1) The study surveyed mothers participating in the WIC program in Loudoun County, Virginia to understand infant vitamin D supplementation practices. 2) Only 27% of infants were supplemented with vitamin D, and 24% met the AAP recommendation of 400 IU per day. Exclusively breastfed infants had the lowest supplementation rates. 3) Most mothers started vitamin D supplementation later than the AAP recommended first few days of life, with over half starting at 4 months of age or later.

1. Infant Vitamin D Supplementation:
Practices of Mothers Participating
in a Local WIC Program
Sina Gallo, RD, PhD1
Amara Channell Doig, MPH1
Jennifer Brady, BS2
David Goodfriend, MD, MPH2
Janine Rethy MD,MPH2
National WIC Association Conference, April 2017
1Nutrition & Food Studies, George Mason University, Fairfax, VA
2Loudoun County Health Department, Leesburg, VA;

2. Funding
1. Community Partnerships for Healthy Mothers & Children
National WIC Association & Centers for Disease Control
To develop and implement community-driven plans to reduce
and prevent chronic disease in high-risk areas
2. Preventive Health and Health Services Program
Virginia Department of Health
Preventing and Controlling Obesity and Chronic Disease
Through Evidence Based Programming

3. Community based prevention model
to create a culture of health in
Loudoun County
• David Goodfriend, MD, MPH - Health
Director
• Janine Rethy, MD, MPH, FAAP, FABM
- Physician Advisor
• Jennifer Brady, BSc - Health Educator
• Internship/Practicum students
• Collaboration with George Mason
University since 2014
Loudoun County Health Department
Obesity & Chronic Disease Prevention Division
Team Meeting with Community Partnerships for Healthy
Mothers and Children Program Managers, Sept. 2016.

4. Dr. Sina Gallo, RD, is an Assistant Professor in the Department of
Nutrition and Food Studies. She earned her Ph.D. in Human Nutrition
from McGill University in Montréal, Québec, Canada. She is a
registered dietitian with active membership in the US Academy of
Nutrition and Dietetics.
Dr. Gallo’s research explores the role of early life nutrition in chronic
disease prevention. Specific interests in Vitamin D supplementation
and prevention of bone diseases and family based interventions
aimed at preventing obesity during the critical periods of life.
chhs.gmu.edu/faculty-and-staff
Sina Gallo, RD-PhD

5. Objectives
By the end of the session, participants will be able to:
1. Participants will be able to define the American Academy of
Pediatrics' infant vitamin D supplementation
recommendations.
2. Participants will be able to identify 2 benefits of vitamin D
supplementation for infants.
3. Participants will be able to list 2 strategies to improve vitamin
D supplementation adherence in WIC mothers.

6. Outline
1. Vitamin D
• Sources, functions, recommendations, risks for deficiency
2. Adherence with infant vitamin D supplementation
• WIC and provider survey results
3. Practice guidelines
• Parent education, selection of products, Medicaid coverage

7. Part 1
Vitamin D

8. Vitamin D =
Sunshine vitamin

9. Vitamin D
Vitamin D
Adapted from Hollick. J Nutr, 2005.

10. Photosynthesis of Vitamin D
CHOLESTEROL 7-DEHYDROCHOLESTEROL PRE-VITAMIN D3
DIETARY
SOURCES
SKIN
UVB
(SUN)
VITAMIN D3
(CHOLECALCIFEROL)

11. People with increased skin melanin requires
longer exposure to sunlight
Lightly pigmented white subjects (skin type II)
Heavily pigmented black subjects (skin type V)
Clemens et al. Lancet, 1982.

