Vitamin D Association

The Vitamin D Association Frequently Asked Questions for pregnant and breastfeeding mothers in the UK.

What is the error in UK guidelines on supplementing breastfed infants?

We have discovered evidence of a serious error in the official UK guidelines on vitamin D supplementation of breastfed infants. The current guidelines are that where mothers have followed the guidelines for themselves, their breastfed infant should receive a multivitamin supplement, including vitamin D, starting only at month six. The correct guideline should have been that all breastfed babies should receive a vitamin D3 only supplement of about 8 micrograms (320 UI) per day beginning in the first few weeks of life.
 

Which countries do we know about, where the official advice is to start direct supplementation of breastfed infants starting soon after birth?

USA
Canada
Ireland
France
Germany
Austria
The Netherlands
Sweden
Norway
Finland

The UK is essentially unique in having no specific advice for direct supplementation with vitamin D for breastfed infants soon after birth.

What about formula fed infants?

Worldwide, infant formula is vitamin D enriched with about 400 UI/L. So formula fed infants are automatically supplemented, from their first feed of formula onwards.

Is direct vitamin D supplementation of breasted infants soon after birth safe?

Yes. As can be seen from the above, it has been standard practice for tens of millions of infants in the countries above, and it is standard practice for the millions of infants in the UK who have been formula fed.  

It is now the official guideline in the UK from 1 month, but only if you have been following the other guidelines! 

What are the chances of vitamin D deficiency for my child under the first six months of life, if I exactly follow the current UK guidelines during pregnancy and breastfeeding ?

The medical understanding of vitamin D deficiency is going through a major change, so the understanding of what constitutes deficiency has been changing. We use the term deficiency as <50nmol/L, as per the most recent USA guidelines. We use the term severe deficiency if the level is <25nmol/L, and acutely deficient if the level is <12.5nmol/L. In essence, a person who is deficient is deemed to be at material risk of impaired bone development, and an infant who is severely deficient is at material risk of developing rickets. 

Direct up to date figures on the vitamin D status of young infants is scarce, possibly because doctors and mothers are reluctant to take blood from babies without a specific clinical objective. Our figures are estimates, but always based on real studies. In some cases we have had to estimate the outcome for infants, from data for deficiency of the mothers during pregnancy, or from the deficiency in adult women in general. If we have had to use only the data from adult women, then the estimate is for more than (>) the number, because we know that vitamin D levels of pregnant women are significantly lower than those of non-pregnant women. For the benefit of health professionals we include the main sources we have used. We have tried to make our estimates conservative.

As most vitamin D in the UK comes from sun exposure during summer, the risks of deficiency are very different, depending on season, region, and ethnic group and on whether the mother has been following the current guidelines, i.e. taking 10 micrograms of vitamin D per day during pregnancy and breastfeeding.

To repeat, all of the estimates below are for breastfed infants whose mothers have exactly followed the current guidelines. The estimates are for deficiency occurring any time during the first six months of life.

Estimated incidence of vitamin D deficiency in young white infants in Scotland and Northern Ireland for babies born during winter and spring:

The main sources of data are Ala-Houhala et al (1986), Cockburn et al (1980), Holmes et al (2009) and Zgaga et al (2011).

We estimate that 90% of infants in this category will experience vitamin D deficiency, 35% will experience serious deficiency. That is an estimate of 38,000 deficient young infants and 15,000 seriously deficient young infants in Scotland and Northern Ireland per year. The data from Ala-Houhala suggests that the picture for western and northern Scotland may be far worse, with perhaps 35% in this group acutely deficient.

Estimated incidence of infant vitamin D deficiency in white infants in the whole of the UK during winter and spring:

 If you are in England, these are useful ballpark estimates.

The main source of evidence is Hypponen and Power (2007). We estimate that the rate of deficiency in this group is >50%, and the rate of serious deficiency is >15%. That is >175,000 young infants per year in the UK experiencing deficiency, and >50,000 young infants per year experiencing serious deficiency.

South Indian and African infants in England:

As only 5.6% of the population of the UK falls into this group, and there is no reliable source of data on the overall vitamin D status of the group. This is unfortunate, because approximately 90% of all the most serious consequences of vitamin D deficiency, that is rickets, low-calcium-seizures, and vitamin D-related cardiomyopathy, and approximately all of the vitamin D-related infant deaths, occur within this group. The numbers are likely to be worse than those for white infants in Scotland, so the rate of deficiency, at any time of the year is likely to be >90%, with very high but unknown rates of serious and acute deficiency.

What are the medical risks associated with these deficiencies:

For all white babies:

Impaired bone development:

For a long time, it has been well established both in terms of basic science, and in terms of the medical consequences, that vitamin D deficiency and even more so serious deficiency carries a significant risk of impaired bone development. For white infants in the UK, this is very unlikely to result in rickets, but may well result in slower bone growth, and in weaker bones both as an infant and lasting well into childhood.

Impaired immune system:

In the last few years, it has become well established in terms of basic science, that lower levels of vitamin D are associated with an impaired immune system. These discoveries are recent, and there is as yet not enough data to establish what increased risk of ill-health is caused by immune system impairment associated with infant vitamin D deficiency. However infectious disease and auto immune disease are of major importance to infant and child health. Until proven otherwise, failing to correct or avoid vitamin D deficiency in young infants is subjecting them to a real and unnecessary risk of impaired management of infection or of autoimmune illness.

Other disease:

There are a host of other disease where there are substantial grounds for suspicion, that vitamin D deficiency in early life plays a role. For each of these diseases, further studies might prove that vitamin D is not the cause. However, avoiding or correcting vitamin D deficiency removes whatever risks are associated with these other possibilities.

South Asian and Black infants across the UK:

The immediate serious consequences of vitamin D deficiency include rickets, seizures, cardiomyopathy, and cardiac failure. The known consequences include may be life-long impairment of body size and bone strength, and fractures in infancy. Sometimes the consequences are fatal. Almost all of the cases of these serious events in the UK are confined to infants of South Asian or Black origin. This community makes up only one eighteenth of the UK population. The incidence of these cases has been increasing, and using recently published data, our estimates are that the incidence of theses serious cases are extraordinary, and completely unacceptable as they are so easily avoided. Our estimate is that the risk of one of these serious events is more than one in one hundred South Asian or Black children born in the UK every year. On a conservative basis, there are more than 360 such incidents a year, amounting to more than one per day, of the hundred children born in this community every day. If this rate of events were occurring in the white population at the same rate, there would be 20 serious cases per day or 7000 serious cases per year.

These figures are for the whole of the UK. As expected the position will be much worse for South Asian and Black infants in Scotland and Northern Ireland, and not so bad for South Asian and Black infants in southern England.

South Asian and Black infants in Scotland and Northern Ireland:

There are very few infants belonging to this group in Northern Ireland, but in Scotland, South Asian Black residents make up 1.04% of the population. On a simple estimate, there are about 600 births per year in this group. A recent publication (Ahmed 2011) shows that the rate of serious consequences of the kind listed has been rising rapidly, and in 2008 constituted about 40 cases in South Asian and Black infants. This amounts to an extraordinary rate of one case of serious illness per 30 births. To put this into perspective, if this were occurring in the white population this would amount, in Scotland alone, in 5 cases of serious illness arising from vitamin D deficinecy per day or 2,000 cases a year in Scotland alone.