Can more vitamin D improve the health of nursing moms and babies?

The Pediatric Insider

© 2016 Roy Benaroch, MD

“Breast is best” is a simple, catchy phrase—but to be honest, it’s one that should be followed by a bunch of asterisks and qualifiers. Some mother-baby pairs have a hard time with nursing, and need support and understanding (rather than a simple dismissal of their concerns.) And breast milk, we know, isn’t a great source of absorbable iron, which is especially an issue for premature babies. But the biggest drawback of human breastmilk, compared with commercial formula, is that it is an inadequate source of vitamin D.

A new study shows that this doesn’t have to be the case. Perhaps insufficient vitamin D isn’t really a fundamental problem with breast milk, but a problem with mom’s vitamin D intake.

Backing up a second – we’ve known for a long time that breast-fed babies are much more at-risk for nutritional rickets than formula-fed babies. This is especially true for families with dark skin. Rickets is caused by insufficient vitamin D, and can lead to poor growth, bowed limbs, and other health problems. For most of human history our vitamin D came from sunlight exposure. The skin of babies and mothers can manufacture vitamin D, though it requires sunlight to do it. Darker skin is less efficient at making vitamin D than lighter skin.

To combat the risk of insufficient vitamin D in breast-fed babies, the AAP has recommended a daily vitamin D supplement, starting from birth. In practice, this recommendation is followed maybe 20% of the time. Parents don’t like to give their newborns medicine, and I think pediatricians are reluctant to focus on the possible inadequacies of human breast milk.

In the current study, researchers sought to determine if giving higher doses of vitamin D to nursing moms could result in enough vitamin transfer in their milk. 334 mother-infant pairs were recruited, and randomized into three groups. In group one, moms were given an ordinary vitamin supplement, and their babies a vitamin D supplement (400 IU/day, matching the current recommendation.) In group 2, the babies were given no extra D, but moms took 2400 IU/day; in group three, moms were given 6400 IU each day. Babies and moms underwent regular blood and urine tests to see if these doses resulted in good vitamin D levels in the babies, and to see if these doses caused any metabolic problems with vitamin D, phosphorus, or calcium metabolism.

There was a relatively high drop-out rate—of the original 334 pairs, just 148 stuck with the plan for exclusive breastfeeding, and were thus able to complete the trial (families who discontinued breastfeeding or added formula supplements were not included in the final analysis.)

All of the babies who received regular supplementation had robust vitamin D levels and normal biochemical testing – we know, if that 400 IU a day for babies is given, it works. That was group 1. Group 2, where moms were given vitamin D 2400 IU/day,  was a failure—they actually stopped this arm of the study early, because many of the babies in this group did not have adequate vitamin D levels on their blood tests. But the babies in group 3 – who themselves received no direct vitamin D supplements, but whose moms got 6400 IU/day—did as well as group 1, with perfectly good vitamin D levels and no evidence for any side effects or problems. And, bonus, their moms also benefitted, with normal vitamin D levels and no side effects.

A reasonable question, though—is 6400 IU of D a day safe for moms to take? A prior guideline from the Institute of Medicine had suggested an upper limit of 2000 IU/day (though that has since been increased to 4000); the Endocrine Society now sets their upper limit at 10,000. During the past decade many studies have used adult D supplementation in the range of thousands of units per day, and according to the authors of this paper not a single adverse event was observed.

This study supports a safe alternative for families, and perhaps one that’s easier to do. Moms are used to taking prenatal vitamins, and continuing to take them while nursing. Adding 6,000 IU of D to the typical 400 in a prenatal isn’t expensive, and seems to be safe and effective at making sure their babies get enough D. Breast milk can have enough D – but only if mom gets her own supplement.

Vitamin D update: Your kids probably need more

The Pediatric Insider

© 2013 Roy Benaroch, MD

Charles wrote in about Vitamin D: “I read your post about Vitamin D from 2008. I continue to read about scientists learning how Vitamin D playing an important role in the immune system and how a significant portion of the population’s health (both adults and children) would benefit from having their Vitamin D checked. My doctor checked my Vitamin D during an annual checkup and recommended I supplement. Have your thoughts on Vitamin D changed much with 5 additional years for Vitamin D research? Do you recommend children have their Vitamin D levels checked?”

I last wrote about vitamin D in 2008? Wow, it has been a while! It is about time for an update—

First: As I sort-of-predicted in 2008, the AAP did increase their recommendation for Vitamin D intake from 200 to 400 IU/day for children of all ages. They’re also recommending that all babies who get less than 1 liter a day of formula (that includes all breastfeeding babies) get a supplement of 400 IU/day. US government authorities have settled on 400 IU/day for babies  less than 12 months, and 600 IU a day for older children and teens. These recommendations were based on widespread studies showing vitamin D insufficiency was common at all ages.

