The American Academy of Pediatrics and the Canadian Paediatric Society recommend vitamin D supplementation for all infants and children to ensure that the small percentage of infants/children who need additional vitamin D (due to the below mentioned factors) do not become deficient.
- Is your baby at risk for vitamin D deficiency?
- Recommended vitamin D intake
- How much sunlight is needed to generate adequate vitamin D?
- Food sources for vitamin D
- Can we supplement the mother instead of the baby?
- More information
First of all, babies rarely need vitamin D supplements. The babies who do need these supplements need them due to a lack of sufficient sunlight. Factors that put your breastfed baby at risk for vitamin D deficiency (rickets) are:
- Baby has very little exposure to sunlight. For example: if you live in a far northern latitude, if you live in an urban area where tall buildings and pollution block sunlight, if baby is always completely covered and kept out of the sun, if baby is always inside during the day, or if you always apply high-SPF sunscreen.
- Both mother and baby have darker skin and thus require more sun exposure to generate an adequate amount of vitamin D. Again, this is a “not enough sunlight” issue – the darker your skin pigmentation, the greater the amount of sun exposure needed. There is not much information available on how much more sunlight is needed if you have medium or darker toned skin. See the section below regarding amount of sunlight needed.
- Mother is deficient in vitamin D – there is increasing evidence in the last few years indicating that vitamin D deficiency is becoming more common in western countries. The amount of vitamin D in breastmilk depends upon mom’s vitamin D status. If baby gets enough sunlight, mom’s deficiency is unlikely to be a problem for baby. However, if baby is not producing enough vitamin D from sunlight exposure, then breastmilk will need to meet a larger percentage of baby’s vitamin D needs. If mom has minimal exposure to sunlight (see above examples) and is not consuming enough foods or supplements containing vitamin D, then she may be vitamin D deficient. More below on supplementing mom with vitamin D.
Vitamin D supplementation is often recommended, particularly in Canada and other northern latitudes since these areas don’t receive much sunlight during certain parts of the year. If you don’t get much sunlight exposure, consider taking a vitamin D supplement. The 2002 results of the Canadian Paediatric Surveillance Program confirmed 20 cases of nutritional rickets in Canada during 6 months of study. The researchers noted that:
“Intermediate- and dark-skinned children who were breast-fed without vitamin D supplementation were at risk for the disease. Among identified cases, the mothers were frequently veiled, did not receive vitamin D supplementation following delivery, and infrequently ingested milk (thus eliminating a potential dietary source of vitamin D)… A subset of residents in Canada are particularly at risk for nutritional rickets, including darker-skinned, breast-fed infants whose mothers adhere to a diet that is low in vitamin D and have limited sun exposure.” [p. 43-44]
Per [Hamosh 1991, p. 156],
“In summary, exclusive breastfeeding results in normal infant bone mineral content when maternal vitamin D status is adequate and the infant is regularly exposed to sunlight. If the infant or mother is not exposed regularly to sunlight, or if the mother’s intake of vitamin D is low, supplements for the infant may be indicated.”
World Health Organization information [Butte 2002, p. 29 ] states,
“…although there is abundant evidence suggesting that breastfed infants often receive less vitamin D than is required, most studies fail to find rickets in breastfed infants less than 6 months of age… infants who are exclusively or predominantly breastfed for 6 months or longer can be at an increased risk of rickets if their mothers are at risk of vitamin D deficiency, and the infants receive limited sun exposure and no vitamin D supplements.”
If you are in doubt as to whether vitamin D supplements are needed and prefer not to give supplements “just in case” — getting a blood test to determine the vitamin D status of you or your child is always an option.
In the US, the recommended intake of vitamin D for infants and children (including adolescents) is 400 IU (10 micrograms) per day. The recommended intake of vitamin D for lactating mothers is currently 200 IU (5 micrograms) per day, the same as for all adults under the age of 50. Many feel that the recommended level for adults is too low, based upon recent research on vitamin D; per the AAP’s 2008 Policy Statement on prevention of vitamin D deficiency, “New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer.”
Infants 0-12 months should not exceed 1,000 IU (25 µg) per day. Anyone aged 1-50 years should not exceed 2,000 IU (50 µg) per day.
The amount of vitamin D in human milk is small: 0.5-3.4 µg/liter (20-136 IU/liter) [Hamosh 1991, Good Mojab 2002] in mothers who are not vitamin D deficient. However, the vitamin D in human milk is in a form that is very easily used by the baby and therefore adequate for most infants, when combined with a small amount of sun exposure.
The best way to get vitamin D, the way that our bodies were designed to get the vast majority of our vitamin D, is from modest sun exposure. Going outside regularly is generally all that is required for you or your baby to generate adequate amounts of vitamin D. (Keep in mind that there is a concern of sunburn and increased risk of skin cancer with too much sun exposure, however.)
Per “Infant feeding: the physiological basis” [WHO, 1991] by James Akre,
“…it is now understood that the optimal route for vitamin D ingestion in humans is not the gastrointestinal tract, which may permit toxic amounts to be absorbed. Rather, the skin is the human organ designed, in the presence of sunlight, both to manufacture vitamin D in potentially vast quantities and to prevent the absorption of more than the body can safely use and store.”
