Posted by: Diana Cassar-Uhl, MPH, IBCLC | April 12, 2011

My thoughts on the vitamin D controversy


In April of 2011, Best for Babes unveiled a new website, and I was thrilled to be the first guest for the “Making Sense of the Science” blog section.  My article on vitamin D and breastfeeding has caused quite a stir on Facebook fan pages where its link was posted, such as The Leaky Boob and KellyMom, as well as on the blog post itself.  Rather than try to answer all of the excellent questions that were raised (some more kindly than others!), I will try to clarify the major issues here.

Be sure to read the article at Best for Babes, as this post relates directly to that.

A reminder:  I am an IBCLC, which stands for International Board Certified Lactation Consultant.  I am not a doctor.  It is not in my scope of practice as an IBCLC to prescribe or recommend a medical course of action to any mother/baby. I cite the recommendation that has been published by the American Academy of Pediatrics, but I also present other points for consideration, such as which factors an individual family might weigh when deciding whether to go with the AAP’s recommendation on vitamin D for breastfed babies … but at no time do I make a recommendation myself.

I wrote La Leche League International’s tear-off information sheet (Vitamin D, Your Baby, and You, 2010) after months of review of the literature, specifically the ongoing research by Drs. Carol Wagner, Bruce Hollis, and Sarah Taylor , which deals with the vitamin D status of pregnant and lactating women.  This research is very new (first reports were published in May of 2010) and perhaps your OB/GYNs, midwives, and pediatricians have not yet come across it.  This team’s studies are exactly what the National Institutes of Health/Institute of Medicine (IOM) have stated it needs more of (and is funding) in order to embrace vitamin D’s role in outcomes besides bone health: randomized, controlled trials.

A fabulous, comprehensive resource about this research is the book New Insights Into Vitamin D During Pregnancy, Lactation, & Early Infancy, written by the researchers. I was fortunate to hear Dr. Wagner present at a La Leche League educational event in July of 2009.

Before my exposure to Dr. Wagner’s work, I was, like many of you, very skeptical of any guidance that suggested my breastmilk wasn’t all my baby needed.  I believed “vitamins make expensive pee!” and I was emphatic about getting my nutrition from my Very Good Diet (really … it is Very Good).

But, here’s the thing I learned right away: vitamin D isn’t a nutrient.  It’s a pre-hormone, and most of us only get 10% of what we need from diet.  This made me ask the question, as many of you are asking: why, then, do we feel like our babies need to get their necessary vitamin D from diet?

Before I address this issue, let me comment on how the recommendation for 400 IU/day for babies was arrived at.  This is the amount of vitamin D that has been proven, through lots of data, to provide adequate “antirachitic activity” (prevents rickets).  This recommendation is based upon what the medical community knows about vitamin D and bone health.

Should our babies be getting all their vitamin D from breastmilk/diet?

Honestly, this is my million dollar question, one I can’t answer.  What I can do is muse out loud a bit about the alternatives.  One option is to completely disregard the research that suggests babies need 400 IU/day of vitamin D and just breastfeed and hope for the best.  Another is to completely buy into the AAP’s recommendation (which mirrors the IOM’s 2010 report) and supplement with 400 IU/day of vitamin D.  Other options include measuring vitamin D status in mothers and supplementing them, which improves the vitamin D status of both mother and baby (and eliminates the need to give babies anything else by mouth except our milk); still another alternative is sun exposure for mother, baby, or both.

Get out in the sun for vitamin D.

Of course, this is the solution that our bodies were created to live within … but there are several valid reasons why this option does not appeal to some families.

  • Legitimate concern about skin cancer and dermatological recommendations that we limit sun exposure altogether.  The key is to avoid sunburn!
  • Latitude – the research seems to agree that the 30th parallel (Houston) or 35th parallel (Atlanta) is the cut-off point for the sun’s year-round value. If you live south (or north, if you’re in the Southern hemisphere) of or near that and are outside each day, year-round, your vitamin D status may be adequate.  However, the further away you live from the equator, the less likely you are to be getting what you need from the sun for at least half of the year.  New York, for example, is located at 40 degrees … the sun’s rays aren’t potent enough to do their job most of the year in New York (which is why I said that even making snow angels naked in February wouldn’t augment your vitamin D status).
  • Clothing and sunscreen use – if it covers your skin, the sun can’t do its job.  Sunscreen completely blocks the rays that trigger vitamin D synthesis in your body, as does clothing.  Most of your body needs to be exposed, not just hands and face.
  • Skin pigmentation – those with darker skin need longer periods of time in the sun to get the same vitamin D production benefit as those with lighter complexions.  Perhaps this also means the darker among us don’t need as much vitamin D?  Or, consider that populations used to be distributed on our planet such that those with darker pigmentation lived close to the equator.

