3. The role of vitamin D in calcium and gin consuming 200 IU/day of vitamin D to both the 2003 and 2008 AAP vitamin
phosphorus homeostasis and bone during their first 2 months of life.4 D recommendations among infants
metabolism has been well established; Although there currently is no national during their first year of life. Because
however, the presence of vitamin D re- surveillance of nutritional rickets in infants’ level of vitamin D consumption
ceptors in many cell types suggests the United States, cases of rickets would likely differ by the extent to
that vitamin D has other physiologic among hospital patients continue to be which they were formula fed, we pro-
functions.1 For example, vitamin D de- reported.9,10 The prevalence of poor vi- duced separate prevalence estimates
ficiency has been associated with re- tamin D status among US infants also for infants who were breastfed, for-
spiratory infections, type 1 diabetes, remains high by most measures, al- mula fed, and “mixed fed” (both
cardiovascular diseases, and cancer though data on infant vitamin D status breastfed and formula fed).
in later life,1–3 which emphasizes the can be difficult to interpret because of
importance of vitamin D nutrition a lack of consensus on optimal vitamin METHODS
throughout the life span. In children, D levels or on what constitutes vitamin We analyzed data from the Infant Feed-
nutritional rickets typically occurs in D deficiency. Depending on the defini- ing Practices Study II (IFPS II), a longi-
severe cases of vitamin D deficiency, tions used, vitamin D deficiency has tudinal survey of US mothers of
causing softening and weakening of been reported in 10% to 65% and insuf- healthy singletons, followed from late
the bones, and is associated with im- ficiency in 40% to 56% of US neonates, pregnancy through the first year of
paired growth, developmental delays, infants, and toddlers,11–13 which sug- their infant’s life, which was con-
lethargy, and hypocalcemic seizures.4 gests that vitamin D levels may not be ducted from 2005 through 2007 by the
In addition to being obtained through optimal in these groups. Given the US Food and Drug Administration in
the diet, vitamin D is synthesized endo- growing evidence that the level of vita- collaboration with the Centers for Dis-
genously in the skin after exposure to min D consumption it recommended in ease Control and Prevention.17 The
ultraviolet light. The American Acad- 2003 may not be sufficient, in Novem- sample was drawn from a consumer-
emy of Pediatrics (AAP) advises that ber 2008 the AAP released a new rec- opinion mail panel that was nationally
children younger than 6 months be ommendation that all children receive distributed but not nationally repre-
kept out of the sun altogether and that 400 IU/day of vitamin D from their first sentative. Women were recruited in
those aged 6 months or older wear few days of life through adolescence.14 their third trimester of pregnancy;
protective clothing and sunscreen to The IOM is also reviewing its current mothers at least 18 years of age, moth-
minimize sun exposure.5 Some re- recommendations for vitamin D con- ers and infants without medical condi-
searchers recommend short episodes sumption and plans to release a report tions that would affect feeding, and in-
of sun exposure as a way of obtaining on the findings of this review in May fants who were born after at least 35
vitamin D; however, the safety of this 2010. weeks’ gestation and weighed at least
method for infants with regard to fu- Although breast milk is the best single 5 lb were included in the study. Exten-
ture skin cancer is not known.6,7 In ad- source of food for infants,15 it only con- sive details of the IFPS II methodology,
dition, one’s ability to produce vitamin tains 25 to 78 IU/L of vitamin D14 and, the IFPS II sample, and a comparison of
D is affected by latitude, season, sun- thus, is insufficient, by itself, to provide the IFPS sample with a nationally rep-
screen use, skin pigmentation, and air adequate levels of vitamin D for in- resentative sample of women from the
pollution, which make sun exposure an fants. Foods that are good sources of National Survey of Family Growth
unreliable source of vitamin D. Thus, vitamin D include oily fish, egg yolks, (NSFG) have been published previous-
infants need to obtain vitamin D either and fortified foods such as infant for- ly.18 Generally, IFPS II participants were
primarily or entirely from their diet. In mula and milk.16 Most infants, how- older and more educated, had a higher
1997, the Institute of Medicine (IOM) ever, will not consistently consume income and fewer children, were
recommended that 200 IU/day be con- these foods during their first year of breastfed longer, and were more likely
sidered “adequate intake” of vitamin D life unless they are primarily fed infant to be white than those in the NSFG
for infants, although it did not have suf- formula. All infants require a supple- sample.
