Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods

James A. Taylor, Leah J. Geyer and Kenneth W. Feldman

Pediatrics 2010;125;105-111; originally published online Nov 30, 2009;
DOI: 10.1542/peds.2009-1195

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/125/1/105

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ARTICLES

Use of Supplemental Vitamin D Among Infants

Breastfed for Prolonged Periods
AUTHORS: James A. Taylor, MD,a Leah J. Geyer, AB,a and
Kenneth W. Feldman, MDa,b
aDepartment of Pediatrics, University of Washington, Seattle,
Washington; and bDepartment of Pediatrics, Seattle Childrens
Hospital, Seattle, Washington

KEY WORDS
breastfeeding, vitamin D, infants, rickets
ABBREVIATIONS
AAPAmerican Academy of Pediatrics
PSPRNPuget Sound Pediatric Research Network
OR odds ratio
CI condence interval

WHATS KNOWN ON THIS SUBJECT: Because of the risk of

nutritional rickets, vitamin D supplementation is recommended
for all breastfed infants. There is emerging evidence of other
benets of vitamin D for children.
WHAT THIS STUDY ADDS: The results of this study provide
insight into the proportion of breastfed infants who receive
vitamin D supplementation and the reasons parents choose to
provide the vitamin to their children.

www.pediatrics.org/cgi/doi/10.1542/peds.2009-1195
doi:10.1542/peds.2009-1195
Accepted for publication Jul 30, 2009
Address correspondence to James A. Taylor, MD, University of
Washington, Child Health Institute, Box 354920, Seattle, WA
98195. E-mail: uncjat@u.washington.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.

abstract
OBJECTIVES: To determine the rate of vitamin D supplementation in
predominantly breastfed children. To identify patient characteristics,
parental beliefs, and practitioner policies associated with supplementation.
METHODS: A prospective observational study was conducted in a
practice-based research network. Network pediatricians completed a
survey regarding their policy on vitamin D supplementation for breastfed infants. Parents of children 6 to 24 months old completed a survey
on the initial type of feeding given to the child, length of breastfeeding,
formula supplementation, and use of multivitamins. Parents indicated
their level of agreement with statements regarding vitamin D supplementation.
RESULTS: Among 44 responding pediatricians, 36.4% indicated that
they recommended vitamin D supplementation for all breastfed infants. A total of 2364 surveys were completed on age-eligible children;
1140 infants were breastfed for at least 6 months with little or no
formula supplementation. The rate of vitamin D use for these infants
was 15.9%. Use of vitamin D was signicantly associated with parental
agreement that their childs pediatrician recommended supplementation (odds ratio [OR]: 7.8), and that vitamins are unnecessary because
breast milk has all needed nutrition (OR: 0.12). Among parents of predominantly breastfed infants who indicated that their childs doctor
recommended vitamin D, 44.6% gave the supplementation to their
child. Conversely, 67% of parents agreed that breast milk has all
needed nutrition, and only 3% of these parents gave vitamin D to their
children.
CONCLUSIONS: A minority of breastfed infants received vitamin D supplementation. Educational efforts directed at both physicians and parents are needed to increase compliance with vitamin D supplementation guidelines. Pediatrics 2010;125:105111

PEDIATRICS Volume 125, Number 1, January 2010

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105

Because the vitamin D content in human milk may be relatively low, breastfed infants are at risk for rickets unless they are exposed to adequate
amounts of sunshine to produce endogenous vitamin D or receive it from
other sources.14 For more than a decade, supplemental vitamin D has been
recommended for certain infants who
are breastfed to prevent rickets.5 In
2003, the American Academy of Pediatrics (AAP) recommended that all
breastfed infants receive at least 200
IU/day of supplemental vitamin D;
in 2008, the recommendation was
changed to at least 400 IU/day.2,6
Estimates of physician adherence to
the AAP recommendations regarding
vitamin D supplementation vary. A
1999 survey of North Carolina pediatricians found that 44.6% recommended
the supplement for all breastfed infants, and 38.6% recommended it for
some infants.7 These results are similar to a study of Las Vegas, Nevada,
pediatricians in which 48% recommended vitamin D for breastfed infants.8 Recently, it was reported that
89% of responding pediatricians in the
US military recommended supplementation for all, or some, infants fed human milk.9 More important, however,
there have been few data on whether
these recommendations inuence parental behavior and how many breastfed infants actually receive supplemental vitamin D. In a study on the
prevalence of hypovitaminosis D in
young children in the Boston, Massachusetts, area, Gordon et al10 reported
that only 2% of breastfed infants received supplemental vitamin D.
We conducted a study to determine the
rate of supplemental vitamin D usage
among a group of infants from the Seattle, Washington, area who were predominantly breastfed for at least the
rst 6 months of life. We were interested in identifying the reasons parents choose to supplement, or to not
106

TAYLOR et al

supplement, their breastfed infants.

