D during their first year of life.Accepted for publication Nov 24, 2009 METHODS: Using data from the Infant Feeding Practices Study II, con-Address correspondence to Cria G. Perrine, PhD, 4770 Buford ducted from 2005 to 2007, we estimated the percentage of infants whoHwy NE, MS K-25, Atlanta, GA 30341. E-mail: met vitamin D recommendations at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). months (n 1952–1633).Copyright © 2010 by the American Academy of Pediatrics RESULTS: The use of oral vitamin D supplements was low, regardlessFINANCIAL DISCLOSURE: The authors have indicated they have of whether infants were consuming breast milk or formula, rangingno financial relationships relevant to this article to disclose. from 1% to 13%, varying by age. Among infants who consumed breastFunded by the National Institutes of Health (NIH). milk but no formula, only 5% to 13% met either recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation. Among those who consumed formula but no breast milk, 81% to 98% met the 2003 recommendation, but only 20% to 37% would have met the 2008 recommendation. CONCLUSIONS: Our findings suggest that most US infants are not con- suming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should en- courage parents of infants who are either breastfed or consuming 1 L/day of infant formula to give their infants an oral vitamin D supple- ment. Pediatrics 2010;125:627–632PEDIATRICS Volume 125, Number 4, April 2010 627 Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  3. 3. The role of vitamin D in calcium and gin consuming 200 IU/day of vitamin D to both the 2003 and 2008 AAP vitaminphosphorus homeostasis and bone during their first 2 months of life.4 D recommendations among infantsmetabolism has been well established; Although there currently is no national during their first year of life. Becausehowever, the presence of vitamin D re- surveillance of nutritional rickets in infants’ level of vitamin D consumptionceptors in many cell types suggests the United States, cases of rickets would likely differ by the extent tothat vitamin D has other physiologic among hospital patients continue to be which they were formula fed, we pro-functions.1 For example, vitamin D de- reported.9,10 The prevalence of poor vi- duced separate prevalence estimatesficiency has been associated with re- tamin D status among US infants also for infants who were breastfed, for-spiratory infections, type 1 diabetes, remains high by most measures, al- mula fed, and “mixed fed” (bothcardiovascular diseases, and cancer though data on infant vitamin D status breastfed and formula fed).in later life,1–3 which emphasizes the can be difficult to interpret because ofimportance of vitamin D nutrition a lack of consensus on optimal vitamin METHODSthroughout the life span. In children, D levels or on what constitutes vitamin We analyzed data from the Infant Feed-nutritional rickets typically occurs in D deficiency. Depending on the defini- ing Practices Study II (IFPS II), a longi-severe cases of vitamin D deficiency, tions used, vitamin D deficiency has tudinal survey of US mothers ofcausing softening and weakening of been reported in 10% to 65% and insuf- healthy singletons, followed from latethe bones, and is associated with im- ficiency in 40% to 56% of US neonates, pregnancy through the first year ofpaired growth, developmental delays, infants, and toddlers,11–13 which sug- their infant’s life, which was con-lethargy, and hypocalcemic seizures.4 gests that vitamin D levels may not be ducted from 2005 through 2007 by theIn addition to being obtained through optimal in these groups. Given the US Food and Drug Administration inthe diet, vitamin D is synthesized endo- growing evidence that the level of vita- collaboration with the Centers for Dis-genously in the skin after exposure to min D consumption it recommended in ease Control and Prevention.17 Theultraviolet light. The American Acad- 2003 may not be sufficient, in Novem- sample was drawn from a consumer-emy of Pediatrics (AAP) advises that ber 2008 the AAP released a new rec- opinion mail panel that was nationallychildren younger than 6 months be ommendation that all children receive distributed but