ficient information to determine a rec- mental source of vitamin D from an Each IFPS II participant was mailed 1
ommended dietary allowance.8 In 2003, oral vitamin D supplement, fortified in- prenatal and 10 postnatal question-
the AAP released vitamin D–consumption fant formula, or both. naires at approximately monthly inter-
guidelines in line with those of the IOM Our objective for this analysis was to vals that asked about various infant
and recommended that all children be- estimate the prevalence of adherence feeding and care practices. We ana-
628 PERRINE et al
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4. ARTICLES
lyzed data collected about infants at TABLE 1 Percentage of Infants Fed According to Each of Three Feeding Practices by Age
ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 Infant Age, mo (wk) No. Breast Milk, % Mixed, % Formula, %
months as if the data were from sepa- 1 (3 to 7) 1804 42.5 31.6 25.9
2 (7 to 11) 1714 42.8 24.1 33.1
rate cross-sectional surveys; sample
3 (11 to 15) 1952 41.6 20.2 38.2
sizes ranged from 1952 mothers of in- 4 (15 to 19) 1837 38.2 19.5 42.4
fants at 3 months to 1633 mothers of 5 (19 to 24) 1927 36.3 18.0 45.7
infants at 10.5 months. Regarding sup- 6 (24 to 29) 1870 33.6 17.1 49.3
7.5 (29 to 36) 1862 31.8 14.7 53.5
plement use, mothers were asked on 9 (36 to 43) 1790 29.4 12.8 57.8
each monthly questionnaire, “Which of 10.5 (43 to 51) 1633 27.1 11.0 61.9
the following was your baby given in Feeding-practice categories are mutually exclusive and based only on consumption of breast milk and formula.
vitamin or mineral drops or pills at
least 3 days a week during the past 2
cent of infants at 10.5 months were recommendation (which applies to in-
weeks? If your baby was given drops or
consuming any cow’s milk; for half of fants beginning within their first few
pills that contained more than 1 of the
these infants, consumption frequency days of life) if they were either receiving
items listed, please mark each of the
was less than once per day. When we an oral vitamin D supplement or con-
separate items.” If the mother checked
compared the results of our analysis suming at least 1 L/day of formula.4,14
the box for vitamin D, the infant was
for all infants aged 10.5 months with
categorized as having received an oral
results for the same group excluding RESULTS
vitamin D supplement. Thus, our esti-
those reported to have consumed any At 1 month of age, 43% of the infants
mate of vitamin D supplementation
cow’s milk, we found no significant were breastfed, 32% were mixed fed,
was not of daily administration, but of
differences. and 26% were formula fed (Table 1).
a minimum of 3 days per week.
The IFPS II data were collected from With increasing age, the percentage
On each of the postpartum surveys,
2005 to 2007, at which time the 2003 of infants who were breastfed de-
mothers were also asked to estimate
AAP recommendation would have been creased, and the percentage who were
the average number of ounces of for- current. We used both the 2003 and formula fed increased; by 10.5 months
mula their infants consumed at each 2008 recommendations in this analy- of age, 27% of the infants were breast-
feeding (response options were 1–2, sis to obtain estimates of the preva- fed, 11% were mixed fed, and 62% were
3– 4, 5– 6, 7– 8, and 8 oz) and the av- lence of infants who were meeting the formula fed. Throughout the first year
erage number of feedings per day or 2003 recommendation and the preva- of life, mean formula intake ranged
week for both breast milk and formula. lence of infants who would meet the from 310 to 352 mL/day in the mixed-
In our analyses, we used the midpoint 2008 recommendation without any be- fed group, with little variation by age,
of the formula consumption response havior changes. Infants’ multivitamin and from 770 to 987 mL/day in the
options reported (1.5, 3.5, 5.5, 7.5, and and vitamin D– only preparations formula-fed group, with formula in-
8.5 oz) and the average number of available in the United States supply take generally increasing with age un-
feedings per day to estimate average 400 IU/day; thus, infants who receive til peaking at 4 to 6 months and then
daily formula consumption, converting an oral vitamin D supplement would decreasing.