12. Holick, MF. Am J Clin Nutr, 2004.
Sunscreen with a sun protection factor (SPF) of 8
reduces skin capacity to make vitamin D

13. Factors Affecting Endogenous Synthesis
of Vitamin D
• Skin pigmentation
• Sunscreen
• Season
• Latitude
• Time of day
• Clothing
• Cloud cover
• Pollution

14. Sun Safety Recommendations – AAP, 2014
• Keep infants less than 6 months out of direct sunlight to
reduce the risk of skin cancer
• Begin effective sun protection early in life including sun
screens
• Minimize sun exposure from 10 am to 4 pm
AAP: American Academy of Paediatrics (www.healthychildren.org)

15. Vitamin D
Vitamin D
Can be found in
the D3 or D2 forms
Adapted from Hollick. J Nutr, 2005.
Fortified
Milk or
Juices
Salmon
Supplementation

16. Vitamin D Recommendations
Good Housekeeping 1934. Good Housekeeping 1940.

17. AAP Recommendation
400 IU/d supplemental vitamin D
• Breastfed and partially breastfed infants beginning in the first few days of
life until they start receiving at least 1 litre of formula per day.
• Non-breastfed & older children consuming <32 oz (1 L) / day of vitamin D-
fortified formula or milk
• Adolescents who do not get 400 IU of vitamin D/d through foods
Wagner & Greer. Pediatrics, 2008.

18. Maternal Supplementation: Not Evidence-Based
Hollis et al. Pediatrics, 2015.
Breastfeeding mothers and
infants (n=334) from SC & NY
randomized at 4-6 weeks
postpartum x 6 months:
• Group 1: 400 IU / d mothers
+ 400 IU / d infants
• Group 2: 2,400 IU / d
mother + No infant vitamin
D -- Arm Stopped
• Group 3: 6,400 IU/d + No
infant vitamin D

19. Breastfeeding mothers and
infants (n=334) from SC & NY
randomized at 4-6 weeks
postpartum x 6 months:
• Group 1: 400 IU / d mothers
+ 400 IU / d infants
• Group 2: 2,400 IU / d
mother + No infant vitamin
D -- Arm Stopped
• Group 3: 6,400 IU/d + No
infant vitamin D
Hollis et al. Pediatrics, 2015.
Baseline 7 months
Maternal Supplementation: Not Evidence-Based

20. Vitamin D
Vitamin D
Can be found in
the D3 or D2 forms
Adapted from Hollick. J Nutr, 2005.
Fortified
Milk or
Juices
Supplementation
Salmon
Liver 25(OH)D
CYP27A1
1,25(OH)2D
CYP27B1
“Biologically Active”
Kidney
Calcium regulation
Intestinal absorption
Bone resorption
Renal excretion

21. Metabolic bone disease
which causes bones to
demineralize resulting in soft
weak bones, which can
become bowed or curved.
Vitamin D deficiency is the
leading cause.
Diagnosis between 4 months
to 4.5 years.
Nutritional Rickets

22. ~1900s Exposure to sun lamps effective treatment for rickets

23. ~1930s Fortification of milk with vitamin D to 100 IU / cup

24. Cases of Rickets in the U.S.
• National prevalence is unknown as rickets is not included as
part of pediatric surveillance
• 24 per 100,000 from 2000-2009 in Olmsted County, MN1
• Black children highest risk: ~220 per 100,0001
• Breastfed without supplementation2
• Enrolled in WIC3
• Worldwide re-emergence noted particularly among ethnic
minority children4
• Does not account for asymptomatic vitamin D deficiency
1Thacher et al. Mayo Clinic Proceedings, 2013; 2Weisberg et al. Am J Clin Nutr, 2004; 3Mylott et al. Wisconsin Medical J, 2004;
4Ladhani et al. Arch Dis Child, 2004

25. Long Term Benefits to Bone
Vitamin D supplementation during infancy is associated with higher bone
mass at 7-9 years among girls
Zamora et al. Clin Endocrinol Metab, 1999.
V it D + V it D -
0 .0
0 .2
0 .4
0 .6
0 .8
0 .3 0 1  0 .0 0 3 0 .2 8 3  0 .0 0 8
p = 0 .0 3
D
is
ta
l
ra
d
iu
s
a
B
M
D
(g
/c
m
3
)
V it D + V it D -
0 .0
0 .2
0 .4
0 .6
0 .8
0 .6 3 8  0 .0 0 7
0 .5 8 4  0 .0 2 1
p = 0 .0 1
F
e
m
o
ra
l
n
e
c
k
a
B
M
D
(g
/c
m
3
)

