Vitamin D Supplementation: Give to Mother or to Infant?

Lara C. Pullen, PhD

September 29, 2015

Supplementing mothers with 6400 IU vitamin D per day results in breast milk with adequate vitamin D to satisfy a nursing infant's requirement. Thus, maternal vitamin D supplementation may represent an alternative strategy to direct supplementation of an infant.

Bruce W. Hollis, PhD, from the Medical University of South Carolina Children's Hospital in Charleston, and colleagues published the results of their randomized controlled trial online September 28 and in the October issue of Pediatrics. The double-blind trial explored whether supplementation of maternal vitamin D can substitute for infant supplementation.

The study included three dosing schedules (400, 2400, or 6400 vitamin D3/day) in lactating women, and vitamin D levels were measured in their exclusively/fully breast-feeding infants. Supplementation was continued for 6 months. The two-site study was conducted at distinct latitudes and included a wide range of racial/ethnic diversity.

The dose of 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline relative to 400 IU/day (P < .001). It also raised infant 25(OH)D levels to those seen in infants who breast-fed from mothers who were not supplemented with vitamin D but who themselves received 400 IU vitamin D per day.

The investigators note that at the time the study was initiated, the Institute of Medicine had set an upper limit of 2000 IU per day for vitamin D, a dose that was much lower than the dose found in this study to be effective. The IOM also reported that vitamin D toxicity is associated with hypercalciuria and hypercalcemia, as well as risk for kidney stones.

Breast Milk Insufficient

Although vitamin D toxicity has been documented, physicians agree that solely breast-fed infants are almost universally deficient in vitamin D unless they receive oral vitamin D supplementation. As a consequence, it has long been recognized that human milk supplies an inadequate amount of vitamin D to meet the nutritional needs of a solely breast-fed infant and leaves the infant at increased risk for rickets.

The medical community therefore recommends that a vitamin D supplement be given to breast-feeding infants, starting within the first few days after birth. Specifically, the American Academy of Pediatrics recommends that infants be given 400 IU oral vitamin D daily.

However, the documented lack of vitamin D in breast milk raises the possibility that it is the mothers who are deficient, and that the mothers are passing their deficiency on to their offspring. If this is true, then the question becomes: Which physicians should be prescribing the vitamin D to the mothers? A recommendation for vitamin D supplementation of mothers, for example, would no longer fall under the American Academy of Pediatrics guidelines.

Whichever way you look at it, the research raises many questions that demand answers and solutions.

"Strategies to overcome financial barriers are needed: Medicaid health maintenance organizations do not issue infant insurance cards for several weeks or the plan may request 'prior authorization,' and the cost of multivitamin drops may tip the budget for low- or middle-income families," Lydia Furman, MD, from the University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine in Cleveland, Ohio, writes in an accompanying editorial.

"Free medication alone, however, is not a panacea: a free prescription program in Montreal failed to improve odds of obtaining vitamin D for the infant, with reduced prescription uptake and an increased prevalence of rickets cases over the 4-year study period," Dr Furman writes.

"Other possible stratagems include public health messaging, addition of infant vitamin D to ambulatory electronic medical record order sets, and augmented trainee education. Finally, we need a way to track rates of vitamin D deficiency rickets, rather than just relying on case reports, and a National Registry could facilitate this," Dr Furman concludes. "Excellent studies, like the work of Hollis et al, generate as many questions as answers, and ultimately energize us to tackle tough clinical questions."

The investigators and Dr Furman have disclosed no relevant financial relationships.

Pediatrics. 2015;136:625-634. Abstract

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