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Pediatrics

Many infants and toddlers don't get enough vitamin D: Researchers call for supplements for breastfeeding infants and increased milk intake for toddlers

Many otherwise healthy infants and toddlers have inadequate vitamin D levels that may put future bone health at risk, finds a study from Children's Hospital Boston.

The major risk factor for infants was exclusive breastfeeding without vitamin D supplementation; for toddlers, it was inadequate milk consumption. Findings appear in the June issue of Archives of Pediatrics & Adolescent Medicine.

Led by Catherine Gordon, MD, MSc, Director of the Bone Health Program at Children's, the researchers studied 365 infants and toddlers who visited the hospital's general pediatric clinic for well-child exams at age 9 and 18 months, respectively.

Blood testing found that 40 percent of the children had vitamin D levels below the optimum considered good for bone health, and 12 percent were frankly deficient.

Of the deficient group, 13 children (32.5 percent) had evidence of bone loss, as assessed by computed radiography of the wrist and knee. Three children (7.5 percent) had bone changes consistent with rickets (a softening of the bones that can lead to fractures, stunted growth and deformities like curved spine and bowed legs), although only one of these children had signs of rickets on physical examination.

"We were struck by the number of children in our study with suboptimal vitamin D levels," says Gordon. "Vitamin D status is not routinely checked as part of routine care, and the majority of the children did not show signs of rickets or other evidence of a deficiency, so it is concerning that this problem would have otherwise gone undetected."

In infants, the major predictor of deficiency was exclusive breastfeeding without vitamin D supplements. Infants in this category were 10 times more likely to be vitamin D deficient than infants who were exclusively bottle-fed. (Breast milk does not contain vitamin D, whereas formula and cow's milk are fortified with the vitamin.) In toddlers, the major risk factor was inadequate milk consumption: blood vitamin D levels increased in close correlation with the number of cups per day of milk the child drank.

"As a pediatrician, I am pleased that breastfeeding has become more common among new mothers," says Gordon. "Of concern, however, is the rise in cases of rickets accompanying this trend. Our data suggest the importance of vitamin D supplementation for young children, and particularly breast-fed infants."

The authors were struck by the strength of the correlation between vitamin D deficiency and breastfeeding without supplementation, since only 8 percent of children in the study were exclusively breastfed.

Although the American Academy of Pediatrics and Institute of Medicine recommend that infants and children receive 200 IU daily of supplemental vitamin D, few breastfed infants in this study were receiving such supplementation.

Since both dark skin and sunscreen reduce absorption of the ultraviolet rays that help the body manufacture vitamin D, the researchers expected to find skin pigmentation, sunscreen use and time spent outdoors to be predictive of vitamin D deficiency.

However, their data revealed no significant correlation with these factors. They speculate that the layers of clothing babies are typically dressed in may prevent them from absorbing enough sunlight.

"We were surprised that neither skin pigmentation nor season significantly predicted vitamin D deficiency," Gordon says. "Our data suggest that unique risk factors for this problem can arise, ones that pediatric health care providers should be cognizant of in the care of young children."

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