26. Vitamin D
Vitamin D
Can be found in
the D3 or D2 forms
Adapted from Hollick. J Nutr, 2005.
Fortified
Milk or
Juices
Supplementation
Salmon
Liver 25(OH)D
CYP27A1
1,25(OH)2D
CYP27B1
“Biologically Active”
Kidney
Calcium regulation
Intestinal absorption
Bone resorption
Renal excretion
Noncalcemic functions
Type I diabetes
Asthma
Autism
Multiple Sclerosis
Heart Disease

27. Incidence of type 1 diabetes per 100,000 men
by latitude in 51 regions worldwide
Mohr et al. Diabetologia, 2008.

28. Benefits Beyond Bone
• Type I diabetes
• Finnish children given 2,000 IU / day vitamin D from 1 year of age
showed 80% decreased risk of developing type 1 diabetes throughout
the next 20 years1
• Vitamin D improves ability of the pancreas to produce insulin and decrease
insulin resistance
• Respiratory tract infections2-3
• Asthma4
1Hyppönen et al. Lancet, 200; 2Christensen et al. Pediatr Infect Dis J. 2017; 3Feng et al. J Allergy Clin Immunol. 2016.
4Wolsk et al. J Allergy Clin Immunol. 2017.

29. Our current vitamin D
recommendations are not
based on non-bone
outcomes.

30. Vitamin D deficiency: Who is at risk?
• Maternal vitamin D deficiency
• Mothers with dark skin and without sufficient storage of vitamin D
• Limited sun exposure or residing in latitudes far from equator
(>40° North or South)
• Exclusively breastfeed infants without supplementation
“It is inappropriate to actively promote breastfeeding
for a vulnerable patient population, but not
encourage use of vitamin D supplementation.”
Mylott et al. Rickets in the Dairy State. Wisconsin Medical J, 2004

31. Are infants receiving supplemental vitamin D?
Knowledge Gaps

32. Part 2
Adherence with infant vitamin D supplementation.

33. Adherence in the U.S.
1Ahrens et al. Clin Pediatr, 2016.
27%
19%
31%
• Using data from NHANES 2009-2012, % of infants (0-11 mo)
meeting the AAP vitamin D recommendation
• 1 L (32 oz.) of formula per day or 400 IU/d from supplement

34. Loudoun County, Virginia
• Median household income
~$118,000
• 20% born outside the United
States
• Increasingly diverse
• 17% Asian
• 14% Hispanic
• ~40% increase in a decade
• 7% Black
• 4% living below federal poverty
line
• 12% Hispanic / Latinos Individuals living below the Federal Poverty Line

35. WIC Survey
• Ethnic minority children at risk for vitamin D deficiency and
rickets more common among those enrolled in WIC
• There is a paucity of data on vitamin D adherence among infants
enrolled in WIC
Objective
• To describe vitamin D supplementation practices of mothers of
infants participating in a WIC program
• Explore the determinants and barriers to supplementation

36. Methods
• Self-administered online survey using tablets (via Qualtrics) at
both Loudoun County WIC clinics
• Available in English and Spanish
• 5 sections, 58 questions
• Vitamin D intake and knowledge
• ~25 min. to complete
• Anonymous and de-identified, 18 years +
• IRB approval from George Mason University and VDH
• Completed between July - August 2016