A brief lesson about how our bodies synthesize vitamin D after sun exposure:  there is a cholesterol in our skin that ultraviolet-B rays from the sun activates.  After 15-20 minutes of midday, mostly uncovered exposure for light-skinned individuals (at the right latitude or during the right season), a healthy body will synthesize 10,000 – 20,000 IU of vitamin D in the next 24 hours.  Those with darker skin tones may require up to an hour of exposure for the same benefit.  The cholesterol in the skin converts the UV-B rays to vitamin D3, which is then converted by the body to the active hormone, 1,25(OH)D.  (Keep in mind that many doctors unknowingly measure this 1,25(OH)D value, which may even be elevated in individuals with a 25(OH)D deficiency.)  A body can’t  “overdose” on vitamin D from the sun, because once the body has enough, synthesis shuts down (oral toxicity is possible, but improbable at sensible supplemental levels).  Vitamin D is fat soluble and is stored in the body.  Some postulate that we store up enough in the summer to carry us through most of “the dark season,” but start to really crave sunshine come February!  Anecdotally, some claim they avoided seasonal depression by supplementing with vitamin D throughout the winter.  Placebo effect?  Perhaps, but randomized, controlled trials are being conducted to support or refute this theory.

Please note: the old recommendation of 15 minutes a day of sun exposure to hands and face (which your doctor may still believe), year-round is not accurate.  Sun exposure alone may not be adequate for your body, or it may be … I don’t know, but the data I’ve seen in the 3 years I’ve spent on this topic suggests there are widespread insufficiencies of vitamin D.

My doctor says my level is fine.

This is another major point of contention in the medical community: the definition of vitamin D sufficiency.  As I stated in the article, the IOM sets 20 ng/mL of circulating 25(OH)D as “generally considered adequate for 97.5% of the population” and a level under 12 ng/mL as deficient (for bone health).  This level of vitamin D is fairly easy to arrive at with the current Recommended Daily Intake of 600 IU/day, and is sufficient for bone health.  However, there are smart people who suggest (and have data to support) that 32 ng/mL of circulating 25(OH)D is sufficient; levels between 20-32 ng/mL are “insufficient” and deficiency is defined by a level under 20 ng/mL.  There are other physiological factors taken into consideration when defining vitamin D sufficiency, such as the level at which calcium is best absorbed, the level at which bones are well mineralized, or the level at which parathyroid hormone is stable.  It is interesting to note that the IOM, in its review of data for its 2010 report on vitamin D intake, discovered adverse effects in some people whose circulating 25(OH)D was over 50 ng/mL.

In another corner we find Hollis, Wagner, and Taylor’s published findings from their RCT’s.  Their work focuses specifically on pregnant and lactating women.  One aspect of  study involves 3 groups of pregnant women, after the 12th week of gestation (double-blinded so neither the researchers nor the subjects know what group they’re in): one group is supplemented with 400 IU/day of vitamin D; one with 2000 IU/day, and the third group with 4000 IU/day.  The incidence of negative pregnancy outcomes, such as pre-eclampsia and preterm labor/delivery, is significantly reduced in the 4000 IU/day group, plus, the breastmilk of those mothers has more of that “antirachitic activity.”  There have been no adverse effects of the higher dose of supplemental vitamin D reported in any mothers or babies that have participated in this study.  More results are being published as additional cohorts complete the trials.

For lactation, preliminary findings indicate that a mother’s circulating 25(OH)D level needs to be at 50-60 ng/mL in order for her milk to provide all the vitamin D her baby needs.  At lower maternal circulating 25(OH)D levels, there is still vitamin D being conferred through breastmilk, just less.  Again, for me, this begs the question: should babies get their full daily complement of vitamin D from breastmilk?  Keeping in mind that there is data suggestive of such high circulating 25(OH)D levels being harmful over time in some individuals (one report showed higher incidence of prostate cancer in a group with a 25(OH)D level over 50 ng/mL … I don’t have a prostate but should I worry?), and also knowing, both from research and personal experience how difficult it can be  to reach that 50-60 ng/mL level of circulating 25(OH)D, even with abundant supplementation (preliminary findings suggest 6400 IU/day, nearly 11x the current RDI) … I’m leaning toward a combination approach.  Let me remind you: I’m not a doctor, and I’m just thinking out loud here – but, looking at the options available for ensuring adequate vitamin D status for me and my children, I like a multi-faceted approach.  Maybe moderate supplementation for me (or more aggressive supplementation when I’m pregnant and breastfeeding an infant), occasional supplementation for my children, and conservative sun exposure might take care of our vitamin D needs?  I don’t know for sure.  All of this information is still so new – and not just to me.