It’s still not entirely clear that 400 IU/day is adequate for all children—some have advocated for 1000 or 2000 IU/day for routine intake. It’s a difficult number to pin down, because many children make plenty of their own vitamin D in their skin when they’re exposed to sunlight. Less vitamin D is made that way in the wintertime, and among children with darker skin, children who live in cooler places, and children who for whatever reason don’t play much outside, or don’t have their skin exposed outside. A single, blanket recommendation for everyone may not be realistic.

What new have we learned since 2008? In addition to vitamin D’s well-known role in bone health, it seems to have some influence on the development of obesity and diabetes. It may also affect the way other hormones work, including steroid hormones and similar molecules that are used in asthma medications.

It’s also become even more clear to me that just about everyone is vitamin D deficient. I’ve been routinely checking vitamin D levels in kids (usually while drawing blood for other tests), and I will tell you that easily 90% of children are insufficient. The only “normal” vitamin D level I’ve seen recently was in my own child, who I know takes a daily supplement.

So: I’m not so sure it’s cost effective to test children, but it’s certainly a good idea to have children take a supplement routinely. 400-1000 IU a day of vitamin D3 (that’s the usual variety found in supplements) will make sure most children keep a good level of vitamin D. I’m not usually a huge fan of supplements, but this one makes sense.

Refusing milk from a cup

The Pediatric Insider

© 2009 Roy Benaroch, MD

 

Analise is trying to get her daughter to continue drinking milk: “My daughter is 14 months old and will only drink milk from a bottle. We introduced a sippy cup at 9 months but made the mistake of only putting water in it. Now she associates the cup with water and the bottle with milk. We’re in the process of weaning her from the bottle but don’t know how to convince her to drink milk from a cup. Do you have any tips or is it just try, try again until she accepts it? Thanks for any behavioral insight or advice!”

 

First, let me get myself in trouble with the dairy council and moms everywhere by letting this secret out: there is no essential need for toddlers to drink milk. It’s a good source of protein and calcium, sure, but there are plenty of other good sources. Lots of children stop drinking milk, and many adults never touch the stuff. There’s no reason to consider milk something crucial for children to drink once they’re outside of the young baby years and able to take solids well.

 

At fourteen months, whether or not your child is willing to drink milk from a cup, you ought to stop using baby bottles. They’re bad for her teeth, and they’re preventing her from developing normal eating habits. Don’t worry that your child won’t get enough fluids—she’ll drink water, and she will not become dehydrated without milk.

 

Though milk isn’t essential, it’s handy and most children continue to drink it. There are, of course, tricks worth trying to get her to drink milk from a cup:

 

• Add a little milk to the water in a cup, and day-by-day start adding more milk and less water. In a few weeks, you can wean up to full strength milk. Do this gradually and maybe she won’t notice.
• Add something to the milk to make it extra tasty: chocolate syrup, or maybe a mashed-up, very soft banana. Little girls (and boys) deserve a little chocolate in their lives.
• Try a different sort of cup, like one with a straw—maybe even a crazy bendy cool straw.
• Make sure she sees you and dad drinking milk from a cup. You two can even use sippy cups for a little while. If parents don’t drink milk, children are far less likely to want it.
• If you’ve been using whole milk, give 2% or skim a try. Older advice did recommended whole milk, but that’s not necessary.
• Try a different sort of milk, like soy or almond milk. These provide similar amounts of protein and calcium as cow’s milk. Rice milk, on the other hand, is a low-protein beverage more similar to juice than milk—stay away from it if you’re looking for something with nutritional value for your children.

 

What to do during the transition? Don’t worry about it. There is no reason a child can’t go weeks or months or even years without milk. If your daughter gets the impression that milk is something very special and important, she’s less likely to touch the stuff—this is called “yanking your parents’ chain,” a skill that all children learn sooner or later. Don’t get caught up in the drama by letting her know you’re worried about this. Win the chain-yanking match by dropping your end.

 

If in the long run your daughter still won’t touch milk, you’ll need some other good calcium sources:

 

• Any other dairy: cottage cheese, yogurt, cheese, ice cream
• Calcium fortified juices
• Calcium supplements, like the little chocolate squares marketed for women as Viactive
• Non fat dry milk powder. Don’t mix this in water to try to drink it—blecch—but sprinkle it in casseroles, soups, eggs, sauces, that kind of thing. Once it mixes in it’s just about impossible to taste. Think of it as cheap calcium –n- protein powder.

 

Try some simple tricks to see if you can get your daughter back on milk, but remember there is no hurry here, and this is not a crucial or even a very important issue. Milk is easy and cheap, but there are many other nutritious things your daughter can take that can replace milk if she’s decided she just won’t drink it any more.

Lactose intolerance

Poornima asked about lactose intolerance and supplements: “Does a lactose intolerant child need calcium supplements? If so, which ones? I thought the soy milk is calcium fortified- but I do understand that there are brands that are not.”

