Maternal Preferences for Vitamin D Supplementation in Breastfed Infants

Puja J. Umaretiya; Sara S. Oberhelman; Elizabeth W. Cozine; Julie A. Maxson; Stephanie M. Quigg; Tom D. Thacher

doi:10.1370/afm.2016

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Author response Re:A Pediatrician's Perspective
Puja J Umaretiya

Published on: 08 February 2017
Author Reply - A Better Way to Administer Vitamin D to the Breastfeeding Infant
Sara S. Oberhelman

Published on: 03 February 2017
A Better Way to Administer Vitamin D to the Breastfeeding Infant
Bruce W. Hollis

Published on: 19 January 2017
A Pediatrician's Perspective
Lydia Furman

Published on: 17 January 2017

Published on: (8 February 2017)
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Author response Re:A Pediatrician's Perspective
Puja J Umaretiya, Resident
Other Contributors:
Dr. Furman,
Thank you so much for your insightful comments! We completely agree that for maternal supplementation to be successful, mothers must be aware of the necessary dosing to pass on therapeutic levels of vitamin D to infants. In our sample of mothers, the majority did not know their vitamin D dose, or were taking 400 IU (though presumably none of these women were taking vitamin D with the intention of ac...
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Dr. Furman,
Thank you so much for your insightful comments! We completely agree that for maternal supplementation to be successful, mothers must be aware of the necessary dosing to pass on therapeutic levels of vitamin D to infants. In our sample of mothers, the majority did not know their vitamin D dose, or were taking 400 IU (though presumably none of these women were taking vitamin D with the intention of achieving therapeutic levels for infants). Whether supplementing mothers or infants, we agree that perhaps the biggest barrier continues to be lack of knowledge/understanding of its importance. As a pediatric resident, I have seen firsthand the importance of introducing vitamin D supplementation in the newborn nursery and continuing to educate families in the primary care setting. It is the responsibility of all those who care for mothers, infants, and the mother-infant dyad to continue to educate families about this important topic!
Competing interests: None declared
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Competing Interests: None declared.
Published on: (3 February 2017)
Page navigation anchor for Author Reply - A Better Way to Administer Vitamin D to the Breastfeeding Infant
Author Reply - A Better Way to Administer Vitamin D to the Breastfeeding Infant
Sara S. Oberhelman, Assistant Professor of Family Medicine
Other Contributors:
We greatly appreciate Drs. Hollis and Wagner's letter and their extensive work regarding vitamin D in human milk. We, too, are excited about the momentum in research to support maternal vitamin D supplementation as a safe and reasonable option for breastfed infants to achieve vitamin D sufficiency. With multiple studies, as Drs. Hollis and Wagner referenced, now showing the safety and effectiveness of this strategy and...
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We greatly appreciate Drs. Hollis and Wagner's letter and their extensive work regarding vitamin D in human milk. We, too, are excited about the momentum in research to support maternal vitamin D supplementation as a safe and reasonable option for breastfed infants to achieve vitamin D sufficiency. With multiple studies, as Drs. Hollis and Wagner referenced, now showing the safety and effectiveness of this strategy and our most recent study finding that breastfeeding mothers are willing to partake in self-supplementation, we hope that maternal supplementation will become a more accepted option. Continued work needs to be done to determine best practices for assuring vitamin D sufficiency in infants.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 January 2017)
Page navigation anchor for A Better Way to Administer Vitamin D to the Breastfeeding Infant
A Better Way to Administer Vitamin D to the Breastfeeding Infant
Bruce W. Hollis, Professor
Other Contributors:
It is very heartening to see basic and clinical research come together to impact actual patient care. This is precisely what the recent report of Umaretiya et al (1) demonstrates. We have been dealing with this dilemma now for over 40 years. The first question we and others asked was, how could ingestion of human milk result in the human infant developing rickets (2)? The initial step was defining the vitamin D content of huma...
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It is very heartening to see basic and clinical research come together to impact actual patient care. This is precisely what the recent report of Umaretiya et al (1) demonstrates. We have been dealing with this dilemma now for over 40 years. The first question we and others asked was, how could ingestion of human milk result in the human infant developing rickets (2)? The initial step was defining the vitamin D content of human milk using modern assay technology (3). From this we indeed found human milk to have low vitamin D content (3). The next question was, how does vitamin D gain access into human milk and what form of the vitamin is most important in this respect? The answer to this question turned out to be the parent compound vitamin D (4). From there the question became, how can one increase the amount of vitamin D in the milk? Of course the answer to that question was to increase solar exposure and/or dietary intake of vitamin D to the lactating mother (5, 6). While the previous questions were answered by basic scientific investigation, the hard part was just beginning; which was changing the perception of how much maternal vitamin D intake would be required to achieve adequate amounts of vitamin D in human milk. Remember, at the time and even today the recommended daily maternal intake of vitamin D was 400 IU/day (7), an amount that did nothing to increase the circulating amount of vitamin D in maternal circulation yet alone human milk (8). Also, keep in mind that government recommendation at the time stated that a vitamin D intake of more than 2,000 IU/day was unsafe (9).