Per Cynthia Good Mojab, MS, IBCLC, RLC in Frequently Asked Questions About Vitamin D, Sunlight, and Breastfeeding:
The amount of sunlight exposure needed to prevent vitamin D deficiency depends on such factors as skin pigmentation, latitude, degree of skin exposure, season, time of day, amount of pollution, degree of use of sunscreen, altitude, weather, the vitamin D status of the lactating mother, and the current status of vitamin D stores in the infant’s body. Recommendations do and should, therefore, vary around the world, taking into account local conditions and practices.
World Health Organization information [Butte 2002, p. 27 ] states, “Two hours is the required minimum weekly amount of sunlight for infants if only the face is exposed, or 30 minutes if the upper and lower extremities are exposed.” This guideline is from a study [Specker 1985] of exclusively breastfed Caucasian infants under six months old at latitude 39°N (Cincinnati, Ohio, USA). Darker skinned infants may require a longer time outside (three to six times the sunlight exposure) to generate the same amount of vitamin D [Good Mojab 2002].
It is not necessary to get sun exposure every single day, as the body stores vitamin D for future use. Per [Good Mojab 2003], “Studies have shown that children can store enough vitamin D to avoid deficiency for several months when they are exposed to only a few hours of summer sunlight.”
Sunlight exposure needed to achieve adequate vitamin D status*
|Infant Group||Clothing||Minutes/Week||Average Minutes/Day||Reference|
0-6 months old,
Cincinnati, Ohio, USA
|fully clothed without a hat||120 min/wk
|17.1 min/day||Specker 1985|
|diaper only||30 min/wk
1-8 months old,
|fully clothed without a hat||168 min/wk
(2 hrs, 48 min)
|24 min/day||Ho 1985|
|* In these studies, this was defined as the amount of sunlight exposure necessary to maintain blood serum concentrations of 25-hydroxyvitamin D at a level above the lower limit of the normal range (11 ng/ml).|
Vitamin D is available in fortified foods (where vitamin D has been added) such as milk, cereals, or margarine. There is also a new vitamin D fortified orange juice available (fortified with the same amount of vitamin D as used in milk). Vitamin D is found naturally in a few foods including fatty fishes & fish oils (salmon, mackeral, sardines, herring, cod liver oil), liver and egg yolk.
|Food sources of Vitamin D|
|Cod liver oil, 1 tablespoon||1360||34.0|
|Fish & Shellfish|
|Pacific oysters, 3.5 oz||640||16.0|
|Salmon. pink, canned, 3 oz||530||13.3|
|Salmon, Atlantic, farmed, cooked, 3.5 oz||360||9.0|
|Mackerel, cooked, 3 1/2 oz||345||8.6|
|Sardines, canned in oil, drained, 3 1/2 oz||270||6.8|
|Tuna, light, canned, 3 1/2 oz||236||5.9|
|Milk, vit D fortified, 8 oz||90-98||2.45|
|Margarine, vitamin D fortified, 1 tablespoon||60||1.5|
|Liver, beef, cooked, 3 1/2 oz||30||0.75|
|Egg yolk, cooked, 1 large||25||0.62|
|Human milk, 1000 mL||20-60||0.5-1.5|
|Yogurt, 1 cup||4||0.10|
|Cheddar cheese, 1 oz||3.5||0.09|
|* Recommended intake is 5 µg, or 200 IU (1 µg = 40 IU) per day.|
During pregnancy: The primary source of vitamin D for babies, other than sunlight, is the stores that were laid down in baby’s body prior to birth. Per [Hamosh 1991, p. 155], several studies “suggest that infants born to mothers with inadequate vitamin D status are highly dependent on a regular supply of vitamin D through diet, supplements or exposure to ultraviolet light.” Because mom’s vitamin D status during pregnancy directly affects baby’s vitamin D stores at birth and particularly during the first 2-3 months, it would be very helpful for pregnant women to make sure they are getting enough vitamin D. It is easy to determine if mom is vitamin D deficient by using a simple blood test to check parathyroid hormones. If these hormones are elevated, it can indicate a deficiency in vitamin D. Baby’s fetal stores of vitamin D are sufficient for around 3 months if baby gets very little sunlight, but will last much longer if baby is exposed to sunlight regularly.
During lactation: Adding a vitamin D supplement to mom’s diet and/or exposure to ultraviolet light will increase the amount of vitamin D in her breastmilk. As long as mom is not vitamin D deficient, her breastmilk will have the right amount of vitamin D. However, babies were “designed” to get only part of their vitamin D from breastmilk and the remainder from sun exposure – what if baby does not get a minimum amount of sun? A 2004 study [Hollis & Wagner 2004] determined that supplementing the mother with 2000-4000 IU vitamin D per day safely increased mother’s and baby’s vitamin D status: the 2000 IU/d dose resulted in a limited improvement, and “A maternal intake of 4000 IU/d could achieve substantial progress toward improving both maternal and neonatal nutritional vitamin D status.” A Finnish study [Ala-Houhala 1986] showed that supplementing the mother with 50 µg (2000 IU) vitamin D per day was as effective for maintaining baby’s vitamin D levels as supplementing the baby with 10 µg (400 IU) per day.