Vitamins and breastmilk
Do babies need vitamin D?
Tuesday, March 22, 2005
New parents intent on exclusively breastfeeding their babies are facing a new issue—liquid vitamin D supplements, which are increasingly being recommended for breastfed babies.
The extra vitamin D is needed to prevent rickets, a once common disease marked by soft or deformed bones. Vitamin D helps the body absorb calcium, which strengthens bones.
This all comes at the same time the American Academy of Pediatrics is reiterating its support of breastfeeding. A new policy statement issued in mid-March says: “Breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant.”
Still, most experts agree that breastfed babies need extra vitamin D—especially African-American babies, whose darker skin makes it harder to absorb the vitamin from the sun. But vitamin D supplements are not profitable in the United States, so companies manufacture a one-size-fits-all multivitamin drop, according to Dr. Lawrence Gartner, chairman of the section on breastfeeding for the American Academy of Pediatrics and professor emeritus of pediatrics and obstetrics and gynecology at the University of Chicago.
So, most babies are being given extra vitamins they don’t need, such as A and C.
It’s not harmful, but it’s not necessary, either. Breastmilk contains enough of those vitamins, says Ruth Lawrence, professor of pediatrics at University of Rochester School of Medicine in New York.
“Vitamin supplements are not recommended for a breastfed baby,” says Katy Lebbing, a certified lactation consultant and manager at La Leche League. “The exception might be vitamin D. Vitamin D is not meant to be in breastmilk. The way babies are supposed to get vitamin D is sunlight. In this area, we don’t usually see a problem unless the baby has very dark skin or never ever gets outside.”
Most doctors agree breastfed babies should receive the liquid supplements, but policies at area hospitals differ on when and how.
In all the confusion, advocates are worried mothers will get the wrong message and become discouraged or decide against breastfeeding despite the evidence that it the best thing for a child.
And no one has yet to address the very real issues of struggling to get babies to swallow these bitter-tasting drops.
I should know.
When I gave birth to my daughter in mid-December at Loyola University Medical Center, I was determined to breastfeed. I knew Loyola had a history of supporting breastfeeding, and both my doctor and nurse encouraged me to nurse before they whisked my little girl off to the nursery to be weighed.
I was shocked when a hospital worker brought my daughter back from the nursery and showed me a bottle of vitamin drops she was supposed to receive once a day.
“Some babies don’t like the taste, so what we do in the nursery is just mix them in a little formula and put it in the nipple of a bottle,” she told me. Formula? Bottles? I couldn’t believe it—but I was in no condition to protest.
The next day I asked the lactation consultant about the vitamins. She told me most babies nowadays don’t get enough vitamin D from the sun. For formula-fed babies, it’s not a concern, since vitamin D is added to formula. But breastfed babies need the drops, she said.
She told me I could give my baby the vitamins straight from a dropper, but I should be careful to put them in the side of her mouth so she wouldn’t choke and get them in her lungs, causing pneumonia.
I thought about pumping and mixing the drops in my own milk, but most books I read advised against pumping for the first few weeks.
When I tried to give her the drops—carefully, in the side of her mouth—she gagged and choked, wheezed and sputtered. I got them down, but then she spit up the drops, along with what seemed like her entire last feeding.
My husband and I tried different ways to get her to take the orange- colored drops. Once he stuck the dropper in her mouth as I nursed her, but I was afraid she would think my milk tasted bad and refuse the breast.
Our pediatrician agreed that, yes, she should have the drops. But after a few more days of watching her spit up orange goo, I gave up. When we pressed our pediatrician further, she said since my daughter is so fair-skinned, holding her in the light a few minutes a day would be good enough.
Whom was I to believe?
It seems there are as many philosophies on vitamin D drops for babies as there are hospitals in Chicago.
Pediatricians began advising in April 2003 that babies receive vitamin D supplements “beginning within the first two months.” Some hospitals begin at birth to start the habit early.
That’s the case at Loyola, where all breastfed babies receive supplemental vitamin D from birth.
