Night weaning and nutrition. Vitamin D for breastfed infants?

Vitamin D for breastfed infants?

CHICAGO, Illinois (AP) --
The American Academy of Pediatrics says all exclusively breast-fed infants should receive vitamin D supplements to prevent rickets, a bone-weakening disease doctors fear may be becoming more common.
Breast-fed infants should receive vitamin supplements beginning at 2 months of age and until they begin taking at least 17 ounces daily of vitamin D-fortified milk, the academy says in a new policy statement. The academy recommends multivitamin supplements containing 200 international units of vitamin D, available as over-the-counter liquid drops or tablets. Supplements containing only vitamin D generally are too concentrated to be safe for routine use, it says.
The new recommendation also applies to:
• Infants who aren't breast-fed but who don't drink at least 17 ounces of fortified formula or milk daily.
• Children and adolescents who don't drink that much fortified milk, who don't get regular sunlight exposure or who don't already take multiple vitamins with at least 200 international units of vitamin D.
Breast milk contains small quantities of vitamin D and doctors used to think babies could get adequate amounts if they also spent time in sunlight, which stimulates the body to produce vitamin D.
However, growing concerns about skin cancer and recommendations that youngsters wear sunscreen and avoid excessive sun exposure may be putting some children at risk for vitamin D deficiency and rickets, said Dr. Nancy Krebs, head of the academy's nutrition committee. The new recommendation, being published Monday in April's Pediatrics, was prompted by reports of dozens of cases of rickets nationwide in recent years.
"We really hope that this is a way to optimize the health of breast-fed infants and not in any way to discourage breast-feeding," Krebs said. The federal Centers for Disease Control and Prevention highlighted concerns about rickets in a 2001 report about several Georgia youngsters hospitalised with the disease. They included breast-fed infants who did not receive vitamin D supplements.
Although reports are rising, it's not clear if the actual incidence of rickets has risen since there are no national statistics on the ailment, said CDC epidemiolog ist Kelley Scanlon.
Most recent cases of rickets have affected black children, whose skin does not absorb as much sunlight. Youngsters who spend a lot of time indoors, perhaps because of parents' long work hours or safety concerns, also are at increased risk. Symptoms include high fever and seizures in infants, and bone pain, delayed walking, small stature and bowed legs in toddlers. Youngsters can be deficient in vitamin D months before symptoms are obvious. Blood tests can diagnose the disease.
Rickets can be treated with adequate vitamin D and sometimes braces or surgery, but short stature and bone deformities may be permanent if not corrected while children are still growing.

From K:
The latest issue of Mothering magazine had a great article on this new troubling recommendation. Vitamin D isn't really a vitamin at all, it is a hormone that is synthesized
naturally when the skin is exposed to sunlight.  The amount of sunlight required for a Caucasian infant is approximately two hours per week fully clothed with bare head, or about 30 minutes per week in only a diaper. Darker-skinned babies need slightly more sunlight.  The time of exposure can be early morning or evening, when sunburn is less likely.  The natural way for humans to acquire vitamin D is through sun exposure, not through diet.
Throughout our evolutionary history, vitamin D has NOT been a part of our traditional diet -- it is only since the very recent fortification of milk with vitamin D (to prevent rickets) that the majority of people get a substantial portion of their vitamin D through dietary means in addition to manufacturing it themselves.  Vitamin D does occur naturally in some other foods (fish oils such as cod liver oil and salmon, for instance), but the body does not need to consume ANY Vitamin D in the diet in order to avoid rickets.  Rickets and vitamin D deficiency are symptoms not of dietary deficiency but of lack of sufficient sun exposure.  The myriad reasons why some people do not have adequate exposure to sunlight include indoor daycare and indoor work environments, unsafe neighborhoods, living at higher latitudes, living in urban areas with pollution and/or buildings that block sunlight, sunscreen use, covering much or all of the body when outside (due to custom, cold climate, fear of skin cancer).  These risk factors are more likely to affect people with darker skin pigmentation, who require somewhat more sun exposure than Caucasions to synthesize adequate vitamin D.