ounces to milliliters. We also used the obtain enough vitamin D to meet both
reported frequency of breast milk and Overall, only 4% to 7% of the infants
the 2003 and 2008 recommendations.14
formula feedings to divide infants into Therefore, we classified infants as were receiving an oral vitamin D sup-
3 mutually exclusive feeding-practice meeting the 2003 recommendation plement (Table 2), with infants 1 month
groups: breast milk (consumed breast (which recommended beginning sup- of age having the lowest prevalence of
milk only); mixed (consumed breast plementation at 2 months of age and supplement use. The prevalence of
milk and formula); and formula (con- thus does not apply for infants oral supplement use ranged from 5%
sumed formula only). These classifica- younger than 2 months) if they were to 13% in the breastfed group and
tions referred only to consumption of either receiving an oral vitamin D sup- from 4% to 11% in the mixed-fed group.
breast milk and formula; infants may plement or consuming at least 500 mL/ Only 1% to 4% of the infants in the
also have been consuming other foods day of vitamin D–fortified infant for- formula-fed group were receiving an
or liquids, such as water or juice. Al- mula, which in the United States is oral supplement.
most no children consumed cow’s milk fortified at a level of 400 IU/L.14 We clas- We estimated that over the first year of
until 10.5 months of age. Fourteen per- sified infants as having met the 2008 life, 44% to 58% of infants met the 2003
PEDIATRICS Volume 125, Number 4, April 2010 629
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5. TABLE 2 Percentage of Infants Who Received an Oral Vitamin D Supplement According to Feeding were doing so by consuming at least 1
Practice by Age
L/day of formula. Thus, the pattern of
Infant Age, mo (wk) Total, % Breast Milk, % Mixed, % Formula, %
formula-fed infants who achieved AAP
1 (3 to 7) 3.9 5.3 4.3 1.1
2 (7 to 11) 5.5 9.4 5.1 0.9
2008 recommended levels of vitamin D
3 (11 to 15) 6.8 10.3 8.9 1.7 followed a pattern similar to that of
4 (15 to 19) 6.8 10.8 9.8 1.7 formula intake, increasing with age
5 (19 to 24) 7.3 12.6 9.8 2.0
until peaking at 4 to 6 months and then
6 (24 to 29) 7.0 12.1 9.4 2.6
7.5 (29 to 36) 6.9 11.3 11.0 3.1 decreasing.
9 (36 to 43) 6.0 11.2 7.9 2.9
10.5 (43 to 51) 6.7 11.1 10.7 3.9 DISCUSSION
Classification as having received a vitamin D supplement indicates that infants received an oral supplement at least 3
days/week during the previous 2 weeks. Feeding-practice categories are mutually exclusive and based only on consumption At the time the IFPS II data were col-
of breast milk and formula. lected, the 2003 AAP recommendation
was the current guideline regarding vi-
TABLE 3 Percentage of Infants Who Met the 2003 AAP Vitamin D Recommendation and the tamin D intake for the prevention of
Percentage Who Would Have Met the 2008 Recommendation According to Feeding vitamin D deficiency and rickets. Al-
Practice by Age
though we found that most formula-
Infant Age, mo (wk) Total, % Breast Milk, % Mixed, % Formula, %
fed infants were meeting the recom-
2003 2008 2003 2008 2003 2008 2003 2008
a a a a
mendation, we also found that only
1 (3 to 7) NA 11.4 NA 5.3 NA 8.7 NA 24.8
2 (7 to 11) 43.6 16.4 9.4 9.4 29.8 8.5 98.1 31.2
approximately one-tenth of breastfed
3 (11 to 15) 48.5 20.1 10.3 10.3 33.5 12.4 98.0 34.9 infants and one-third of mixed-fed in-
4 (15 to 19) 52.2 22.1 10.8 10.8 33.0 12.6 98.2 36.6 fants were meeting it. This poor adher-
5 (19 to 24) 55.4 23.7 12.6 12.6 35.3 13.0 97.4 36.7
6 (24 to 29) 56.3 25.0 12.1 12.1 31.6 14.4 95.0 37.4
ence to the 2003 recommendation was
7.5 (29 to 36) 57.8 19.6 11.3 11.3 29.3 13.9 93.3 26.0 because of both low prevalence of oral
9 (36 to 43) 57.9 16.9 11.2 11.2 28.0 12.2 88.2 20.9 vitamin D supplement use and most
10.5 (43 to 51) 57.0 16.8 11.1 11.1 33.3 13.3 81.3 19.9
mixed-fed infants not consuming
2003 AAP recommendation: receive an oral vitamin D supplement or consume 500 mL/d of infant formula beginning at 2
months; 2008 recommendation: receive an oral vitamin D supplement or consume 1 L/d of infant formula beginning at birth. enough formula to meet the recom-
Feeding practice categories are mutually exclusive and based only on consumption of breast milk and formula. mended consumption level of 200 IU/
a The 2003 recommendation does not apply to infants in this age category.