37. Participant Characteristics
Race / Ethnicity
• 74% Latino / Hispanic
• 90% Spanish speaking
• 14% Black / African
American
• 5% Asian
Primary Language
• 68% Spanish
0 1 0 2 0 3 0 4 0 5 0 6 0
E u r o p e
As ia
Afr ic a
S . Am e r ic a
N . Am e r ic a
C . Am e r ic a
% o f P a rtic ip a n ts
C
o
u
n
t
r
y
o
f
B
ir
th
5 5
2 3
8
6
6
2
n = 1 8 3

38. Participant Characteristics cont’d
• Maternal age: 30 ± 7 years
• No. of Children: 2 ± 3
• Education
• 45% did not complete high school
• 66% earned less than the federal poverty line
• WIC income criteria <185% of federal poverty line

39. Maternal Vitamin D Supplementation
• 95% of women took a prenatal supplement (multivitamin/mineral)
• ~400 IU / d
• 27% took additional vitamin D
• Of which, 19% took more than 800 IU / d

40. Infant Supplemented with Vitamin D
E x c lu s iv e ly
B r e a s tfe d
M ix e d F e e d in g F o r m u la F e d
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
In fa n t F e e d in g a t 3 M o n th s
N
o
.
o
f
p
a
r
t
ic
ip
a
n
t
s
n = 1 3 5
41
22
72
1 1 (2 7 % )
8 (3 6 % )
1 8 (2 5 % )
*Analysis limited to child <5 years
Overall, 37 infants (27%)
were supplemented
with vitamin D

41. Infant Met AAP Vitamin D Recommendation
E x c lu s iv e ly
B r e a s tfe d
M ix e d F e e d in g F o r m u la F e d
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
In fa n t F e e d in g a t 3 M o n th s
N
o
.
o
f
p
a
r
t
ic
ip
a
n
t
s
n = 8 8
29
12
47
6 (2 1 % )
1 (8 % )
1 4 (3 0 % )
*Analysis limited to child <5 years
Overall, 21 infants (24%)
met AAP vitamin D
recommendation

42. Comparison: Met AAP Recommendation
Feeding Type WIC sample,
3 months
(Loudoun co, VA)
US sample,
0-12 months
(Ahrens et al., 2016)
Exclusively
Breastfed
21%
19%
Mixed Feeding 30%
Formula Fed 8% 31%
Data presented as %.
26%

43. Comparison: Met AAP Recommendation
Feeding Type WIC sample,
3 months
(Loudoun co, VA)
US sample,
0-12 months
(Ahrens et al., 2016)
Canadian
sample, 6 months
(Gallo et al., 2010)
Exclusively
Breastfed
21%
19%
74%
Mixed Feeding 30% 51%
Formula Fed 8% 31% 36%
Data presented as %.
26% 64%

44. Age Started Vitamin D Supplement
0 1 0 2 0 3 0 4 0 5 0 6 0
1 2 m o
6 m o
4 m o
2 m o
1 m o
L e s s th a n 1 m o
5
2 0
5 5
1 0
5
5
n = 2 0
% o f P a rtic ip a n ts

45. 0 1 0 2 0 3 0 4 0 5 0 6 0
1 m o
3 m o
4 m o
5 m o
9 m o
1 2 m o
S till ta k in g
4
5 6
9
4
9
1 3
n = 2 3
4
% o f P a rtic ip a n ts
Age Stopped Vitamin D Supplement

46. 0 1 0 2 0 3 0 4 0 5 0 6 0
1 m o
3 m o
4 m o
5 m o
9 m o
1 2 m o
S till ta k in g
4
5 6
9
4
9
1 3
n = 2 3
4
% o f P a rtic ip a n ts
Age Stopped Vitamin D Supplement
Average duration of
supplementation:
3.6 months

47. Vitamin D Preparations
Supplement n (%)
D-Vi Sol 16 (59)
Tri-Vi-Sol 7 (26)
Baby Ddrops 4 (15)
n=27
Baby Ddrops
Ddrops Company
400 IU / drop
D-Vi-Sol
Mead Johnson
400 IU / mL
TRI-Vi-Sol
Mead Johnson
400 IU / mL