We were particularly interested in the
role that their childs pediatrician had
in inuencing this choice. Before the
project, we postulated that approximately one third of infants who were
breastfed for at least 6 months would
receive supplemental vitamin D and
that a parents decision regarding supplementation would be highly inuenced by the recommendation of their
childs pediatrician.

METHODS
A prospective observational study was
conducted by the Puget Sound Pediatric Research Network (PSPRN), a regional practice-based network of primary care pediatric practices in the
Seattle, Washington, area. For this
project, 44 PSPRN practitioners from 7
private practice ofces and 1 innercity pediatric clinic participated. The
study consisted of 2 surveys, including
a practitioner vitamin D survey and an
infant-feeding survey completed by
parents. Survey data were collected
between July 2006 and June 2008.
Before collecting data on infants, the
practitioner vitamin D survey was distributed to 44 PSPRN pediatricians. The
pediatricians were asked about their
current recommendation regarding vitamin D supplementation for breastfed
infants. Possible responses included
recommend vitamin D for all breastfed
patients; recommend for high-risk children; discuss pros and cons of supplementation with parents; and do not routinely discuss vitamin D with parents.
Pediatricians were asked to indicate
their level of agreement with 4 statements regarding supplemental vitamin
D by using a 6-point Likert scale, with
possible responses to each statement
ranging from completely agree to
completely disagree. The statements
on vitamin D usage are shown in Table 1.
For the analysis of data in the practitioner vitamin D surveys, the

TABLE 1 Statements Regarding Vitamin D

Supplementation and Rickets on the
Practitioner Vitamin D Survey and
Parental Survey of Infant Feeding
Practitioner vitamin D survey
In order to practice high quality medicine it is
important to follow AAP practice guidelines.
A major limitation of the AAP recommendation
that all breastfed infants receive
supplemental vitamin D is that the
recommendation is not evidence-based.
Routinely recommending vitamin D for
breastfed babies may result in some
mothers electing to formula feed instead.
Some of my breastfed patients will likely
develop rickets if they dont receive
supplemental vitamin D.
Parental survey of infant feeding
I think that giving vitamins to babies and young
children is important for their overall
health.
Vitamins may be needed to prevent rickets or
other bone diseases in some babies.
It is inconvenient to give vitamins to young
babies.
When my baby was less than 6 months old,
he/she didnt need any extra vitamins
because the breast milk or formula that
he/she took had everything my baby needed.
If babies are out in the sunlight and fresh air
they dont need extra vitamins.
My childs doctor recommended that I give my
baby vitamins.

responses to statements by pediatricians who indicated that they recommended vitamin D for all breastfed
infants were compared with the responses of those who had some other
practice regarding supplementation.
Likert-scale responses were transformed to an ordinal scale for the analysis. Regression analysis was used to
assess differences; generalized estimating equation techniques were used
to account for the clustering of pediatricians in different practices.11
The infant-feeding survey was distributed to parents of children 6 to 24
months old at the time of an ofce visit
to a PSPRN practice. This survey was
anonymous; no identifying health information was collected. Surveys were
available in both English and Spanish
and were distributed by a research assistant who visited practices on a regularly scheduled basis. Surveys were