What is wrong with proposing that breastfed infants be given vitamin D supplements?  Well, here are just a few reasons:

1. Recommending that breastfed, but not formula-fed, infants need certain supplements undermines breastfeeding by suggesting that breastmilk is deficient, lacking, or inferior to formula in at least one way.  There is already such a huge world-wide perception that breastfeeding and formula-feeding are roughly equivalent, and even that formula-feeding is superior. This recommendation by the AAP perpetuates the myth that technology and science are needed to complement and improve breastmilk.

2. What are the possible dangers of giving multi-vitamins to infants?  Study after study shows that infants do best when given NOTHING orally except breastmilk during their first 4-6 months of life.  Supplements of any kind can increase risk of allergy, change gut flora and pH, irritate the gastro-intestinal tract, and increase susceptibility to infection.  In addition to vitamin D, multi-vitamin drops (the kind recommended by the AAP) contain other vitamins most certainly NOT needed by infants (and potentially harmful to them), as well as other ingredients such as sugar, preservatives, and natural and artificial flavors.  It is unknown what effect supplementation of vitamins that infants don't need has on their long-term growth and development.  Vitamin toxicity in the infant is possible, if mothers give more than the recommended dose or if certain infants have metabolic disorders preventing them from metabolizing and/or excreting vitamins.

3. The recommendation that all mothers give their breastfed babies vitamin drops does not address the fundamental underlying issue: that the health of some mothers and their children is at risk because they are not being exposed to adequate sunlight.  Addressing the cultural, sociological, economic and political factors that make this fact a reality is much less straightforward than recommending vitamin drops for all babies.  Rather, recommending vitamins gives the appearance of solving a complex public health problem while distracting us from the real issues that need to be addressed.

4. A recent study showed that Infants born to mothers with adequate vitamin D levels during pregnancy have enough stored vitamin D at birth to meet their needs for approximately eight weeks, with no supplements, even in the absence of sun exposure.  I assume that the AAP recommendation to begin vitamin supplementation at two months is based on this research.  However, for those babies born to mothers who did not have adequate vitamin D during pregnancy, administering supplemental vitamins beginning at the age of two months is too late -- the neonate would have been vitamin D deficient from birth (as well as in utero).  It is likely that the risk factors for vitamin D deficiency apply equally to mothers and their children: dark skin pigmentation, long hours indoors because of parents' work hours, cultural or religious traditions (or simply weather) that require covering much of the skin, etc.  Those infants who are most at risk for vitamin D deficiency, therefore, were probably born to mothers who were vitamin D deficient during pregnancy, and beginning supplementation at 2 months of age is not an effective treatment for those children.  Those infants who are not vitamin D deficient during their first two months of life (because their mothers had sufficient vitamin D stores during pregnancy) are unlikely to need supplementation at two months or at any age.  It therefore seems that an across-the-board vitamin supplementation recommendation starting at two months not only foists vitamins supplements on babies who don't need it, but fails to solve the vitamin D deficiencies of those who are truly in need: vitamin D deficient mothers, and their unborn and newborn children.

Conclusions:
A universal recommendation for multi-vitamin supplementation in breastfed babies beginning at two months of age is ineffective at targeting those babies who are most at risk, sends a negative message about breastfeeding, foists an unnecessary cost onto breastfeeding mothers, and exposes infants to (as yet unknown) risks that may be associated with vitamin supplementation.  In the absence of further research, such a recommendation is clearly unwarranted and even counterproductive.
A more effective recommendation by AAP would be to urge people to exposure themselves and their children to moderate amounts of sunlight on a regular basis.  Pediatricians, family doctors, gynecologists, midwives, and other practitioners who come into contact with pregnant women and children would reinforce this recommendation and, when indicated, recommend vitamin drops only to those individuals most at risk for vitamin D deficiency.