day. Our estimates regarding the 2008
recommendation provide a sense of
the prevalence of infants among the
AAP recommendation that they con- would have met the 2008 recommen- various feeding-practice groups who
sume 200 IU/day of vitamin D, whereas dation; those who met the 2003 recom- would meet the new recommendation
only 11% to 25% would have met the mendation did so primarily through if there was no change in behavior re-
2008 recommendation of 400 IU/day of formula intake, whereas those who garding vitamin D intake. Fewer than
vitamin D (Table 3). Among breastfed met the 2008 recommendation did so 15% of the infants in both the breast-
infants, who must have received an primarily with the use of an oral vita- fed and mixed-fed groups would have
oral vitamin D supplement to meet ei- min D supplement, suggesting that few met the 2008 recommended level of vi-
ther of the AAP recommendations, only mixed-fed infants consume enough tamin D consumption.
9% to 13% were receiving enough vita- formula to obtain 400 IU/day of vitamin The difference in the percentage of in-
min D at 2 to 10.5 months of age to D. More than 90% of formula-fed in- fants who met the 2 recommended in-
meet the 2003 or 2008 recommenda- fants aged 2 to 7.5 months met the take levels was particularly striking
tion. The 2008 recommendation (but 2003 recommendation, as did 80% of among formula-fed infants. Whereas
not the 2003 recommendation) applies formula-fed infants aged 9 and 10.5 most formula-fed infants were con-
to infants at 1 month; only 5% of months. However, only 20% to 37% of suming the 500 mL/day of formula re-
1-month-old infants who were breast- these infants would have met the new quired to obtain 200 IU of vitamin D,
fed received an oral vitamin D supple- 2008 recommendation at any month of only approximately one-third were
ment and, thus, would have met the age. Because use of an oral vitamin D consuming the 1 L/day required to ob-
2008 recommendation. Among mixed- supplement was very low among tain 400 IU. Among this group, adher-
fed infants, 28% to 35% met the 2003 formula-fed infants, most who were ence peaked at 4 to 6 months, which
recommendation, but only 9% to 14% meeting the 2008 recommendation is when many infants would begin to
630 PERRINE et al
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6. ARTICLES
consume complementary foods and light and, thus, need an alternate year of life and at as early as 1 month
reduce their formula intake. The 2008 source of vitamin D. of life.