not nationally repre-kept out of the sun altogether and that 400 IU/day of vitamin D from their first sentative. Women were recruited inthose aged 6 months or older wear few days of life through adolescence.14 their third trimester of pregnancy;protective clothing and sunscreen to The IOM is also reviewing its current mothers at least 18 years of age, moth-minimize sun exposure.5 Some re- recommendations for vitamin D con- ers and infants without medical condi-searchers recommend short episodes sumption and plans to release a report tions that would affect feeding, and in-of sun exposure as a way of obtaining on the findings of this review in May fants who were born after at least 35vitamin D; however, the safety of this 2010. weeks’ gestation and weighed at leastmethod for infants with regard to fu- Although breast milk is the best single 5 lb were included in the study. Exten-ture skin cancer is not known.6,7 In ad- source of food for infants,15 it only con- sive details of the IFPS II methodology,dition, one’s ability to produce vitamin tains 25 to 78 IU/L of vitamin D14 and, the IFPS II sample, and a comparison ofD is affected by latitude, season, sun- thus, is insufficient, by itself, to provide the IFPS sample with a nationally rep-screen use, skin pigmentation, and air adequate levels of vitamin D for in- resentative sample of women from thepollution, which make sun exposure an fants. Foods that are good sources of National Survey of Family Growthunreliable source of vitamin D. Thus, vitamin D include oily fish, egg yolks, (NSFG) have been published previous-infants need to obtain vitamin D either and fortified foods such as infant for- ly.18 Generally, IFPS II participants wereprimarily or entirely from their diet. In mula and milk.16 Most infants, how- older and more educated, had a higher1997, the Institute of Medicine (IOM) ever, will not consistently consume income and fewer children, wererecommended that 200 IU/day be con- these foods during their first year of breastfed longer, and were more likelysidered “adequate intake” of vitamin D life unless they are primarily fed infant to be white than those in the NSFGfor infants, although it did not have suf- formula. All infants require a supple- sample.ficient information to determine a rec- mental source of vitamin D from an Each IFPS II participant was mailed 1ommended dietary allowance.8 In 2003, oral vitamin D supplement, fortified in- prenatal and 10 postnatal question-the AAP released vitamin D–consumption fant formula, or both. naires at approximately monthly inter-guidelines in line with those of the IOM Our objective for this analysis was to vals that asked about various infantand recommended that all children be- estimate the prevalence of adherence feeding and care practices. We ana-628 PERRINE et al Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  4. 4. ARTICLESlyzed data collected about infants at TABLE 1 Percentage of Infants Fed According to Each of Three Feeding Practices by Ageages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 Infant Age, mo (wk) No. Breast Milk, % Mixed, % Formula, %months as if the data were from sepa- 1 (3 to 7) 1804 42.5 31.6 25.9 2 (7 to 11) 1714 42.8 24.1 33.1rate cross-sectional surveys; sample 3 (11 to 15) 1952 41.6 20.2 38.2sizes ranged from 1952 mothers of in- 4 (15 to 19) 1837 38.2 19.5 42.4fants at 3 months to 1633 mothers of 5 (19 to 24) 1927 36.3 18.0 45.7infants at 10.5 months. Regarding sup- 6 (24 to 29) 1870 33.6 17.1 49.3 7.5 (29 to 36) 1862 31.8 14.7 53.5plement use, mothers were asked on 9 (36 to 43) 1790 29.4 12.8 57.8each monthly questionnaire, “Which of 10.5 (43 to 51) 1633 27.1 11.0 61.9the following was your baby given in Feeding-practice categories are mutually exclusive and based only on consumption of breast milk and formula.vitamin or mineral drops or pills atleast 3 days a week during the past 2 cent of infants at 10.5 months were recommendation (which applies to in-weeks? If your baby was given drops or consuming any cow’s milk; for half of fants beginning within their first fewpills that contained more than 1 of the these infants, consumption frequency days of life) if they were either receivingitems listed, please