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Home > Nutrition > Vitamins

Does my baby need vitamin D supplements?

By Kelly Bonyata, IBCLC

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

Is your baby at risk for vitamin D deficiency?

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 - this is rare 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 live in the far north and don't receive much sunlight, you might consider a vitamin D supplement. However, Dr. Jack Newman, a Canadian pediatrician and breastfeeding expert, indicates that Vitamin D supplements are rarely needed - even in Canada. 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.

 

Recommended vitamin D intake

In the US, the recommended intake of vitamin D for babies and lactating mothers is 200 IU (5 micrograms) per day, the same as for anyone else under the age of 50.

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.

 

How much sunlight is needed to generate adequate vitamin D?

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
Caucasian infants, 0-6 months old, latitude 39°9'N, Cincinnati, Ohio, USA	fully clothed without a hat	120 min/wk (2 hours)	17.1 min/day	Specker 1985
	diaper only	30 min/wk (1/2 hour)	4.3 min/day
Chinese infants, 1-8 months old, latitude 39°55'N, Beijing, China	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).

 

Food sources for vitamin D

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.

Can we supplement the mother instead of the baby?

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. However, some feel that higher levels of maternal supplementation (greater than the "safe" level of 2000 IU) would be needed to maintain adequate infant vitamin D levels.

 

More information

Overview | Articles | Policy | Research | Commentary | General Information

 

Overview articles to get started on the subject

Sunlight Deficiency, Vitamin D, and Breastfeeding by Cynthia Good Mojab, MS, IBCLC, RLC

Vitamin D supplements: Necessary for a nursing baby? by Debbi Donovan, IBCLC (note that this is two pages long)

"D-mystifying" the prevention of nutritional rickets from the newsletter Nutrition and Your Child (No. 1, 2001), USDA/ARS Children’s Nutrition Research Center at Baylor College of Medicine

 

Articles - most recent listed first

Some Breastfeeding Myths by Dr. Jack Newman, updated January 2005

Breastfeeding babies need extra vitamin D - Not true! Everyone needs vitamin D. Formula has it added at the factory. But the baby is born with a liver full of vitamin D, and outside exposure allows the baby to get the vitamin D from ultraviolet light even in winter. The baby does not need a lot of outside exposure and does not need outside exposure every day. Vitamin D is a fat soluble vitamin and is stored in the body. In some circumstances (for example, if the mother herself was vitamin D deficient during the pregnancy) it may be prudent to supplement the baby with vitamin D. Exposing the baby to sunlight through a closed window does not work to get the baby more vitamin D.

Breastfeeding and Other Foods by Dr. Jack Newman, updated January 2005

Behind the new recommendations: Now we need to supplement with Vitamin D?!? by Christine Climer, 2004.

Sunlight Deficiency: Helping Breastfeeding Mothers Find the Facts by Cynthia Good Mojab, MS, IBCLC, RLC, from Leaven, Vol. 39 No. 4, August-September 2003, pp. 75-79.

Sunlight Deficiency, "Vitamin D," and Breastfeeding LLLI Press Release, April 17, 2003

Vitamin D Supplementation by Kathy Kuhn, IBCLC, April 2003

Good Mojab, C. Sunlight deficiency: A review of the literature. Mothering.
March-April 2003; 117:52-55; 57-63.

Comments on New American Academy of Pediatrics Vitamin D Recommendation for Infants by William Sears, MD, March 2003

Breastfed Babies and Vitamin D by Teresa Pitman, from Today's Parent, December/January 2002.

Breastmilk and Vitamin D Adequacy: Breastfeeding in the Park Assures Adequate Vitamin D by Anne-Marie Kern of IBFAN, from the Winter 1999 newsletter of INFACT Canada/IBFAN North America

Vitamin D, Rickets and the Breastfed Baby  LLL Press Release (May 1, 1995)

 

Policy - most recent listed first

Draft - Vitamin D for Breastfed Infants 2004 Health Canada Recommendation

AAP recommendations for Vitamin D supplementation & Policy Statement on the Prevention of Rickets and Vitamin D Deficiency (April 2003) In 2003, the AAP decided to recommend vitamin D supplementation for all infants and children to ensure that the small percentage of infants/children who need additional vitamin D do not become deficient.

 Vitamin D Expert Panel Meeting, Final Report, October 11-12, 2001, Centers for Disease Control, Atlanta, GA, USA. Summary of the proceedings of a meeting of scientists, health practitioners, and policy makers from the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and other US academic and professional institutions and government agencies.

 

Research - most recent listed first

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 Dec;80(6 Suppl):1752S-8S.

Vitamin D deficiency rickets study from the Canadian Paediatric Society. See also the June 17, 2004 News Release and Fact Sheet .

Hollis BW, Wagner CL. Assessment of dietary vitamin D requirements during pregnancy and lactation. Am J Clin Nutr. 2004 May;79(5):717-26.

Vitamin D deficiency rickets. In: Canadian Paediatric Society. Canadian Paediatric Surveillance Program - 2002 Results, Ottawa: Canadian Paediatric Society, 2003, p. 41- 44.

Good Mojab, C. Sunlight deficiency and breastfeeding. Breastfeeding
Abstracts. 2002; 22(1):3-4.

Butte NF, Lopez-Alarcon MG, Garza C.  Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva, Switzerland; World Health Organization 2002, pp. 26-30.

Olafsdottir AS, Wagner KH, Thorsdottir I, Elmadfa I. Fat-soluble vitamins in the maternal diet, influence of cod liver oil supplementation and impact of the maternal diet on human milk composition. Ann Nutr Metab 2001;45(6):265-72.

Hamosh M, Dewey, Garza C, et al: Nutrition During Lactation. Institute of Medicine, Washington, DC; National Academy Press 1991, pp. 133-140. This book is available free from the HRSA Information Center (look under Nutrition publications).

Ala-Houhala M, Koskinen T, Terho A, Koivula T, Visakorpi J. Maternal compared with infant vitamin D supplementation. Arch Dis Child 1986 Dec;61(12):1159-63.

Ho ML, Yen HC, Tsang RC, Specker BL, Chen XC, Nichols BL. Randomized study of sunshine exposure and serum 25-OHD in breast-fed infants in Beijing, China. J Pediatr. 1985 Dec;107(6):928-31.

Specker BL, Valanis B, Hertzberg V, Edwards N, Tsang RC. Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants. J Pediatr. 1985 Sep;107(3):372-6.

 

Commentary

The Politics of Vitamin D: Questioning Universal Supplementation by Katherine Barber and Mishawn Purnell-O'Neal, from Mothering, Issue 117, March/April 2003

Resist Much Obey Little: an editorial on proposed AAP vitamin D recommendations by Peggy O'Mara, from Mothering, Issue 108, September/October 2001

Vitamin D commentary by Jack Newman, MD, FRCPC

 

General information (not lactation related)

Vitamin D from the National Institutes of Health

Vitamin D Nutrition Fact Sheet from Feinberg School of Medicine at Northwestern University

Caryl A Nowson and Claire Margerison. Vitamin D intake and vitamin D status of Australians. MJA 2002 177 (3): 149-152.

Rickets from the MEDLINEplus Medical Encyclopedia

Dietary Reference Intakes (DRI) and Recommended Dietary Allowances (RDA) from the US Department of Agriculture's Food and Nutrition Information Center

 

Page last modified: 05/04/2005
Written: 09/13/1998

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