At Edward Hospital in Naperville, premature babies get vitamins in the nursery, often mixed with their mother’s pumped breastmilk. Full-term babies are sent home with vitamins but don’t get them at the hospital, says Nicole Tracy, a pediatric dietician.
Other hospitals feel it’s too much to ask a mother just beginning to breastfeed to worry about the drops.
At Northwestern Memorial Hospital in Chicago, pediatricians tell parents about vitamin drops at the follow-up visit. At Advocate Christ Medical Center and Hope Children’s Hospital in Oak Lawn, pediatricians start babies on the drops at the 1-week visit.
Oak Lawn pediatrician Zoe Alikakos says most parents give the vitamins straight from the dropper without any problems. She is especially vigilant during the winter months, when babies are less likely to be in the sun.
Supplements in the real world
Some health professionals worry that promoting the vitamin drops might discourage mothers from breastfeeding. They might opt for vitamin-fortified formula rather than take on the battle of coaxing their babies to swallow the foul-tasting drops.
During a 2001 conference at the Centers for Disease Control and Prevention in Atlanta, there was a discussion with doctors and researchers about the racial differences in babies’ need for vitamin D supplements. Everyone acknowledged rickets strike more African-American babies, yet the American Academy of Pediatrics decided to keep the recommendation the same for all babies.
Breastfeeding advocates at La Leche League disagree. Their guidebook says treating each mother and baby as a “unique pair” lessens the need for supplemental vitamins.
Lebbing also takes issue with hospitals giving the drops in a bottle nipple: “Putting it in a nipple can set you up for a nipple confusion situation.”
Babies also receive supplements in other countries. In Germany, vitamin D is put on the mother’s nipple once a day before nursing, to avoid putting a rubber nipple in the baby’s mouth.
In Canada, a vitamin D-only drop is available, says Gartner, which tastes better than the multivitamin drops here. Gartner says doctors should prescribe triple vitamin drops—which contain just three vitamins—not drops with the bitter-tasting B vitamin.
Dr. James Raettig, medical director of the Newborn Nursery at Loyola, says such distinctions are trivial and it doesn’t matter which solution is given—babies get used to taking the drops.
Raettig says there is no evidence-based medicine suggesting the drops interfere with breastfeeding. “I personally prefer to start these things as soon as possible to get the parents in the habit,” Raettig says.
He says it is not hospital procedure to administer the drops in formula. “That must have been that one person’s idea,” he says.
Gartner says the academy’s advisory is open: “The way the wording is—within the first two months—allows leeway. For many mothers having to start the baby out the first few days when they’re just getting into the breastfeeding, giving the drops was just one more burden.”
Gartner says a healthy mother taking prenatal vitamins during pregnancy gives her baby enough vitamin D through the placenta to last two months. Unfortunately, he says, many women don’t take prenatal vitamins.
Although my doctor suggested sunlight as an alternative, the pediatricians’ position is that sunlight cannot be relied upon to prevent rickets.
Because sunlight is difficult to measure, its effect on vitamin D absorption is hard to study. And then there is the racial difference. Some doctors estimate African-Americans need 10 times the two-hour-per-week recommendation to absorb enough vitamin D.
Complicating matters, some studies have shown early childhood sun exposure can be a risk factor for skin cancer.
“People say, ‘Why don’t you recommend 15 minutes of sun a day? That won’t cause skin cancer,’ ” Gartner says. “Well, we don’t know that. We do know that giving vitamin D drops is perfectly safe.”
The formula frenzy
Since formula is fortified with vitamin D, breastfed babies are at greater risk for rickets than formula-fed ones. Some health professionals fear women will hear the wrong message: Their breastmilk is deficient.
Others worry that formula makers—already feeling the financial crunch as more women choose to breastfeed—will try to capitalize on the problem by pushing formula feeding as a solution.
In fact, a leading manufacturer of vitamin supplements for babies is Mead-Johnson, the maker of Enfamil. Poly-Vi-Sol, a commonly prescribed liquid vitamin that contains vitamin D, comes with the Enfamil logo prominently displayed on the box.
The problem is worse in Canada, where Mead-Johnson manufactures vitamin D-only drops in packaging that implies human milk is deficient, Gartner says.