mark each of the was less than once per day. When we an oral vitamin D supplement or con-separate items.” If the mother checked compared the results of our analysis suming at least 1 L/day of formula.4,14the box for vitamin D, the infant was for all infants aged 10.5 months withcategorized as having received an oral results for the same group excluding RESULTSvitamin D supplement. Thus, our esti- those reported to have consumed any At 1 month of age, 43% of the infantsmate of vitamin D supplementation cow’s milk, we found no significant were breastfed, 32% were mixed fed,was not of daily administration, but of differences. and 26% were formula fed (Table 1).a minimum of 3 days per week. The IFPS II data were collected from With increasing age, the percentageOn each of the postpartum surveys, 2005 to 2007, at which time the 2003 of infants who were breastfed de-mothers were also asked to estimate AAP recommendation would have been creased, and the percentage who werethe average number of ounces of for- current. We used both the 2003 and formula fed increased; by 10.5 monthsmula their infants consumed at each 2008 recommendations in this analy- of age, 27% of the infants were breast-feeding (response options were 1–2, sis to obtain estimates of the preva- fed, 11% were mixed fed, and 62% were3– 4, 5– 6, 7– 8, and 8 oz) and the av- lence of infants who were meeting the formula fed. Throughout the first yearerage number of feedings per day or 2003 recommendation and the preva- of life, mean formula intake rangedweek for both breast milk and formula. lence of infants who would meet the from 310 to 352 mL/day in the mixed-In our analyses, we used the midpoint 2008 recommendation without any be- fed group, with little variation by age,of the formula consumption response havior changes. Infants’ multivitamin and from 770 to 987 mL/day in theoptions reported (1.5, 3.5, 5.5, 7.5, and and vitamin D– only preparations formula-fed group, with formula in-8.5 oz) and the average number of available in the United States supply take generally increasing with age un-feedings per day to estimate average 400 IU/day; thus, infants who receive til peaking at 4 to 6 months and thendaily formula consumption, converting an oral vitamin D supplement would decreasing.ounces to milliliters. We also used the obtain enough vitamin D to meet bothreported frequency of breast milk and Overall, only 4% to 7% of the infants the 2003 and 2008 recommendations.14formula feedings to divide infants into Therefore, we classified infants as were receiving an oral vitamin D sup-3 mutually exclusive feeding-practice meeting the 2003 recommendation plement (Table 2), with infants 1 monthgroups: breast milk (consumed breast (which recommended beginning sup- of age having the lowest prevalence ofmilk only); mixed (consumed breast plementation at 2 months of age and supplement use. The prevalence ofmilk and formula); and formula (con- thus does not apply for infants oral supplement use ranged from 5%sumed formula only). These classifica- younger than 2 months) if they were to 13% in the breastfed group andtions referred only to consumption of either receiving an oral vitamin D sup- from 4% to 11% in the mixed-fed group.breast milk and formula; infants may plement or consuming at least 500 mL/ Only 1% to 4% of the infants in thealso have been consuming other foods day of vitamin D–fortified infant for- formula-fed group were receiving anor liquids, such as water or juice. Al- mula, which in the United States is oral supplement.most no children consumed cow’s milk fortified at a level of 400 IU/L.14 We clas- We estimated that over the first year ofuntil 10.5 months of age. Fourteen per- sified infants as having met the 2008 life, 44% to 58% of infants met the 2003PEDIATRICS Volume 125, Number 4, April 2010 629 Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  5. 5. TABLE 2 Percentage of Infants Who Received an Oral Vitamin D Supplement According to Feeding were doing so by consuming at least 1 Practice by Age L/day of formula. Thus, the pattern ofInfant Age, mo (wk) Total, % Breast Milk, % Mixed, % Formula, % formula-fed infants who achieved AAP 1 (3 to 7) 3.9 5.3 4.3 1.1 2 (7 to 11) 5.5 9.4 5.1 0.9 2008 recommended levels of vitamin D 3 (11 to 15) 6.8 10.3 8.9 1.7 followed a pattern similar to that of 4 (15 to 19) 6.8 10.8 9.8 1.7 formula intake, increasing with age 5 (19 to 24) 7.3 12.6 9.8 2.0 until peaking at 4 to 6 months and then 6 (24 to 29) 7.0 12.1 9.4 2.6 7.5 (29 to 36) 6.9 11.3 11.0 3.1 decreasing. 