This document discusses vitamin D supplementation for breastfed infants. It begins by presenting a case of an infant with seizures from vitamin D deficiency. It then reviews the clinical presentations of acute versus chronic vitamin D deficiency. Risk factors for deficiency include limited sunlight exposure and fat malabsorption. The American Academy of Pediatrics recommends all infants receive a daily vitamin D supplement of 400IU. While breastmilk contains little vitamin D, breastfeeding is still recommended with supplementation. Oral liquid vitamin D drops are available for infants without other vitamins. However, many breastfed infants still do not receive supplements.

1. Breastfeeding and Vitamin D
Supplementation
2014
MMIMSR

2. Objectives
•Understand the clinical presentation of vitamin D
deficiency in the neonatal period
•Describe current recommendations for vitamin D
supplementation in breastfeeding
•Learn anticipatory guidance regarding Vitamin D
supplementation

3. Case #1
A 12-day-old girl born in October presents to clinic with new-onset focal seizures. In
the previous 5 days, she has had right-sided arm and leg twitching, left-sided head
turning and lip smacking. These episodes lasted for approximately 30 s, and their
frequency had increased to eight times per hour. There is no history of fever, trauma,
sick contacts or neonatal sepsis risk factors. The baby is breastfed and supplemented
with formula. He is found to have hypocalcemia.
•What is the relationship between an acute versus
chronic presentation of Vitamin D deficiency?
•What are risk factors for Vitamin D deficiency?

4. What is the presentation?
Acute
•Acute presentations occur in period of rapid growth with increased
metabolic demand such as neonatal period
• An unsupplemented infant will reach deficient state more rapidly than
infant whose mother had adequate vitamin D state
•Associated signs and symptoms:
•Hypocalcemia (including seizures)
• More likely in infants of diabetic or preeclamptic mother
• May occur in infants born to mothers with hyperparathyroidsm
•Lethargy
•Irritability
•Predisposition to respiratory infections in infancy

5. What is the presentation?
Chronic
•State of deficiency occurs months before findings are
apparent on physical exam
•Rickets/ decreased bone mineralization:
•Lab findings: normocalcemia or asymptomatic
hypocalcemia
•Rickets: peak incidence between 3 -18 mo

6. What are the risk factors?
Vitamin D deficiency rickets among breastfed infants is rare, but it can occur if
an infant does not receive additional vitamin D from a vitamin supplement or
from adequate exposure to sunlight. A number of factors decrease vitamin D
level. These factors include:
Decreased synthesis from sunlight.
• Living at high latitudes, particularly during winter months
• Air quality conditions such as high levels of air pollution
• Skin pigmentation as in darker skin types
• Weather conditions such as dense cloud covering
• The degree to which clothing covers the skin
• Use of sunscreen
Decreased GI absorption from chronic disease:
• Fat malabsorption (e.g. cystic fibrosis)
• Anticonvulsant medication use (induce cytochrome p450 and other enzymes)

7. Stages and Clinical Signs

8. Case #2
A young mother in your practice presents for the 2 week newborn exam
for her second child whom she is breastfeeding. She would like to
breastfeed exclusively until she returns to work at which time she would
like to start supplementing with formula.
• What is the MOST appropriate advice to give this mother about her
child’s nutrition?
• How would your advice change if she were want to transition
completely to formula?

9. Recommendations for Vitamin D
Supplementation in Breastfed and Partially
Breastfed Infants
• The American Academy of Pediatrics (AAP) recommends a daily intake of
vitamin D of 400 IU/day for all infants and children beginning in the first
few days of life (and continued into childhood)
• Human milk typically contains a vitamin D concentration of 25 IU per liter
or less.
• When maternal vitamin D status is deficient, particularly in winter, the
unsupplemented infant 25-OH-D concentration is very low
• *Though rare, a breastfed infant may need vitamin B12 supplements
before age 6 mo if mother is vitamin B12 deficient.

10. Recommendations for Vitamin D
Supplementation in Breastfed and Partially
Nonbreastfed Infants
• All infant formulas in the U.S. must have a minimum 40 IU/100 kcal and a
maximum concentration of 100 IU/100 kcal
• Most formula-fed infants with feed 1 L of formula per day after the first
month of life
• Any infant who receives <1 L or 1 qt of formula per day requires an
alternative way to obtain 400 IU/day of vitamin D
• An infant receiving Vitamin-D fortified formula (>1 L per day) or a child one
year of age or older who is weaned to vitamin-D fortified milk, then further
supplementation is not necessary.

11. Case #3
You are addressing a group of expectant mothers at a local
health clinic as part of a community education program. You
explain that exclusive breastfeeding is the best nutrition for most
infants after birth. You also explain these infants should receive
Vitamin D supplementation.
•What Vitamin D formulations are available?
•How are we doing as pediatricians with making
recommendations for supplementation with Vitamin D while
breastfeeding?

12. Forms of Vitamin D Supplements
•Adequate amounts of vitamin D can be achieved by currently
available multivitamin products containing 400 IU of vitamin D
per mL or the newly available preparations that contain 400
IU/mL vitamin D alone without other vitamins.
•These products are available over the counter.
•Prescription preparations of vitamin D have very high
vitamin D concentration and are not for routine home use.

13. Oral Vitamin D Preparations

14. How are we doing?
• A minority of breastfed infants receive vitamin D
supplementation.
• Vitamin D use is strongly linked to physician recommendations
• Many parents believe breastmilk has all the needed nutrition.
• Educational efforts directed at physicians and parents are
needed to increase compliance with Vitamin D supplementation
guidelines.

16. PREP Question
You are seeing an infant in the newborn nursery who was born
this morning to a woman who has hepatitis C virus (HCV)
infection. The infant is healthy. The mother wants to know if she
should breastfeed her infant.
Of the following, the MOST appropriate information to share
with this mother is that:

17. PREP Question
A. breastfeeding is contraindicated if the mother has
evidence of liver dysfunction
B. breastfeeding is contraindicated when a mother has HCV
infection
C. breastfeeding is recommended if the mother does not
also have hepatitis B virus infection
D. breastfeeding is recommended if the mother does not
also have human immunodeficiency virus infection
E. breastfeeding is recommended only if viral cultures of
human milk show no evidence of HCV

18. PREP Question
A. breastfeeding is contraindicated if the mother has
evidence of liver dysfunction
B. breastfeeding is contraindicated when a mother has HCV
infection
C. breastfeeding is recommended if the mother does not
also have hepatitis B virus infection
D. breastfeeding is recommended if the mother does not
also have human immunodeficiency virus infection
E. breastfeeding is recommended only if viral cultures of
human milk show no evidence of HCV

19. References and Future Reading
– Breastfeeding: More Than Just Good Nutrition. RM Lawrence and RA Lawrence; Pediatrics in Review 2011;
32:267-280; doi:10.1542/pir.32-7-267
– AAP Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics Vol. 129 No. 3 March 1, 2012 pp.
e827 -e841 (doi: 10.1542/peds.2011-3552)
– PREP 2012, Question 13
– Wagner CL, Freer FR; Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin
D deficiency in infants, children, and adolescents . Pediatrics. 2008;122:1142-1152.
-Institute of Medicine, Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary
Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2012.
- Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods. James A. Taylor, Leah J. Geyer
and Kenneth W. Feldman. Pediatrics. 2010;125;105