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also distributed to parents by ofce

staff in participating practices during
multiple data-collection periods that
ranged from 1 to 3 months.
For the infant-feeding survey, parents
of age-eligible children provided the
current age of their child and were
asked the initial type of feeding for him
or her (breast milk or infant formula).
Parents of those infants who were initially breastfed were asked how long
their child received human milk, how
much formula their child received on a
routine basis, and how often the child
received 16 oz of formula in a single
day (possible responses included
never or almost never, a few days
each week, almost every day, or
every day,). Parents were asked
whether their child routinely received
a multivitamin (all containing vitamin
D) during the rst 6 months of life. The
parent was also asked to provide the
name of his or her childs pediatrician
during the childs rst 6 months of life
and to indicate how important this
physicians recommendation was regarding the decision of whether to give
his or her infant vitamins; responses
were categorized with a 5-point Likert
scale that ranged from very important to very unimportant. Parents
were also asked to provide the race
and ethnicity of their child.
Six statements regarding vitamin D
supplementation were listed on the
survey. As with the practitioner survey,
parents indicated their level of agreement with each statement by using a
6-point Likert scale. The statements on
the infant-feeding survey are listed in
Fig 1.
Much of the analysis of data in the
infant-feeding surveys was focused on
those children who were predominantly breastfed for at least the rst 6
months of life. Children were considered to be predominantly breastfed if
they routinely received 8 oz of forPEDIATRICS Volume 125, Number 1, January 2010

mula daily during the rst 6 months of

life and never or almost never received 16 oz of formula in 1 day. Because commercial formula contains
400 IU/L,12 the infants who were dened as being predominantly breastfed received 100 IU of vitamin D from
formula on a routine basis and never
or almost never received 200 IU daily.
On the basis of the recommendation
for 200 IU of supplemental vitamin D
daily that was in place when the study
data were collected,2 none of these
predominantly breastfed, unsupplemented study children received 50%
of the recommended vitamin D dose
from infant formula on a daily basis
and virtually never received all of the
recommended dose from this source.
The rate of supplemental vitamin D use
in the children who were predominantly breastfed for at least 6 months
was calculated. The rate of breastfeeding, prolonged breastfeeding,
and vitamin D use was also computed for children from different racial and ethnic groups; 95% condence intervals (CIs) around point
estimates were calculated.
Characteristics and parental beliefs
associated with supplemental vitamin
D use in children who were predominantly breastfed for at least 6 months
were assessed with the use of logistic
regression. Generalized estimating
equation techniques were used in
these analyses to account for the clustering of patients in different practices.11 Characteristics assessed included race, ethnicity, and age. Data on
the infant-feeding surveys regarding
the childs pediatrician during the rst
6 months of life were linked to responses on the practitioner vitamin D
surveys. On the basis of this linkage,
the association between having a pediatrician who recommended vitamin D
for all breastfed infants versus having
a provider who had another policy re-

garding supplementation and use of

vitamin D in study patients was assessed. Parental agreement with
statements regarding vitamin D use
was dichotomized; responses of completely agree or agree were compared with all other responses for
each item. Similarly, the response to
the item in the infant-feeding survey in
which parents were asked how important their childs pediatricians
recommendation was regarding supplemental vitamin D was dichotomized
by comparing responses of very important or important to other
responses.
Each individual characteristic or belief
was compared with the use of vitamin
D in predominantly breastfed study patients. Those characteristics and beliefs statistically associated with vitamin D use in univariate analyses,
dened as an odds ratio (OR) with a
95% CI that did not include 1.0, were
included in a multivariate model to
identify factors independently associated with vitamin D use in breastfed
children.
Finally, during the study period, there
was increasing publicity regarding vitamin D deciency in children and
adults.13,14 To protect the anonymity of
study children and their parents, we
did not collect data on the date that
infant surveys were completed (these
dates corresponded to dates of physician visits, which is considered to be
identiable health information).15 However, information on the surveys was
entered into databases as they were
collected. To assess the effects of secular trends in vitamin D use during the
study period (2006 2008), we categorized study patients into tertiles on the
basis of the chronological order of
when their data were entered into the
study databases.
The study was approved by the Seattle
Childrens Hospitals institutional review board.

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107

RESULTS

2433 completed surveys

-69 surveys on children <6 mo or >25 mo old
2364 surveys on eligible children (97.2%)