Over the last fifteen years we have performed studies to prove what amount of vitamin D is truly required to meet the needs of the pregnant mother and lactating mother-infant dyad (8, 10-12). To perform these studies we had to retain a waiver in the form of an IND from the FDA (11). Earlier limited studies on this subject showed effectiveness (8, 10, 13).Our larger safety and effectiveness clinical trial had not been published (12) when the 2008 AAP recommendations were made (14). Following the publication of our comprehensive RCT in 2015, the recommended practice of maternal vitamin D supplementation of 6,000 IU/day may be more widely accepted (12).
The article of Umaretiya et al (1) also confirms our belief that mothers would rather take the vitamin themselves than give it daily to their infant. It is our hope that through maternal supplementation alone the vitamin D status of the breastfed infant will be improved over the terrible rate of compliance now observed when only offering direct infant supplementation (12, 15).
References
1. Umaretiya P, Oberhelman S, Cozine E, Maxson J, Quigg S, Thacher T. Maternal preferences for vitamin D supplementation in breastfed infants. Ann Fam Med. 2017;15(1):68-70.
2. Bachrach S, Fisher J, Parks JS. An outbreak of vitamin D deficiency rickets in a susceptible population. Pediatrics. 1979;64:871-7.
3. Hollis B, Roos B, Lambert P. Vitamin D and its metabolites in human and bovine milk. J Nutr. 1981;111:1240-8.
4. Hollis BW, Pittard WB, Reinhardt TA. Relationships among vitamin D, 25(OH)D, and vitamin D-binding protein concentrations in the plasma and milk of human subjects. J Clin Endocrinol Metab. 1986;62:41-4.
5. Greer FR, Hollis BW, Cripps DJ, Tsang RC. Effects of maternal ultraviolet B irradiation on vitamin D content of human milk. J Peds. 1984;105:431-3.
6. Greer FR, Hollis BW, Napoli JL. High concentrations of vitamin D2 in human milk associated with pharmacologic doses of vitamin D2. J Pediatrics. 1984;105:61-4.
7. Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. The Journal of clinical endocrinology and metabolism. 2011;96(1):53-8.
8. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med. 2006;1(2):59-70.
9. Food and Nutrition Board. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, D.C.: National Academy Press; 1997.
10. Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr. 2004;80(6 Suppl):1752S-8S.
11. Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. Vitamin D supplementation during pregnancy: double-blind, randomized clinical trial of safety and effectiveness. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2011;26(10):2341-57.
12. Hollis BW, Wagner CL, Howard CR, Ebeling M, Shary JR, Smith PG, et al. Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics. 2015;136(4):625-34.
13. Oberhelman SS, Meekins ME, Fischer PR, Lee BR, Singh RJ, Cha SS, et al. Maternal Vitamin D Supplementation to Improve the Vitamin D Status of Breast-fed Infants: A Randomized Controlled Trial. Mayo Clin Proc. 2013;88(12):1378-87.
14. Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-52.
15. Gordon CM, Feldman HA, Sinclair L, Williams AL, Kleinman PK, Perez-Rossello J, et al. Prevalence of vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med. 2008;162(6):505-12.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (17 January 2017)
Page navigation anchor for A Pediatrician's Perspective
A Pediatrician's Perspective
Lydia Furman, Physician
Thank you for the opportunity to comment on this very interesting and thoughtful article. As a pediatrician who does not treat expectant or adult women, my perspective may be a bit different. I would make 2 points.
(1) While results are not generalizable to all populations, the authors found that most surveyed women (88%) preferred to treat themselves rather than their infant, and most (57%) preferred daily supplem...
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Thank you for the opportunity to comment on this very interesting and thoughtful article. As a pediatrician who does not treat expectant or adult women, my perspective may be a bit different. I would make 2 points.
(1) While results are not generalizable to all populations, the authors found that most surveyed women (88%) preferred to treat themselves rather than their infant, and most (57%) preferred daily supplementation. While 76% of women in the study were reported as currently supplementing themselves with vitamin D, their dose was not reported, and herein is one meaningful challenge of maternal treatment. While Hollis et al (reference #7) did indeed find that 6,400 IU of maternal vitamin D led to sufficient infant levels, the trail arm in which mothers received 2,400 IU of vitamin D had to be stopped for safety reasons because infant vitamin D levels were not adequate. This means that maternal dosing must be correct, that compliance must be excellent, and this implies that either insurance or finances must cover the medication.
(2) If the main identified reasons that mothers are not supplementing their infants can be summarized as lack of knowledge/understanding and convenience reasons, then these are "treatable" causes of failure to supplement and public health strategies should be employed, including beginning supplementation in the newborn nursery with appropriate educational campaigns. This is a responsibility of all of us who care for newborns, and I include pediatricians. Again, these results too may not true of all populations, and additional work could be done to verify their generalizability. This study is an excellent example of good and interesting research that contributes to understanding this important public health issue.
Competing interests: None declared
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Competing Interests: None declared.