When your doctor says “your vitamin D status is fine,” by which standard is he defining “sufficiency?”  Does he value any of the still-being-studied claims that higher levels of 25(OH)D might affect conditions other than bone health, such as diabetes, certain cancers, multiple sclerosis, and respiratory illnesses?  Do you?

It’s a lot to consider, and frankly, the vitamin D controversy remains huge in the medical community, not just among us breastfeeding mothers.  It may be years before enough randomized, controlled trials produce the conclusive data needed to affect changes in public health guidelines … what will you do in the meantime?  The choice is yours, for your body and for your family.

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Responses

  1. This is really fascinating. Thanks for going into even more depth than your original article. I’ve been wondering about this a lot as I have a 5 month old. I haven’t felt truly comfortable giving a supplement, so she only gets it once in awhile. Any day that is warm enough, we hang out outside with her in just a diaper or less for 30-40 minutes. (We’re in Kansas so hopefully we get a little benefit). I may add a Vitamin D supplement to my current vitamin and try and make sure she gets her supplement once or twice a week and keep up the sun exposure and call it good.

  2. Excellent follow-up to your bestforbabes post and certainly answers many questions in my mind (as a vitamin/supplement cynic).

  3. It would be itneresting to know what the content of Vitamin D in breastmilk is when Women are taking in the maximum amount of vitamin D they could theoretically get from Sun exposure (about 10,000 IU per day). One can argue that this would be the natural situation, becuase you reach this maximum dose quite fast in the tropics,and Homo Sapiens has evolved in Africa, we’ve been round for more than 200,000 years and lived there for most of that time.

    So, presumably the amount of vitamin D in breastmilk in that case would be the natural dose that babies need…

    • Your line of thought is spot on … what I’ve found in my review of the information out there, though, is that it is difficult to define these values. First, sun exposure is said to trigger vitamin D synthesis in a range of 10,000-20,000 IU, depending upon several factors (one source said the skin/oil on the skin that “collects” the UV-B rays shouldn’t be washed for 24-48 hours after the sun exposure … which isn’t always practical). That’s a fairly wide range. Another point to consider is that your scenario assumes mother AND baby are not separated and are both getting that maximum sun exposure (so the levels in mother’s milk wouldn’t need to be as high as our culture needs them to be for baby to be replete) …

      There’s so much to think critically about, and until more research is done, a public health recommendation for pregnant and breastfeeding mothers, not to mention lots of other populations for whom vitamin D status is significant, can’t be agreed upon.

      Thanks so much for your comments.

  4. B.t.w., I make sure that my total intake from supplements plus what I get from Sun exposure is about 10,000 IU per day.

    I use this webtool:

    http://nadir.nilu.no/~olaeng/fastrt/VitD_quartMEDandMED.html

    to estimate how much vitamin D I get from solar exposure. In that webform, you have to enter your skin type, your coordinates etc. and also the so called “Total ozone column” in Dobson units, which is usually around 350, and this is the default value displayed. However, you can be more accurate and get the actual value at your location from this website:

    http://www.temis.nl/uvradiation/nrt/uvindex.php

    E.g. I have been getting about 3000 IU per day from solar exposure, so I would want to get 7000 IU per day from supplements. Then what I do is take my 10,000 IU supplements on two days per 3 day period, so that I’m actually getting about 6700 IU per day on average from supplements. Note that vitamin D is processed by the body slowly on long time scales (weeks), so getting the dose right on average over a period of, say, one week is ok.

    The above webtool has to be used with care. It e.g. does not take into account the effect of vitamin D being broken down by UV radiation (this leads to the total amount of vitamin D you can get from the Sun being limited to about 10,000 IU per day). So, the webtool will tend to overestimate the amount of vitamin D you will get (actually underestimate the time you need to achieve a certain target) if you get into the thousands of IUs.

  5. I visit a tanning booth w/high % UVB 1x/week in the non-summer months (I live at the 40th parallel), and I supplement with 7500IU/day of D3. I supplement my children with 1200 & 1600 IU/day of D3. We do not wear sunscreen, but we are sensible in the sun – and do not get burned. IF we are going to place without adequate shade, and expect to be out for a long period of time, we will wear a barrier sunscreen like Badger, but that’s rare.

    When I supplement regularly & keep up with my light therapy, my vitamin D levels are closer to 40 (still low; I can’t seem to get them higher, but without any supplementation, I am sub-20) I do not get as sick. When I don’t, I do. And in the Summer, we don’t get sick.

    I believe vitamin D is vital to overall health – whether through sun exposure (which is best) or supplementation. Baby D drops are all natural.

  6. Thank you for posting. My doctor never explained why she was prescribing vitamin d for my son and never tested us to see our levels. I was left totally uninformed about the topic but chose not to supplement. We walk daily and live near Atlanta.