A total of 44 PSPRN pediatricians completed the practitioner vitamin D survey. At the time that the survey was
completed, 16 pediatricians (36.4%) indicated that they routinely recommended supplemental vitamin D for all
of their breastfed patients. Fourteen
respondents (31.8%) recommended
supplemental vitamin D for breastfed
infants who were at high risk for developing rickets. Six pediatricians
(13.6%) responded that they discussed
the pros and cons of supplementation
with parents of breastfed infants, and
8 (18.2%) indicated that they did not
routinely discuss vitamin D supplementation with parents.
Physicians who did not recommend vitamin D for all breastfed infants had
signicantly higher levels of agreement with the statement, A major limitation of the AAP recommendation
that all breastfed infants receive supplemental vitamin D is that the recommendation is not evidence based,
than pediatricians who recommended
vitamin D for all breastfed infants (39
total responses; P .011). Those practitioners who were not universally recommending vitamin D also had higher
levels of agreement than those who
universally recommended supplementation for breastfed children with the
statement indicating that recommending supplementation might lead some
mothers to choose to not breastfeed
their infants (P .042). There were no
signicant differences in levels of
agreement for the statement regarding the importance of following AAP
guidelines and the statement regarding the possibility of rickets in breastfed children who were not supplemented between those pediatricians
who routinely recommended vitamin D
and those who had another policy regarding supplementation.
Data on completion of the infantfeeding survey by parents and on
108

TAYLOR et al

1945 initially breastfed (82.6%)

8 missing

411 formula fed (17.4%)

1456 infants breastfed for 6 mo (75%)

4 missing

- 287 infants who took 8 oz/d formula on

routine basis and/or 16 oz formula a few
d/wk or more (20.1%)
-29 with missing data

1140 infants predominately

breastfed for 6 mo
(58.6% of those initially breastfed)

FIGURE 1
Survey completion and breastfeeding practices in study children.

TABLE 2 Rate of Initial Breastfeeding Among Study Infants of Different Racial and/or Ethnic Groups
and Rates of Being Predominately Breastfed for at Least 6 Months
Race/Ethnicity

No.a

% Initially
Breastfed

% Predominantly
Breastfed for 6 mo

Black
American Indian/Alaskan Native
Asian/Pacic Islander
White
Hispanic ethnicityb

120
42
427
1695
232

62.5
88.1
81.5
85.1
73.7

24.2
52.4
44.8
52.4
41.0

a
b

Data on children whose parents indicated that they were of multiple races are included in more than 1 race category.
Includes children from all racial groups.

breastfeeding practices of their children are summarized in Fig 1. Among

the 2364 eligible children whose parents completed surveys, 1945 (82.6%
[95% CI: 81.0% 84.1%]) were mainly
fed with human milk during their rst
month of life. The race and ethnicity of
eligible children are shown in Table 2
along with the rates of initial breastfeeding and the proportion who were
predominantly fed human milk for at
least 6 months. The mean age of the
infants and toddlers at the time their
parents completed the survey was 12.1
months (SD: 4.8 months); 25% were
aged 8 months or younger, and 25%
were aged 16 months or older.

As shown in Fig 1, surveys were completed by parents of 1140 children who

were predominantly breastfed for at
least the rst 6 months of life. The rest
of the analysis was focused on these
1140 study infants and toddlers. Overall, 181 of 1139 of these children
(15.9% [95% CI: 13.8%18.1%]) were
routinely given supplemental vitamin D
during the rst 6 months of life. Information on vitamin D use for 1 child was
missing. Use of supplemental vitamin
D in predominantly breastfed infants
varied according to race, with values ranging from 14.2% (95% CI:
11.9%16.6%) among white children to
27.1% (95% CI: 20.9%34.0%) among

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TABLE 3 Univariate Association Between Vitamin D Use and Patient Characteristics, Parental
Beliefs, and Policy of the Childs Pediatrician Among Study Children Who Were
Predominantly Breastfed for at Least the First 6 Months of Life
Variable

ORa

95% CI

No.b

White
Nonwhite race and/or Hispanic ethnicityc
Black
Asian/Pacic Islander
Hispanic ethnicity
Childs age
Parent agrees: vitamins important for overall health
Parent agrees: vitamins needed to prevent rickets/other diseases
Practitioner survey: childs doctor recommends vitamin D for all
breastfed infants
Parent agrees: childs doctor recommended vitamin D
Parent agrees: vitamins unnecessary, breast milk has all needed nutrition
Parent agrees: giving vitamins inconvenient
Parent agrees: vitamins not needed if infant is out in sunlight
Childs doctors recommendation regarding vitamin D important in
parents decision about vitamin D supplementation