Manufacturers can’t make big money from vitamin D since it can’t be patented, Gartner adds, leaving formula companies looking to exploit the issue to win over breastfeeding moms.
“The only ones interested in making [vitamin D] would do so to market a product that has a big profit margin, like formula,” says Gartner, who notes that formula companies give large contributions to the academy.
Gartner, a breastfeeding advocate, says he worries that if the drops are not given routinely, rickets could make a comeback and create negative publicity for breastfeeding.
“My concern is that every time there’s a report of breastfed babies developing rickets, people will assume breastfeeding is dangerous,” he says. “Breastfeeding is not dangerous.”
Although the recommendation had its intended effect in my case—educating me about rickets and vitamin D—the message may not be getting to those who need it most.
Chinita Williams, an African-American mother from Chicago’s West Side, chose to breastfeed her daughter for the same reason most women do: It’s proven best for the baby’s health and development.
Despite her daughter Kourtney’s increased risk of rickets because of her skin color, Williams says she was told nothing about the disease or vitamin D. She was not given the vitamins in August when Kourtney was born at Gottleib Memorial Hospital in Melrose Park. Her doctor has never mentioned them, either.
“If it’s something that can affect her health, then, yes, I wish I’d known,” Williams says.
Alice Hohl is a writer who lives in Forest Park with her husband and baby daughter.
If you think rickets sounds like an old-fashioned disease, you’re right. In the early 1900s, nearly 80 percent of children developed rickets—soft or deformed bones—according to Dr. Lawrence Gartner, chairman of the section on breastfeeding for the American Academy of Pediatrics and professor emeritus of pediatrics and obstetrics and gynecology at the University of Chicago.
Some doctors fear rickets may be on the rise as many babies fail to get enough vitamin D, which helps the body absorb the calcium it needs for strong bones.
“Rickets is a loss of calcium from bone,” Gartner explains.
“What your body is trying to do is maintain a normal level of calcium in the blood. The body will take calcium out of bone to keep calcium levels high enough in the blood.”
The onset of the Industrial Revolution and migration of thousands of people to windowless tenement houses in dusty, smoke-filled cities caused an epidemic of rickets in the early 20th century.
Babies who didn’t get enough sunlight were prone to the disease, since sunlight is a major source of vitamin D, which is found in few foods.
Many children became bowlegged. Some babies died as their rib cages became too soft to protect their lungs.
Along with bone deformities, rickets can also lead to soft skulls and delays in crawling and walking, according to the American Academy of Pediatrics.
To solve the problem, health officials directed milk suppliers to add vitamin D to milk. Cases of rickets decreased substantially.
Although the Centers for Disease Control and Prevention in Atlanta has concluded there are no reliable national data on the number of rickets cases in the United States, some doctors say rickets appears to be on the upswing.
Many parents shelter their children from cancer-causing sunshine throughout childhood. (Sunscreen filters out vitamin D, along with harmful rays.)
Residents of cities, where pollution is higher and opportunities for outdoor play are fewer, may not realize their children are not getting enough vitamin D. Some parents also shy away from vitamin D-fortified cow’s milk for themselves and their children.
Health officials are especially concerned about some minority populations. The darker a baby’s skin, the more sunlight is required to absorb adequate vitamin D. Also of concern are girls and women whose religion or culture requires them to be completely covered and therefore receive almost no sunlight on their skin.
Vitamin D deficiency in the mother can also contribute to problems in babies since a fair amount of vitamin D is passed through the placenta from the mother at birth.
However, a mother probably cannot safely ingest enough vitamin D to pass on an adequate amount through her breastmilk.
Since breastmilk was never intended to be a source of the vitamin, little of it passes through breastmilk. Nature intended babies to receive their vitamin D from the sun, not their mother’s milk.
Baby formula is fortified with vitamin D. Breastfed children can also receive vitamin D through supplemental drops.
Vitamin D influences how much calcium is absorbed in the intestines: Just 10 to 15 percent is absorbed if no vitamin D is present, but 30 to 80 percent is absorbed with vitamin D, according to the CDC. Alice Hohl