  7. [...] Vitamin D and breastmilk…what’s a babe to do? and My thoughts on the vitamin D controversy [...]

  8. I went for a bloodwork screening around my son’s 6 month mark, encouraged so by my doctor. At that time I was found to be Vitamin deficient (severely defficient at that!). I was prescribed a dosage of 4,000 iu twice a week in addition to my normal prenatal (it’s important to note that I did start taking a Calcium +D supplement in addition to prenatal when I was 20w (ok’d by OB) because I was concerned that my lack of calcium intake was going to affect my son). I further went for a Bone Density Test (at 29 years old!) And was found to be Ostepeanic, which is basically described as on the way to osteoperosis, but not quite there yet. After 12w on the 4,000iu schedule I was retested and they found my Vitimin D levels to be off the charts high and I was subsequently instructed to stop taking the additional supplement ans stick with just my prenatal.

    Now, at 15w pregnant with #2 while still breastfeeding my son, I am a little scared about what may happen with my levels (though I will get plenty of natural D with a due date in Late August)… so far so good, OB says my initial D levels were good and within normal range. She encouraged me to take a prenatal twice daily rather than Calcium +D supplement. I should mention that I started this ppregnancy 20lbs underweight.

    • Sorry about split post. On my phone & couldn’t get back to where I left off….

      I have chosen not to supplement my redheaded son with Vitamin D until the ped tells me I should. After seeing the knee jerk reaction to my inital bloodtest, the treatment, and subsequent 180 in the opposite direction… I’ll take the wait & see approach with him (he’s 2 weeks shy of 18 months).

      Do you suggest otherwise?

      • Hi Stephenie,

        While I can’t make any medical suggestions to you because I’m not a doctor and I don’t know your full history, it does seem strange that a 4000 IU/day regimen would send your 25(OH)D level to 180 ng/mL in 12 weeks. That said, the things I’d be looking for would include:

        — was the test for the right level? 25(OH)D NOT 1,25(OH)D

        — who said “off the charts high?” The lab will read “normal” anything over 20 ng/mL but for pregnancy and lactation, research indicates a level of 50+ ng/mL as preferable (though that will read as “high” on a lab report)

        — was your 25(OH)D level 180 ng/mL? That is very high, and extremely rare unless you have an underlying medical condition. One such condition is called sarcoidosis, which is explained here:

        http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001140/

        There could be other medical reasons your vitamin D levels and bone health are not consistent with the norm. Again, because I am not a doctor and I do not know your full medical history, I am not qualified to advise you, but I encourage you to get detailed, informed explanations from your doctor and to look into why a relatively conservative dose (4000 IU/day) of vitamin D caused such a rapid and sharp increase in your circulating level.

        Good luck,
        Diana

  9. [...] money on these.  But he is keeping mother/baby pairs in Vit D (for info on the importance of Vit D click here). And he’s doing so with a reputable brand without selling out to formula companies, handing [...]

  10. [...] [...]

  11. [...] Many parents are asking this question so I thought what better time to post information about this topic. After reading many articles and taking a look at the nutrition information of 3 popular brands, I have come to this conclusion. No, your toddler does not NEED milk, however Cow’s milk is really just a convenient source of calcium, protein, fats, vitamin D [...]

  12. [...] Should I give my baby a Vitamin D supplement? [...]

  13. I loved your follow up article! As a mom of a severe asthmatic who was always getting sick, and nursing mom to a lil guy, I decided enough was enough. My oldest sons doc kept increasing dosages, changing meds and nothing was controlling his asthma. It was uncontrolled constantly. Not to mention always sick too since the steroids lessen the immune system. I started doing tons of research and came back with vitamin D3. My 8 yr old twins (asthmatic and his sister) have been on 2,000IU of D3 since early October and my son has had NO asthma! Not even a teensy little bit! His appetite has returned, and he’s sleeping much better! Now is when he’s usually hospitalized because the weather is so bad. I will drop them down to 1,000 in spring/summer and then back up in fall. As a nursing mom who is gluten and lactose intolerant, I take 10,000 IU and will drop to 5,000 in spring/summer.

    My question is, should I also be supplementing my infant? I am giving him 400 IU of an all natural D3 because I know he’s getting some of mine, I’m just not sure how much. We are currently in the painstaking process of finding another pediatrician who is ok with our beliefs, so I can’t get them tested at this time to see what their levels are. Any advice would be appreciated and thought through carefully!

  14. Thank you for informative post. As an endocrinology nurse, I have seen babies with Vit D deficiency and subsequent Rickets. I have also seen obese teenagers with elevated cholesterol and insulin resistance with Vit D deficiency. Thank you for bringing this into the (sun)light!


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