In April, 2003, the American Academy of Pediatrics (AAP) issued a recommendation that all exclusively breastfed infants be given supplemental Vitamin D. The principal reason for this recommendation is that we continue to see cases of rickets in the United States. Rickets is a softening of the bones resulting from a number of causes, including Vitamin D deficiency. Since we live in a prosperous country and Vitamin D is widely available, it was judged that any case of "nutritional" rickets was unacceptable.

The second reason for the recommendation was that a mother’s breast milk contains less Vitamin D than fortified infant formula or milk.

Why is Vitamin D Important?
Vitamin D is actually not a vitamin at all, but is a steroid hormone, which is necessary for the body to absorb calcium from food – and calcium is necessary for bone formation. Very few foods naturally contain significant amounts of Vitamin D. It should come as no surprise that there was a time in the not-so-distant past when there was no such thing as Vitamin D fortified milk. So how did we get this all-important vitamin in the "bad old days"?

We got it from the sun. Vitamin D is made in our skin, through a chemical reaction triggered by sunlight. If we didn’t get adequate amounts of sun, then we wouldn’t make enough Vitamin D (not very much sun is necessary, as we will see below). Without Vitamin D we wouldn’t absorb enough calcium to build strong bones.

When humans began to wear clothes and migrated to northern latitudes, rickets became more common. Prior to the introduction of Vitamin D in milk, rickets was very common in the United States. The other place that babies got Vitamin D was from their mothers. If a baby’s mother had a healthy store of Vitamin D in her body, her breast milk would contain more Vitamin D.

Who is at risk for rickets?
Too much sun exposure was not a problem for early man: he didn’t live long enough to develop skin cancer. As our average lifespan increased, so did the incidence of skin cancer. I counsel parents to keep their infants out of direct sunlight, and to apply sunscreen to exposed skin starting from 6 months of age. We believe that screening out ultraviolet light from the sun is the best way to prevent skin cancer. Now that we are covering up our babies and slathering on the sunscreen, are we putting our babies at risk of Vitamin D deficiency and rickets?

The answer is: it depends.
The individuals who are at risk for developing Vitamin D deficiency and rickets are exclusively breastfed infants who are dark-skinned, especially African-American babies. Dark skin is made dark by the presence of melanin. Melanin absorbs ultraviolet light that helps prevent sunburn in dark-skinned people. Unfortunately, melanin also absorbs the ultraviolet light that would help skin create Vitamin D. The other group of babies at risk for nutritional rickets are those whose bodies are kept largely covered up all year, particularly babies from devout Muslim families. Infants are at additional risk if the mother herself is deficient in Vitamin D.

The Argument Against the Recommendation
Breastfeeding advocacy groups were understandably unhappy with the AAP recommendation. Although the practice of breastfeeding is enjoying resurgence in recent years, there are still many communities in the United States where formula feeding remains the norm. One of these is the African-American community. In North Carolina, where cases of nutritional rickets were described in breast-fed African-American babies, breastfeeding has become much more popular in recent years. Advocates for breastfeeding would like to keep this trend moving. Any perceived "bad news" might discourage a mother who was ambivalent about breastfeeding at the outset.

The AAP is on record as strongly encouraging breastfeeding whenever possible. Critics argued that the Vitamin D recommendation gives the appearance of undermining the AAP’s breastfeeding advocacy effort.

Others have criticized the recommendation for failing to target the very groups who are most at risk for development of nutritional rickets: African-American and Muslim babies. By issuing a blanket recommendation to all breastfeeding mothers, the AAP sought to minimize the stigma that might attach to these racial and ethnic groups. Critics argued that we couldn’t help a racial or ethnic minority group by failing to address their risk for particular diseases. On the contrary, the less attention we focus on any at-risk groups, the less likely we are to help them.

Who is Right?
My opinion is that the critics of the recommendation have the better argument. The only groups truly at risk for development of Vitamin D deficiency and nutritional rickets are exclusively breast-fed African-American babies and exclusively breast-fed Muslim babies whose parents observe the custom of keeping the child’s body completely covered outside the home. Healthy Caucasian breast-fed babies are simply not at risk for Vitamin D deficiency. Even in the current era of heavy sunscreen application, the incidental and indirect sunlight that a baby is exposed to is enough for that baby to create adequate amounts of Vitamin D. The best estimates suggest that 20 minutes per week for light-skinned babies is all that is necessary.

For dark-skinned babies, 2 to 4 hours per week of sunlight may be necessary to produce adequate Vitamin D. As this degree of sun exposure is often not possible, and not desirable because of skin cancer risk, I recommend that exclusively breast-fed African-American babies take extra Vitamin D.

The other reason I disagree with the blanket Vitamin D recommendation is that it really does discourage breastfeeding. Most expecting mothers learn about the AAP recommendation through word-of-mouth, or at best through the media. In either case, these mothers do not receive the message that the AAP intended: that breastfeeding is best, but some breastfed babies may need some extra Vitamins. Instead, these mothers come to me in pre-natal consults with questions such as "I hear that breastfeeding may not be so good after all: is this true?"

"One-Size-Fits-All" public health policies seldom fit anyone very well. A baby’s pediatrician or other care provider should be able to assess whether a particular child is at risk for Vitamin D deficiency and would require a supplement. If a mother is committed to trying breastfeeding, and if she feels her baby may not get adequate sunlight to make Vitamin D, she should discuss supplementation with a clinician or lactation consultant.

For more information about Natick Pediatrics, or to talk to the doctor, please call the office at (508) 655-9699.

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Medical Office Building
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Posted: July 18, 2003