9 (36 to 43) 6.0 11.2 7.9 2.9 10.5 (43 to 51) 6.7 11.1 10.7 3.9 DISCUSSIONClassification as having received a vitamin D supplement indicates that infants received an oral supplement at least 3days/week during the previous 2 weeks. Feeding-practice categories are mutually exclusive and based only on consumption At the time the IFPS II data were col-of breast milk and formula. lected, the 2003 AAP recommendation was the current guideline regarding vi-TABLE 3 Percentage of Infants Who Met the 2003 AAP Vitamin D Recommendation and the tamin D intake for the prevention of Percentage Who Would Have Met the 2008 Recommendation According to Feeding vitamin D deficiency and rickets. Al- Practice by Age though we found that most formula-Infant Age, mo (wk) Total, % Breast Milk, % Mixed, % Formula, % fed infants were meeting the recom- 2003 2008 2003 2008 2003 2008 2003 2008 a a a a mendation, we also found that only 1 (3 to 7) NA 11.4 NA 5.3 NA 8.7 NA 24.8 2 (7 to 11) 43.6 16.4 9.4 9.4 29.8 8.5 98.1 31.2 approximately one-tenth of breastfed 3 (11 to 15) 48.5 20.1 10.3 10.3 33.5 12.4 98.0 34.9 infants and one-third of mixed-fed in- 4 (15 to 19) 52.2 22.1 10.8 10.8 33.0 12.6 98.2 36.6 fants were meeting it. This poor adher- 5 (19 to 24) 55.4 23.7 12.6 12.6 35.3 13.0 97.4 36.7 6 (24 to 29) 56.3 25.0 12.1 12.1 31.6 14.4 95.0 37.4 ence to the 2003 recommendation was 7.5 (29 to 36) 57.8 19.6 11.3 11.3 29.3 13.9 93.3 26.0 because of both low prevalence of oral 9 (36 to 43) 57.9 16.9 11.2 11.2 28.0 12.2 88.2 20.9 vitamin D supplement use and most 10.5 (43 to 51) 57.0 16.8 11.1 11.1 33.3 13.3 81.3 19.9 mixed-fed infants not consuming2003 AAP recommendation: receive an oral vitamin D supplement or consume 500 mL/d of infant formula beginning at 2months; 2008 recommendation: receive an oral vitamin D supplement or consume 1 L/d of infant formula beginning at birth. enough formula to meet the recom-Feeding practice categories are mutually exclusive and based only on consumption of breast milk and formula. mended consumption level of 200 IU/a The 2003 recommendation does not apply to infants in this age category. day. Our estimates regarding the 2008 recommendation provide a sense of the prevalence of infants among theAAP recommendation that they con- would have met the 2008 recommen- various feeding-practice groups whosume 200 IU/day of vitamin D, whereas dation; those who met the 2003 recom- would meet the new recommendationonly 11% to 25% would have met the mendation did so primarily through if there was no change in behavior re-2008 recommendation of 400 IU/day of formula intake, whereas those who garding vitamin D intake. Fewer thanvitamin D (Table 3). Among breastfed met the 2008 recommendation did so 15% of the infants in both the breast-infants, who must have received an primarily with the use of an oral vita- fed and mixed-fed groups would haveoral vitamin D supplement to meet ei- min D supplement, suggesting that few met the 2008 recommended level of vi-ther of the AAP recommendations, only mixed-fed infants consume enough tamin D consumption.9% to 13% were receiving enough vita- formula to obtain 400 IU/day of vitamin The difference in the percentage of in-min D at 2 to 10.5 months of age to D. More than 90% of formula-fed in- fants who met the 2 recommended in-meet the 2003 or 2008 recommenda- fants aged 2 to 7.5 months met the take levels was particularly strikingtion. The 2008 recommendation (but 2003 recommendation, as did 80% of among formula-fed infants. Whereasnot the 2003 recommendation) applies formula-fed infants aged 9 and 10.5 most formula-fed infants were con-to infants at 1 month; only 5% of months. However, only 20% to 37% of suming the 500 mL/day of formula re-1-month-old infants who were breast- these infants would have met the new quired to obtain 200 IU of vitamin D,fed received an oral vitamin D supple- 2008 recommendation at any month of only approximately one-third werement and, thus, would have met the age. Because use of an oral vitamin D consuming the 1 L/day required to ob-2008 recommendation. Among mixed- supplement was very low among tain 400 IU. Among this group, adher-fed infants, 28% to 35% met the 2003 formula-fed infants, most who were ence peaked at 4 to 6 months, whichrecommendation, but only 9% to 14% meeting the 2008 recommendation is when many infants would begin to630 PERRINE et al Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  6. 