I looked at labels at the grocery store today, and the common brands of soy milk are calcium and vitamin D fortified—they have essentially the same content of these nutrients as cow’s milk. There are probably smaller brands that are not fortified, so it’s best to check the label.

Lactose intolerance is common in adults, especially among African- and Asian-Americans. However, it is virtually non-existant in babies. Human breast milk is loaded with lactose, and our babies are very good at digesting this natural sugar. Their guts are loaded up with lactase, the enzyme needed for lactose digestion. As children get older, many start to lose this lactase activity and may begin to have trouble digesting lactose. When that happens, symptoms like bloating, abdominal pain, and gassy diarrhea can occur. Because many adults are lactose intolerant, baby formula companies take advantage of this fear to sell special lactose-reduced formulas. Don’t fall for this—the chance of baby being lactose intolerant is probably one in a million.

Diagnosing lactose intolerance is best done by trial and error. If you think your older child has this, take her off milk for a week or so. Then on a day without other big plans, give her a nice big milkshake. Yum! If an hour or so later she’s in the bathroom miserable, she’s probably lactose intolerant. Though there are medical tests to confirm this, they’re difficult to do in children and rarely necessary.

Treatment consists mainly of avoiding lactose sources—that is, all dairy products. Items that are cooked or heated will have less lactose than ordinary milk. Everyone who is lactose intolerant has a “threshold level,” beyond which symptoms will occur. This threshold will be very low for some people (say, only ½ a slice of cheese pizza), while others might be able to tolerate a bit more (maybe one small glass of milk, but no more.) Experiment to find out what the threshold is so you can avoid going over the limit.

There are supplements sold to help with lactose intolerance, usually enzymes that are said to be able to replace the natural effect of lactase. Some people find these effective, but most do not. Almost all natural lactase activity occurs far into the small intestine, and most of any swallowed enzyme is likely broken down long before the food makes it that far down. Still, lactase supplements are safe and feel free to use them if they seem to help.

In a typical American diet, diary products are the major source of both calcium and vitamin D. For infants, milk and dairy are also a significant source of protein and calories. If your child can’t tolerate dairy, you should discuss her individual needs with her pediatrician to make sure that she’s getting enough of these nutrients.

I am not drinking that

Susan posted, “My 19-month old does not like whole milk. He nursed exclusively for a year. Then I would nurse him and pump. I would mix the pumped breastmilk with whole milk for when he went to daycare. Now I am trying to wean him completely but am reluctant to because he does not like to drink anything. He still nurses when he wakes up and just before he goes to bed. I feel like I need to keep doing this so that he gets some hydration. He does not like to drink in general, only taking sips of water or juice from a sippy cup at mealtime. He has had lots of problems with constipation and I have to give him Miralax in small doses every day. I can’t force him to drink but I don’t know what to do. I have also tried soy milk and giving the milk a flavor like chocolate or strawberry. He still has no interest. Help!”

You’re going to have to take a leap of faith here: when your son is thirsty, he will drink. If he’s neurologically normal, his hypothalamus will provide him with an irresistible desire to drink when his body needs fluids. He may not drink as much as you think he needs, but he will drink enough to stay healthy.

Reflux and bones

Just last week I published an article on gastroesophageal reflux (often abbreviated “GERD”). I wrote “All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.”

Well, I think I missed the boat on this one.

Cancer, diabetes, and vegans

A post from EH: “Recently I have been hearing about a link between dairy protein and diseases such as cancer and diabetes. What are your thoughts on this and can a vegan diet be healthy for small children?”

I haven’t seen any good data that supports a strong link between dairy products and either cancer or diabetes. The press likes to report things as if there is a single cause—a “smoking gun”—that’s the root cause of these problems, it’s unlikely that either disease is the result of one kind of food or exposure. As with many health conditions, they’re complex, poorly understood, and difficult to sum up for a 45 second sound bite on the news.

Nonetheless, this is the Pediatric Insider site, and I’m going to take a stab at it: in 45 seconds, what are the best ways to prevent cancer and diabetes?

Which supplements are best for kids?

Andrea posted: “I have two children, ages 4 yrs. and 15 months. Both are very picky eaters. The youngest is quite difficult – he spits out all meats and most fruits/vegetables. I know that a balanced diet is the best answer and that is my goal, but for now I am very interested in supplements. What do you recommend for toddlers? One year olds? And how do you determine the appropriate dosage for each child? I recently read about the benefits of fish oils – do you recommend this supplement? Are there any resources that you recommend where I can learn more about dietary supplements?”

Fortunately, most of the food in the developed world is fortified with multiple vitamins and minerals. With very few exceptions (we’ll talk about those later), vitamin deficiencies are just about unheard of in the United States, at least among children who have ready access to food. On the other hand, an ordinary multivitamin with safe doses of vitamins is going to be harmless, and may put your mind at ease.