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Most breastfeeding mothers not following AAP recommendations on vitamin D
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Survey results recently published in Annals of Family Medicine cited safety and cost as the reason most breastfeeding mothers are not following the AAP’s recommendations of providing 400 IU daily of vitamin D to their infants.
Researchers also indicated that taking the mother’s preferences into consideration may lead to more mothers meeting the requirements.
“Breastfed infants are vulnerable to vitamin D deficiency because of the low concentration of vitamin D in breast milk,” Puja J. Umaretiya, MD, of the Mayo Medical School in Rochester, Minnesota, and Boston Children’s Hospital, and colleagues wrote. “Breast milk can be enriched with vitamin D through daily or intermittent high-dose maternal supplementation to meet infants’ vitamin D requirements. Alternatively, oral vitamin D, 50,000 IU every 2 months, can be given to healthy infants with routine vaccinations to prevent vitamin D deficiency.”
Umaretiya and colleagues analyzed survey responses from 184 women who used both breast and formula milk (n = 44) and women who exclusively breastfed (n = 140) and reported the following:
- 77 infants (42%) received the AAP recommended amount of vitamin D;
- 101 mothers (55%) supplemented their infants with vitamin D the previous week;
- 102 mothers (57%) preferred daily to monthly supplementation;
- 134 mothers (73%) whose clinicians recommended vitamin D were more likely to provide vitamin D supplements to their infants (OR = 8.3%; 95% CI, 3.8-18); and
- 160 mothers (88%) preferred supplementing themselves rather than their infants;
According to researchers, common reasons cited for not supplementing infants with vitamin D were inconvenience or the infants’ dislike of the supplement; mindsets that breast milk delivers the infant the needed nutrition; lack of knowledge; and mindsets that fortified milk delivers the needed vitamin D.
Researchers discussed the benefits of the mother taking the supplement, as well as ways to increase the number of mothers adhering to the AAP’s recommendations.
“Advantages of maternal rather than infant supplementation include increased ease of administration, simultaneous mother and infant supplementation, and avoidance of potential toxicity to the infant from dosing errors,” Umaretiya and colleagues wrote. “Promotion of breastfeeding as a complete nutritional source could be facilitated by providing adequate maternal vitamin D supplementation to breastfeeding mothers. Maternal choice of mode of supplementation may help ensure adequate vitamin D status for infants.”
Previous research has suggested the infants of women taking 6,400 IU vitamin D per day had vitamin D levels comparable to the infants receiving the oral 400 IU vitamin D supplement per day. Other research has suggested women who do not consume enough vitamin D during pregnancy may be increasing their child’s risk for multiple sclerosis. – by Janel Miller
Disclosure: One of the researchers reports being a consultant for Biomedical Systems Inc. and receiving speaking fees from Sandoz. All other researchers report no relevant financial disclosures.
Perspective
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Rose St. Fleur, MD, FAAP, IBCLC
The AAP’s recommendations call for supplementing the infant with 400 IU of oral vitamin D daily. They make no provisions for supplementing the mother. So providers do not think to supplement the breastfeeding mother with vitamin D, much less ask what her preferences might be. This study might be the first study exploring breastfeeding mothers’ preferences for vitamin D administration. Given the findings of this study, maternal supplementation is an option seriously worth considering.
However, preferences are one thing, but is maternal supplementation a viable option? There are pros and cons to consider.
Let’s discuss the pros first. It has always been difficult for providers to attest to the beneficial effects of breast milk while proclaiming, in the same breath, that supplementation is needed. Therefore, one significant pro to maternal supplementation is that it debunks the widespread myth that breast milk is naturally deficient in vitamin D. This study reminds us that breast milk is often deficient in vitamin D, but it can be made sufficient when mothers are adequately supplemented.
Another pro to consider is that when mothers are supplemented, both mother and baby can benefit greatly. If maternal stores are not fully adequate, she can receive the dose she needs while dosing her infant at the same time. The ability to prevent deficiency in two patients with only one intervention is pretty remarkable. This study shows us that, for some families, maternal supplementation is not just beneficial, but even preferred over infant-only supplementation.
However, if maternal supplementation is administered based on patient preference, it is important to know that effective dosing is higher than typically recommended in most settings. Therefore, the provider must look at additional sources of vitamin D that could place the mother at risk for vitamin D toxicity, such as food sources and amount of sunlight exposure. Even if a mother chooses to supplement herself rather than her baby, further research involving larger subject numbers is needed to examine whether toxicity in this setting could occur.
Second, we already know that compliance for delivery may be an issue for administration of vitamin D to the infant. It makes sense that this would also likely be an issue for administration to the mother. We need to make sure that we are not simply replacing one problem with another. Ways to explore increasing compliance in mothers would be a necessary additional step for providers when discussing maternal preferences.
Ultimately, while this study adds light to maternal preferences, with maternal supplementation not being a common practice and a relatively small breadth of research dedicated to this subject — especially on safety of long-term maternal supplementation — the AAP’s recommended practice guidelines to supplement the infant, and not the mother, will likely stand as is, in spite of maternal preferences.
Nonetheless, acknowledgment of maternal preferences is a critical and often-overlooked component to practice. Knowing that, in some cases, mothers would choose to supplement themselves rather than their infants is very important. Also, it reminds us that we should always include input from the families when making management decisions. My advice to the provider is to discuss and educate on options for supplementation with every breastfeeding family, but also recognize that, in the end, the best choice must take into consideration cost, compliance, and margin of safety.
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