0.63
1.67
1.12
2.02
0.93
1.00
5.22
2.77
3.88

0.440.90
1.222.27
0.492.62
1.432.87
0.561.54
0.971.03
3.457.90
1.933.98
2.236.73

1089
1089
1089
1089
1084
1139
1101
1020
926

19.52
0.07
0.59
0.29
2.88

10.6135.93
0.040.13
0.420.84
0.170.49
1.655.03

1083
1109
1087
1074
1037

OR was calculated by using logistic regression after accounting for clustering of children into different practices.
No. indicates number of valid responses to each item.
c Of the study children, 335 of 1090 (30.7%) were nonwhite race and/or Hispanic ethnicity; information on vitamin D
supplementation was collected for 1089 of these children.
b

Asian/Pacic Islander children. A total

of 29 black patients were predominantly breastfed for at least 6 months;
6 of these children (20.7%) received
supplemental vitamin D. The rate of vitamin D usage among Hispanic children who were breastfed for at least 6
months without signicant formula
supplementation was 15.8% (95% CI:
9.1%24.7%).
The univariate association between vitamin D use in predominantly breastfed children and several variables, including race, ethnicity, age, parental
beliefs, and the policy of the childs pediatrician regarding supplementation,
are summarized in Table 3. In the
unadjusted analyses, most of the variables assessed were statistically associated with supplementation. To identify characteristics and beliefs that
were independently associated with vitamin D use in breastfed infants, an
analysis including those variables signicantly associated with supplementation in univariate comparisons was
conducted. Because of both the overlap between several racial and ethnic
groups and evidence that 90% of
children in the United States with nuPEDIATRICS Volume 125, Number 1, January 2010

tritional rickets are nonwhite and/or

Hispanic,16 only 1 race variable (nonwhite race and/or Hispanic ethnicity,
or non-Hispanic white race) was included in the model. In addition, because 213 predominantly breastfed
study children had an initial primary
care provider who was not a member
of PSPRN and did not complete the
practitioner survey, data on the childs
pediatricians vitamin D recommendation policy were not included in the
larger model. The results of the multivariate analysis are shown in Table 4.
Of the variables assessed in the full
model, parental agreement that the
childs pediatrician recommended vi-

tamin D supplementation and that vitamins are important for a childs overall health were the only variables that
were positively and signicantly associated with the use of vitamin D. Conversely, parental agreement that supplementation is unnecessary because
breast milk has all needed nutrition
and that giving vitamins is inconvenient were both signicantly associated with not using vitamin D. Additional models that included all racial
variable terms and/or data on the
childs pediatricians recommendation
regarding supplementation were analyzed. The results of every analysis
were similar. Parental agreement that
vitamin D was recommended by the
childs physician (adjusted ORs ranging from 7.76 to 8.93 in different analyses) and agreement that vitamins are
good for overall infant health (adjusted ORs: 1.98 2.23) were signicantly associated with providing supplementation; agreement that breast
milk had all needed nutrition (adjusted
ORs: 0.10 0.12) and agreement that
giving vitamins is inconvenient (adjusted ORs: 0.45 0 .46) were statistically associated with not giving vitamin D.
When asked to identify their childs
main doctor during the rst 6 months
of life, parents of 927 patients listed a
PSPRN pediatrician who had completed the practitioner vitamin D survey (81.3% of those infants who were

TABLE 4 Multivariate Analysis to Identify Patient Characteristics, Parent Beliefs, and Provider
Policies Associated With Vitamin D Supplementation in Predominantly Breastfed Infants
Variable

ORa

95% CI

Nonwhite race and/or Hispanic ethnicity

Parent agrees: vitamins important for overall health
Parent agrees: vitamins needed to prevent rickets/other diseases
Parent agrees: childs doctor recommended vitamin D
Parent agrees: vitamins unnecessary, breast milk has all needed nutrition
Parent agrees: giving vitamins inconvenient
Parent agrees: vitamins not needed if infant is out in sunlight
Childs doctors recommendation regarding vitamin D important in
decision about vitamin D supplementation

1.29
1.98
1.37
7.76
0.12
0.45
0.94
1.83

0.812.06
1.173.34
0.812.31
4.1114.64
0.070.23
0.260.76
0.422.10
0.774.39

OR calculated using logistic regression after accounting for clustering of children into different practices.

