I've been aggressively addressing this issue for more than a decade now, testing and supplementing almost every client within my midwifery practice. It's an issue I am a bit passionate about and one that I believe well demonstrates the flawed mindset of our country's #sickcare system. Consider that if we really had a healthcare system, the profession would prioritize research towards what level of vitamin D is optimal and strive for those standards in our recommendations, rather than making the absence of rickets our goal for vitamin D supplementation. If practitioners valued health in our culture, they would talk to clients about strategies for optimizing health, not just working to rule out overt disease.
Vitamin D has been recommended to infants for a little more than a decade. There are a number of controversial issues in this recommendation, one being the fact that for whatever reason, optimal levels in the mother throughout the #pregnancy seems not to be of any concern. Routinely supplementing the child seems to be the preferred approach by our professional groups, even though this disrupts their very fragile gut microbiome.
Vitamin D Recommendations
The initial discussion for this supplementation didn't even happen until a formula manufacture shared that human milk was deficient so started recommending vitamin D supplementations in breastfed children. This simply undermines #breastmilk as the optimal feeding method for babies, so I was suspicious this was largely a marketing ploy. As professional groups reviewed the minuscule amounts of literature on this topic, at this time, and began discussing recommendations, the focus after evaluating the increasing rates of rickets in our country became more about wanting to be politically correct and avoid having a pediatrician judge need of vitamin D based on the color of the child's skin; therefore, a blanket recommendation was suggested.
In my own clinical practice, I discuss this history and the evolution of the recommendation with my clients and essentially all agree to evaluating their own levels during pregnancy. We were learning more and more about the critical role of vitamin D during each viral outbreak, H1N1 through COVID, so optimizing this hormone seemed to offer benefit larger than science currently understood. What I found, and somewhat to my surprise, is that not a single mother in my practice was above the current recommended standards for vitamin D, even among the most light-skinned clients. Clearly, none were even close to the levels thought to be more optimal.
As I continued to research this area of health, I found a study that measured the maternal vitamin D level and then evaluated what dose was therefore found in her breastmilk. They determined that a maternal level of about 50 to 60 offered about 400 IUs of vitamin D in human milk, and with this single study my clients most often felt comfortable working to achieve this level than to subsequently supplement their newborn. There are risks many fail to consider with supplementation. Exclusively breastfeeding does not include consuming man-made vitamins, which pose risk for contamination or error, although either way will disrupt the natural gut flora that breastmilk establishes.
The work to discover the right dose was a great mystery however, as I was unaware of any other practitioner taking this approach, now nearly 15 years ago. Following informed consent, most all of my clients would then agree to evaluating their vitamin D levels at their first visit and then supplementing as appropriate, which was almost exclusively necessary, and retesting at their 28 week blood draw. In a rather short amount of time, it was apparent that all my clients were deficient, so we would then only test at the first visit if they had not already been supplementing to save cost, but would initiate supplementation and test at the 28 week visit. Several clients required testing yet again at term to determine if neonatal supplementation was necessary. Rarely was this the case based on the goal of mother's result being between 60 and 80 so she was offering a minimum of 400IU to her child through her milk. Evaluating vitamin D levels is a routine part of my #wellness exams in primary care as well.
Vitamin D Deficiency in Our Littles
It has been determined that about 18 percent of children in the United States are deficient in vitamin D and approximately 1 percent are severely deficient. Breastfed infants are thought to be especially vulnerable because human milk offers a lower concentration of vitamin D; therefore, the American Academy of Pediatrics (AAP) has recommended supplementation of these infants beginning within the very first few days of life. Adherence to this recommendation has been poor however, and there have been no recommendations to evaluate the mother's vitamin D and optimize her health throughout pregnancy and breastfeeding. This recommendation also doesn't changed based on one's location throughout the country, whether in a more sunny location or in the more northern regions. All mothers and babies have been determined to be at risk for vitamin D deficiency.
There are two studies that evaluated the potential of enriching the mother's breastmilk through maternal supplementation, and another study evaluated the potential of offering the child larger boluses of vitamin D, 50K IU every two months, with routine vaccinations to address vitamin D deficiency. However, there has been little investigation into the thoughts and desires of mother regarding vitamin D deficiency in her child.
Mother's Preferences
What has been discovered is that mothers want an option that is convenient, safe, and most natural at the most minimal cost. It seems that about three-fourths of women are taking prenatal vitamins which offer vitamin D, although admittedly, I am a little skeptical of this. It seems women are diligent about this during their first pregnancy, but subsequent pregnancies often get a quick yes answer, but upon further inquiry, they admit to having or owning the #vitamins, but rarely consuming them.
About half of mothers admit to supplementing their infants with vitamin D which is honestly a bit higher than I anticipated as well. That may reflect more on my clientele working hard to reach an optimal level of vitamin D within themselves and having the awareness that when the maternal levels is between 50 and 60, they excrete into their milk a dose of vitamin D equal to current recommendations. Interestingly, only about three-fourths of women share that their practitioners recommended vitamin D supplementation. Non-white women are more likely to supplement than white mothers.
Researchers Umaretiya, Oberhelman, and colleagues (2017) found that the great majority of breastfeeding (88.4%) mothers preferred supplementing themselves rather than their infants for vitamin D. Most expressed a preference for daily supplementation rather than monthly supplementation. They felt this was a safer option and the cost was lower than supplementing their child. This preference was similar whether these mothers were first time mothers or if they had older children.
Those who opted not to supplement shared that they were unaware of the necessity to supplement or believed that breastmilk provided their child with adequate vitamin D. Others felt supplementing was inconvenient or that their infant disliked the supplement.
Ahead of the Times
Simply due to my own critical thinking and the willingness of my clients to dive in a little bit, we have long been supplementing 5K IU of vitamin D as the routine for women, based on their tested results, which research now supports as the optimal level for enriching breastmilk in nursing mothers. I would love to hear from clients in my practice who found this to be true for themselves as well. This dose has not been found to risk toxicity. Admittedly, I don't recommend supplementation higher than 5K IU even when results are low, because anecdotally, I did have three clients who were self-supplementing at higher rates and all three had placenta issues and because vitamin D can create unusual calcifications, I felt this may be an association I didn't want to risk into future pregnancies. We have not seen a recurrence since maintaining supplements at 5K or below.
Mothers are already taking prenatal vitamins, and more often today, vitamin D is part of this blend, but at levels far below 5K which is unfortunate. I should state as well, that my clients have been largely white clientele, and so nonwhite mothers may prove to need a higher dose simply because they require longer duration of sun exposure to boost their own vitamin D levels. Finally, in my mind, this discussion is more about lifestyle than anything else. If one's vitamin D level is low, our first go to recommendation really should not be supplementation, although this really is critical. Our initial focus should be about one's lifestyle. Are they getting outside at all? A discussion about toxic air within indoor environments is critical for optimal health. Further, the need to connect with nature is not in question. We require this for optimal health. Get outside #barefoot on a regular basis! Read my blog about the shoe potentially being the most dangerous modern invention! Read more about earthing.
Umaretiya, P. J., Oberhelman, S. S., Cozine, E. W., Maxson, J. A., Quigg, S. M., & Thacher, T. D. (2017). Maternal preferences for vitamin D supplementation in breastfed infants. Annuals of Family Medicine, 15, 68-70.