48. Vitamin D Knowledge
• 17% of parents correctly identified vitamin D supplement as the
best source
• 23% incorrectly believe breast milk provides adequate vitamin D
• 27% incorrectly believe that sun is the only vitamin D their child needs
• 41% knew about the daily vitamin D recommendation
• 38% had a health provider recommend vitamin D
• Only 15% recommended by WIC nutritionist or breastfeeding counselor

49. Reasons for Not Supplementing
0 1 0 2 0 3 0 4 0 5 0 6 0
C o s t
B a b y d is lik e d
G a v e s e a s o n a lly
D id n o t k n o w
F o r g o t/N o tim e
D id n o t b r e a s tfe e d
W IC n o t r e c o m m e n d
N o t n e c e s s a r y
P e d ia tr ic ia n n o t r e c o m m e n d 4 7
5
1 9
1 6
1 8
n = 9 9
5
5
N o . o f R e s p o n s e s
4
3
Having a health care professional
recommend predicted a
33-X increased likelihood
vitamin D supplementation
(95 %CI: 8, 128, p<0.0001)

50. • Are infants receiving supplemental vitamin D?
• Are mothers receiving information about supplemental
vitamin D for their infants?
Knowledge Gaps

51. Physician Recommendations
• North Carolina (35ºN)1 & Nevada (36ºN)2
• 45-48% health care providers recommended
• Seattle, Washington (47ºN)3
• 36% pediatricians recommended
• 16% of infants received supplement
• Physicians’ knowledge of the AAP recommendations is positively
associated with the likelihood of their recommending vitamin D4
1Davenport et al. Pediatr, 2004; 2Shaikh & Alpert. J Hum Lact, 2004; 3Taylor et al. Pediatr, 2010; 4Sherman et al. Mil Med, 2009.

52. Provider Survey
Objectives:
To determine practices, attitudes and knowledge regarding
infant feeding and vitamin D supplementation among local
Loudoun county, VA primary care providers.

53. Methods
• Online survey (via Survey Monkey)
• Distributed via the Loudoun County Health Department
• 4 sections, 30 questions
• ~15-20 minutes to complete
• Based on protocol and recommendations from AAP, WHO, and ABM
• IRB approval was not necessary
AAP: American Academy of Paediatrics; WHO: World Health Organization; ABM: Academy of Breastfeeding Medicine

54. Provider Responses
• 16 practices
• 28% response rate
• 77% have a vitamin D
policy for breastfed
infants
• 33% have a vitamin D
policy for all infants
• 67% correctly identified infant
vitamin D supplementation dose
recommended by AAP (400 IU)
• 22% correctly identified amount of
formula infants need to obtain
sufficient vitamin D (32 oz.)

55. Part 3
Practice Guidelines

56. Recommend Vitamin D for All Infants
• A vitamin D supplement of 400 IU daily should be
recommended to all breastfed infants in the first few days of life
and continued until can obtain through diet
• Formula feed infants require 32 oz. (1 L) per day of formula
obtain 400 IU of vitamin D
• Infants consuming less than 16 oz. of formula need a supplement
• Half dose or alternate days
• 200 IU from formula plus 400 IU/d supplement not excessive
• 1,000 IU / day is the upper limit

57. Vitamin D Preparations
• Consider alternative preparations
Oil-based supplement
contains 400 IU per drop
Alcohol-based supplement
contains 400 IU per mL
Cost per dose
~$ 0.22
Supply: 50 days
Cost per dose
$ 0.02 - 0.24
Supply: 56 - 500 days
Availability
~2 mile radius WIC
(11 sites)
82% alcohol-based
45% oil-based

58. Educate on Recommendation and Delivery
Infants 6 week of age
randomized:
• Control group: Routine 400
IU/d prescribed
• Intervention group: Routine
400 IU/d given plus education
(pamphlet and demonstration)
C o ntro l Inte rve ntio n
0
2 0
4 0
6 0
8 0
1 0 0