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109

predominantly breastfed). Among

these 927 study children, 218 (23.5%)
were seen by a health care provider
who indicated that he or she routinely
recommended supplemental vitamin D
for all breastfed infants. Parents of
children whose provider universally
recommended vitamin D for breastfed
infants were signicantly more likely
to agree that the provider recommended this supplement than those of
children whose pediatrician had another policy (64.7% and 22.7%, respectively; OR: 3.10 [95% CI: 1.95 4.91]).
Parents of nonwhite and/or Hispanic
children were also more likely to agree
that their childs provider recommended vitamin D than those of white
non-Hispanic children (44.6% and
27.8%, respectively; OR: 1.75 [95% CI:
1.372.27]). Overall, 33.3% of responding parents indicated that their childs
provider recommended vitamin D
supplementation. Among these parents, 44.6% gave the supplement to
their child versus 2.8% of those
whose childs provider did not recommend vitamin D (OR: 19.52 [95% CI
10.6135.93]).
Among the responding parents of children who were predominantly breastfed for at least 6 months, 743 of 1110
(67.0%) agreed with the statement
that vitamin D supplementation is not
required because breast milk has all
needed nutrition. Only 3.0% of children
of these parents received supplemental vitamin D.
There was an increase in the use of
vitamin D in predominantly breastfed
infants during the 2-year study period.
During the rst third of the period,
10.8% of these children received supplemental vitamin D; 12.7% received
the supplement during the middle
third and 24.0% during the last third of
the study period (OR: 1.60 [95% CI:
1.10 2.32] for comparison between
the nal and rst third of the study period). However, after controlling for
110

TAYLOR et al

this secular trend, there were no signicant changes in the results; 4 variables (agreeing that the childs doctor recommended supplementation,
agreeing that vitamins are important
for overall infant health, agreeing that
breast milk has all needed nutrition,
and agreeing that giving vitamins is inconvenient) remained signicantly associated with vitamin D use.

DISCUSSION
Our results indicate that only a minority of study children who were predominantly breastfed for 6 months received supplemental vitamin D. This
rate of usage is explained, to a large
degree, by 2 conicting inuences.
Parents who reported that their childs
pediatrician recommended vitamin D
were 8 times more likely to provide
the supplementation than parents
whose childs pediatrician did not
make this recommendation. However,
only one third of the parents of breastfed infants indicated that the pediatrician recommended vitamin D. In addition, and perhaps the most striking
nding of this study, fewer than half
(44.6%) of the parents who responded
that vitamin D was recommended by
their childs pediatrician actually administered the supplementation. This
counterintuitive result is partially explained by our nding that 67% of the
parents believed that supplementation
is unnecessary because breast milk
has all needed nutrition. Parents who
had this belief were 9 times less
likely to give supplemental vitamin D
than those who did not agree with this
statement.
Initially, vitamin D supplementation
was recommended for breastfed infants as a method to prevent rickets.2
However, there is emerging evidence
that vitamin D may play an important
role in mitigating other disease processes in children.1,17 Information
about this evidence, both in the scien-

tic and lay press, has likely increased

interest in providing vitamin D to
breastfed infants. In our study, we
found that vitamin D use increased signicantly during the nal third of our
study period (roughly covering the period of late 2007 to mid-2008) when
there was publicity about vitamin D.13,14
However, even during this most recent
period, fewer than one quarter of the
responding parents of predominantly
breastfed infants reported giving vitamin D to their children. The same factors (their childs doctors recommendation and a belief that breast milk has
all needed nutrition) remained signicantly associated with a parents decision regarding supplementation.
As expected, we found a high rate of
breastfeeding in this population of infants seen in primary care pediatric
practices in the Seattle area. In 2002, it
was estimated that 71% of US children
had ever been breastfed and that
63.2% were breastfed at 1 month of
age. The Pacic region of the country
had the highest reported rates of
breastfeeding, with 76.4% of infants
from this region reportedly being
breastfed at 1 month of age.18 We found
that 82.6% of the children in our study
were mainly breastfed during the rst
month of life. We also found that
breastfeeding among black infants
was more common in our population
than nationally. However, breastfeeding rates in Hispanic infants in our
study were comparable to US rates for
Hispanic infants.18 Perhaps more surprising was the nding that 1140 of the
2364 infants in the study (48.2%) were
breastfed with little or no formula supplementation for at least 6 months.
This is substantially higher than the
35.1% of infants nationally who are
breastfed for at least 6 months.18
It is possible that the high rate of
breastfeeding in study children was
linked to the reticence of the respond-