6. ARTICLESconsume complementary foods and light and, thus, need an alternate year of life and at as early as 1 monthreduce their formula intake. The 2008 source of vitamin D. of life.AAP guideline suggests that most in- Although the IFPS II included women According to the 2008 AAP recommen-fants older than 1 month will consume from around the country, the sample dation, all breastfed, mixed-fed, andthe 1 L/day of formula required to ob- was not nationally representative. formula-fed infants who consume 1tain 400 IU/day of vitamin D14; however, Among other characteristics, women L/day of formula should receive an oralour results did not support this as- in this sample had achieved higher lev- vitamin D supplement. Our findingssumption and indicated instead that els of education, had fewer children, suggest that few infants are consum-most infants, not just those who are and had breastfed longer than women ing at least 1 L/day of formula; thus,breastfed, would likely need to receive in the NSFG,18 all of which may have many may need to receive oral vita-an oral vitamin D supplement to con- been associated with formula and sup- min D supplements to meet the 2008sume enough vitamin D to meet the plement use. Another limitation of our AAP recommendation that they con-2008 recommendation. study was that all data were self- sume at least 400 IU/day. This findingThe very low prevalence of oral vitamin reported and required mothers to re- should be confirmed in other stud-D supplementation among infants is call information about their infants’ ies. Parents may need support inconcerning if infants are to meet cur- feedings over the previous 7 days and providing supplementation for their supplement use over the previous 2 infants. Supporting adherence inrent recommendations. Results from weeks. Although the validity of this self- this context is challenging becausethe 1999 –2002 National Health and Nu- reported data is unknown, our esti- of the long duration of vitamin D sup-trition Examination Survey showed a mates of daily formula intake among plementation, the lack of tangiblesimilarly low prevalence of vitamin D infants of IFPS II participants were con- health effects after starting supple-supplement use among US infants: sistent with, or only slightly higher mentation, the need for an adult toonly 8.7% of infants aged 0 to 11 than, those from other studies.24–27 administer the daily dose, and themonths had received a vitamin D sup- Other study limitations included our in- need for a willing infant to accept theplement in the previous 30 days.19 Pe- ability to determine the exact quantity supplement. Overall, adherence todiatricians and allied health care pro- prescriptions from health care pro- of vitamin D that infants obtained fromviders are uniquely positioned to help viders is poor, even among adults, oral supplements and our definition ofincrease the percentage of infants and is generally worse the longer the supplement use as use of a supple-who receive adequate amounts of vita- regimen duration is.28 Pediatricians ment on at least 3 days/week rathermin D, because parents are more likely and other health care providers can than more frequently. Our estimates ofto give their children vitamin D supple- the prevalence of supplement use support and promote daily oral vita-ments if they are advised to do so by a would likely have been even lower had min D supplementation of infants byhealth care professional.20 It is unfor- we used a definition that required explaining to parents the purposetunate that many health care profes- more days per week of use. These data and benefits of vitamin D supplemen-sionals are