S
e
ru
m
2
5
(O
H
)D
x
7
w
e
e
ks
(n
m
o
l/L
)
* P = 0 .0 3 v s c o n t r o l, P = 0 .0 0 2 f o r 
1 7  3 9
(n = 2 9 )
5 5  3 0
(n = 2 2 )
M e a n D iffe re n c e 2 8 n m o l/L
( 9 5 % C I: 1 0 .9 , 4 5 .2 )
p = 0 .0 0 2
Madar et al, Eur J Clin Nutr 2009

59. Vitamin D Supplementation
Factsheet for parents and
providers adopted by the
Virginia Department
of Health

60. Medicaid Coverage for Infant Vitamin D
• Vitamin D is an approved Medicaid drug however, health
screening and prescription by a provider must be obtained
• May not issue infant insurance cards for several weeks or the plan may
request “prior authorization”
• Cost of vitamin D supplement may be a deterrent for low- or
middle-income families

61. Providing Infant Vitamin D to WIC Families
• Free prescription program in Montréal without education failed
to improve odds of obtaining vitamin D for the infant1
• North Carolina example:
• In Dec 1999, free 3 month supply of vitamin D supplements provided to
all breastfed infants at 6 weeks of age at 87 local WIC agencies2
• Adherence was not assessed and cost-effectiveness analysis is difficult to assess
as untreated vitamin D deficiency is unknown
1Millette et al. Acta Pædiatrica, 2014; 2Vitamin D Expert Panel Meeting, 2001

62. Conclusions & Recommendations
• Prevalence of infant vitamin D deficiency among WIC enrolled infants is
unknown yet, likely at high risk particularly ethnic minority infants.
• Low adherence with infant vitamin D supplementation among a local WIC
agency and not receiving education from health care providers.
• WIC nutritionists are an untapped resource for educating, and supporting
vitamin D supplementation.
• The cost of untreated vitamin D deficiency is unknown and therefore, need
more research to support the effectiveness of vitamin D education and
possibly provision programs in the WIC setting.

63. Objectives
By the end of the session, participants will be able to:
1. Participants will be able to define the American Academy of
Pediatrics' infant vitamin D supplementation
recommendations.
2. Participants will be able to identify 2 benefits of vitamin D
supplementation for infants.
3. Participants will be able to list 2 strategies to improve vitamin
D supplementation adherence in WIC mothers.

64. Acknowledgments
Funding
Centers for Disease Control and Prevention (CDC)
National WIC Association (NWA)
Loudoun County Health Department
WIC Staff
Study Staff
Graduate & Undergraduate Trainees
Lindi Jones
Julizza Canales
Study Participants

65. Logistic Regression Model:
Received Vitamin D Supplement (n=99)
Variables Odd Ratio 95% Confidence Interval
Maternal age, years 0.98 0.88, 1.10
Number of children 0.67 0.39, 1.15
Education (ref= Completed High school)
Elementary school 1.40 0.20, 9.83
Some high school 1.70 0.41, 7.15
Country of birth North America 0.56 0.13, 2.47
Infant feeding type, 3 months (ref = Mixed)
Breastfed only 1.21 0.28, 5.22
Formula fed 2.08 0.39, 11.21
Health professional recommended 32.6 8.27, 128.4

66. Vitamin D Isoforms
400 IU/d of vitamin D2 vs. D3
0
1 0
2 0
3 0
4 0
5 0 1 4 .3  2 6 .7
(2 4 )
2 1 .9  1 9 .5
(2 6 )
M e a n d iffe re n c e (D 2 -D 3 )= -7 .7 n m o l/L
(9 5 % C I: -2 1 .1 to 5 .8 n m o lL )
p = 0 .2 5 7
D 2 D 3
P
la
s
m
a
2
5
(O
H
)D
1
to
3
m
o
(n
m
o
l/L
)
Gallo et al. J Nutr, 2013.