The UK is unique in not recommending universal supplementation of breastfed infants from birth. Mike Fischer CBE of the Vitamin D Association explains the evidence supporting early supplementation and argues that there is an urgent need for change.
The Vitamin D Association has identified evidence of a serious error in the official Department of Health guidance on vitamin D supplementation of breastfed infants. The current guidelines are that where mothers have taken a vitamin D supplement throughout pregnancy, their breastfed infant should receive a multivitamin supplement, including vitamin D, starting at six months. The correct guideline should have been that all breastfed babies receive vitamin D3 drops measuring 10 micrograms (400 International Units) per day, beginning in the first few weeks of life.
Worldwide, infant formula is vitamin D enriched with about 400 IU/L. This means that formula fed infants are automatically supplemented, from their first feed of formula onwards. Direct supplementation of infants soon after birth is therefore safe – it has been standard practice for tens of millions of infants around the globe, and it is standard practice for the millions of infants in the UK who are formula fed.
Early supplementation is routine in most other comparable countries. The USA, Canada, France, Ireland, Sweden, Finland, Norway and Germany to name a few, all start direct supplementation of infants with vitamin D drops soon after birth. In 2008 the American Academy of Paediatricians (AAP) reviewed their 2003 report on infant vitamin D supplementation and changed the recommendations from a daily supplement of 200IU from the first 2 months of life to 400IU beginning immediately after birth. They based this change on ‘new clinical trials and the historical precedence of safely giving 400IU per day in the pediatric population.’
Research shows that vitamin D is pivotal in setting up an active and correctly developing immune system in the early years of life. The main health consequences of an insufficient supply of the vitamin are a risk of poor bone development and impaired immunological function. In darker skinned populations, acute vitamin D deficiency leads to seizures, heart defects and even death. Until proven otherwise, failing to correct or avoid vitamin D deficiency in young infants is subjecting them to a real and unnecessary risk of a compromised immune system susceptible to infection and autoimmune disease.
There is no medical basis that we know of for the 6 month delay in supplementation in the UK. Evidence shows that a vitamin D supplement is well tolerated by the body and has skeletal and non-skeletal benefits. The NHS Choices page on vita min D states that a mother who takes the recommended vitamin D supplement of 400IU per day throughout her pregnancy will ‘build adequate foetal stores for early infancy’, but the evidence does not support this view. Human breastmilk is also known to be a poor source of the vitamin and will not meet the baby’s requirement on its own.
If you follow all of the current NHS guidelines for breastfeeding mothers and infants, our analysis is that your baby is at significant risk of vitamin D deficiency during the first six months of life. Not only are current guidelines medically questionable, they are also poorly communicated to expectant mothers. A report by the Vitamin D Mission found that 77% of parents were unaware of their child’s daily dietary requirement of vitamin D, with 35% stating that they have never received information from the health services about their child’s specific needs.
On the 13th May 2014 NICE released draft guidance on the implementation of existing measures to prevent vitamin D deficiency, but failed to unequivocally recommend that the body reviewing the national guidelines, SACN, promote supplementation of babies from birth like our colleagues in America and Europe. Even when the SACN report is published later this year, it will come to similar conservative conclusions to the US Institute of Medicine (IOM) regarding adequate vitamin D intake.
Current and future recommendations are likely to be based upon a risk averse interpretation of existing trials evidence. Low levels of supplementation are likely to be recommended primarily for skeletal health, and this will continue to draw criticism from academics and clinicians seeking a more balanced interpretation prioritizing a wide range of health outcomes from a hierarchy of evidence perspective.
Unlike in the bureaucratic arena, some experts and health professionals are making progress with promoting awareness of vitamin D. The health authority in Birmingham ran an independent pilot scheme in 2005 that supplemented all infants from soon after birth. The authority then extended the program to offer free vitamins to all pregnant women and children under 5 in the city. The Chief Medical Officer for England last year commissioned NICE to do a cost effectiveness analysis of rolling out the Birmingham initiative nationwide, but did not call for immediate infant supplementation.
There is a clear argument for change to vitamin D supplementation guidelines for pregnant and breastfeeding women and infants, but insufficient political will to drive it forward. The DH needs a push. If you feel that the government isn’t moving fast enough to update vitamin D policy, please write to your Chief Medical Officer. Dame Sally Davis, CMO for England, can be reached at this email address CMOweb@dh.gsi.gov.uk.