not recommending vitamin were collected from 2005 to 2007, so tation, reminding parents at eachD supplements for infants.21–23 Rea- our estimate of meeting the 2008 AAP visit to give vitamin D supplements tosons that they are not doing so include recommendation assumed no change their children, suggesting that par-beliefs that rickets is rare,23 that in- in behavior since that time. Because ents develop a daily intake routine tofants receive sufficient sunlight,22,23 new vitamin D research is continually help them remember to administerand that breast milk has adequate lev- being generated, it is possible that in- the supplement, asking parentsels of vitamin D.21–23 Because physi- creased media attention on vitamin D about any adverse effects of supple-cians’ knowledge of the AAP recom- has increased the use of vitamin D sup- mentation or barriers to giving theirmendations has been positively plements among infants. Despite these infants supplements, and helpingassociated with the likelihood of their limitations, IFPS II was one of the larg- parents to overcome any barriersrecommending vitamin D supple- est infant-feeding studies in the United that they report.29ments,22 both health care providers States and provides valuable data thatand parents need to be educated about are not available from any other data CONCLUSIONSthe AAP guidelines and the importance source to date, including assessment We found that most infants, not justof vitamin D nutrition, including that of supplement use and food intake at those who are breastfed, may re-infants should not be exposed to sun- multiple times points during the first quire an oral vitamin D supplementPEDIATRICS Volume 125, Number 4, April 2010 631 Downloaded from Provided by Wake Forest Univ School on April 5, 2010
  7. 7. daily, beginning within their first few ACKNOWLEDGMENTS of Women’s Health, National Institutesdays of life, to meet the 2008 AAP rec- This study was funded by the US Food of Health, and Maternal and Childommendation that infants consume and Drug Administration, Centers for Health Bureau in the US Department ofat least 400 IU/day of vitamin D. Disease Control and Prevention, Office Health and Human Services.REFERENCES 1. Prentice A, Goldberg GR, Schoenmakers I. Nutritional rickets among children in the Dietary supplement use among infants, chil- Vitamin D across the lifecycle: physiology United States: review of cases reported be- dren, and adolescents in the United States, and biomarkers. Am J Clin Nutr. 2008;88(2): tween 1986 and 2003. Am J Clin Nutr. 2004; 1999 –2002. Arch Pediatr Adolesc Med. 500S–506S 80(6 suppl):1697S–1705S 2007;161(10):978 –985 2. Walker VP, Modlin RL. The vitamin D connec- 11. Gordon CM, Feldman HA, Sinclair L, et al. 20. Dratva J, Merten S, Ackermann-Liebrich U. tion to pediatric infections and immune Prevalence of vitamin D deficiency among Vitamin D supplementation in Swiss infants. function. Pediatr Res. 2009;65(5 pt 2): healthy infants and toddlers. Arch Pediatr Swiss Med Wkly. 2006;136(29 –30):473– 481 106R–113R Adolesc Med. 2008;162(6):505–512 21. Davenport ML, Uckun A, Calikoglu AS. Pedia- 3. Hypponen E, Laara E, Reunanen A, Jarvelin ¨ 12. Bodnar LM, Simhan HN, Powers RW, Frank trician patterns of prescribing vitamin sup- MR, Virtanen SM. Intake of vitamin D and MP, Cooperstein E, Roberts JM. High preva- plementation for infants: do they contribute risk of type 1 diabetes: a birth-cohort study. lence of vitamin D insufficiency in black and to rickets? Pediatrics. 2004;113(1):179 –180 Lancet. 2001;358(9292):1500 –1503 white pregnant women residing in the 22. Sherman EM, Svec RV. Barriers to vitamin D 4. 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  8. 8. Adherence to Vitamin D Recommendations Among US Infants Cria G. Perrine, Andrea J. Sharma, Maria Elena D. Jefferds, Mary K. Serdula and Kelley S. Scanlon Pediatrics 2010;125;627-632; originally published online Mar 22, 2010; DOI: 10.1542/peds.2009-2571Updated Information including high-resolution figures, can be found at:& Services This article cites 27 articles, 21 of which you can access for free at: & 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 Wake Forest Univ School on April 5, 2010