AAP guideline suggests that most in- Although the IFPS II included women According to the 2008 AAP recommen-
fants older than 1 month will consume from around the country, the sample dation, all breastfed, mixed-fed, and
the 1 L/day of formula required to ob- was not nationally representative. formula-fed infants who consume 1
tain 400 IU/day of vitamin D14; however, Among other characteristics, women L/day of formula should receive an oral
our results did not support this as- in this sample had achieved higher lev- vitamin D supplement. Our findings
sumption and indicated instead that els of education, had fewer children, suggest that few infants are consum-
most infants, not just those who are and had breastfed longer than women ing at least 1 L/day of formula; thus,
breastfed, would likely need to receive in the NSFG,18 all of which may have many may need to receive oral vita-
an oral vitamin D supplement to con- been associated with formula and sup- min D supplements to meet the 2008
sume enough vitamin D to meet the plement use. Another limitation of our AAP recommendation that they con-
2008 recommendation. study was that all data were self- sume at least 400 IU/day. This finding
The very low prevalence of oral vitamin reported and required mothers to re- should be confirmed in other stud-
D supplementation among infants is call information about their infants’ ies. Parents may need support in
concerning if infants are to meet cur- feedings over the previous 7 days and providing supplementation for their
supplement use over the previous 2 infants. Supporting adherence in
rent recommendations. Results from
weeks. Although the validity of this self- this context is challenging because
the 1999 –2002 National Health and Nu-
reported data is unknown, our esti- of the long duration of vitamin D sup-
trition Examination Survey showed a
mates of daily formula intake among plementation, the lack of tangible
similarly low prevalence of vitamin D
infants of IFPS II participants were con- health effects after starting supple-
supplement use among US infants:
sistent with, or only slightly higher mentation, the need for an adult to
only 8.7% of infants aged 0 to 11
than, those from other studies.24–27 administer the daily dose, and the
months had received a vitamin D sup-
Other study limitations included our in- need for a willing infant to accept the
plement in the previous 30 days.19 Pe-
ability to determine the exact quantity supplement. Overall, adherence to
diatricians and allied health care pro- prescriptions from health care pro-
of vitamin D that infants obtained from
viders are uniquely positioned to help viders is poor, even among adults,
oral supplements and our definition of
increase the percentage of infants and is generally worse the longer the
supplement use as use of a supple-
who receive adequate amounts of vita- regimen duration is.28 Pediatricians
ment on at least 3 days/week rather
min D, because parents are more likely and other health care providers can
than more frequently. Our estimates of
to give their children vitamin D supple- the prevalence of supplement use support and promote daily oral vita-
ments if they are advised to do so by a would likely have been even lower had min D supplementation of infants by
health care professional.20 It is unfor- we used a definition that required explaining to parents the purpose
tunate that many health care profes- more days per week of use. These data and benefits of vitamin D supplemen-
sionals are not recommending vitamin were collected from 2005 to 2007, so tation, reminding parents at each
D supplements for infants.21–23 Rea- our estimate of meeting the 2008 AAP visit to give vitamin D supplements to
sons that they are not doing so include recommendation assumed no change their children, suggesting that par-
beliefs that rickets is rare,23 that in- in behavior since that time. Because ents develop a daily intake routine to
fants receive sufficient sunlight,22,23 new vitamin D research is continually help them remember to administer
and that breast milk has adequate lev- being generated, it is possible that in- the supplement, asking parents
els of vitamin D.21–23 Because physi- creased media attention on vitamin D about any adverse effects of supple-
cians’ knowledge of the AAP recom- has increased the use of vitamin D sup- mentation or barriers to giving their
mendations has been positively plements among infants. Despite these infants supplements, and helping
associated with the likelihood of their limitations, IFPS II was one of the larg- parents to overcome any barriers
recommending vitamin D supple- est infant-feeding studies in the United that they report.29
ments,22 both health care providers States and provides valuable data that
and parents need to be educated about are not available from any other data CONCLUSIONS
the AAP guidelines and the importance source to date, including assessment We found that most infants, not just
of vitamin D nutrition, including that of supplement use and food intake at those who are breastfed, may re-
infants should not be exposed to sun- multiple times points during the first quire an oral vitamin D supplement
PEDIATRICS Volume 125, Number 4, April 2010 631
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7. daily, beginning within their first few ACKNOWLEDGMENTS of Women’s Health, National Institutes
days of life, to meet the 2008 AAP rec- This study was funded by the US Food of Health, and Maternal and Child
ommendation that infants consume and Drug Administration, Centers for Health Bureau in the US Department of
at least 400 IU/day of vitamin D. Disease Control and Prevention, Office Health and Human Services.
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632 PERRINE et al
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8. Adherence to Vitamin D Recommendations Among US Infants
Cria G. Perrine, Andrea J. Sharma, Maria Elena D. Jefferds, Mary K. Serdula and
Kelley S. Scanlon
Pediatrics 2010;125;627-632; originally published online Mar 22, 2010;
DOI: 10.1542/peds.2009-2571
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/125/4/627
References This article cites 27 articles, 21 of which you can access for free
at:
http://www.pediatrics.org/cgi/content/full/125/4/627#BIBL
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