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ARTICLES

ing pediatricians to recommend vitamin D in at least 2 ways. Pediatricians

who did not universally recommend
supplementation had a belief that recommending vitamin D might cause
some parents to not breastfeed their
infant. Perhaps these practitioners
were wary of any intervention that
would alter the high prevalence of
breastfeeding. Conversely, pediatricians may have been hesitant to bring
up supplementation to parents who
have strong beliefs about the nutritional advantages of human milk. We
found that 68.2% of responding pediatricians recommended vitamin D
supplementation for some or all
breastfed infants. Although this is
higher than rates found in surveys of
providers conducted before the AAP
recommendation in 2003,7,8 it is
lower than the 89% rate of recommending supplementation that Sher-

man and Svec reported among 128

military pediatricians.9
A potential limitation of this study is
that parents of children up to 2 years
old were asked to report whether vitamins were given during the rst 6
months of life and the reasons for this
choice. It is possible that some parents
did not recollect correctly. To some extent, our nding that signicantly
more parents of study children whose
pediatricians universally recommend
vitamin D indicated that the practitioner recommended supplementation
than those whose childs pediatrician
did not tend to validate the accuracy of
parental reporting on the surveys.

fants among participating pediatricians. Our results suggest that vitamin

D use is strongly linked to physician
recommendations. Efforts to increase
physician acceptance of vitamin D recommendations should lead to more
use in infants and increase compliance with AAP guidelines.6 However,
the results of our study also suggest
that there is a strong belief by parents
that breast milk has all needed nutrition. To a large degree, this belief
supersedes physician recommendation. Thus, to substantially increase vitamin D use in predominantly breastfed infants, public health educational
campaigns should also directly target
parents.

CONCLUSIONS
At the time that we began this study in
2006, there was signicant resistance
to the AAP recommendation for supplemental vitamin D for breastfed in-

ACKNOWLEDGMENT
This study was funded by a grant from
the Agency for Healthcare Research
and Quality.

dren, and adolescents. Pediatrics. 2008;

122(5):11421152
Davenport ML, Uckun A, Calikoglu AS. Pediatrician patterns of prescribing vitamin supplementation for infants: do they contribute
to rickets? Pediatrics. 2004;113(1 pt 1):
179 180
Shaikh U, Alpert PT. Practices of vitamin D
recommendation in Las Vegas, Nevada. J
Hum Lact. 2004;20(1):56 61
Sherman EM, Svec RV. Barriers to vitamin D
supplementation among military physicians. Mil Med. 2009;174(3):302307
Gordon CM, Feldman HA, Sinclair L, et al.
Prevalence of vitamin D deciency among
healthy infants and toddlers. Arch Pediatr
Adolesc Med. 2008;162(6):505512
Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes.
Biometrics. 1986;42(1):121130
Committee on Nutrition. Cow milk-based infant formulas: label claim nutrient contents
(per L at 20 kcal/oz). In: Kleinman RE, ed.
Pediatric Nutrition Handbook. 6th ed. Elk
Grove Village, IL: American Academy of
Pediatrics; 2009:1250 1258
Kids bones at risk from low vitamin D. July 9,

2007. Available at: www.cbsnews.com/stories/

2007/07/09/health/webmd/main3032600.shtml.
Accessed April 24, 2009
Collins AT. Kids low vitamin D worries doctors.
June 18, 2008. Available at: http://abcnews.go.
com/Health/Diet/Story?id4982913&page1.
Accessed April 24, 2009
Gunn PP, Fremont AM, Bottrell M, Shugarman LR, Galegher J, Bikson T. The Health
Insurance Portability and Accountability Act
privacy rule: a practical guide for researchers. Med Care. 2004;42(4):321327
Weisberg P, Scanlon KS, Li R, Cogswell ME.
Nutritional rickets among children in the
United States: review of cases reported between 1986 and 2003. Am J Clin Nutr. 2004;
80(6 suppl):1697S1705S
Liu PT, Stenger S, Li H, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science. 2006;
311(5768):1770 1773
Li R, Darling N, Maurice E, Barker L,
Grummer-Strawn LM. Breastfeeding rates
in the United States by characteristics of
the child, mother, or family: the 2002 National Immunization Survey. Pediatrics.
2005;115(1). Available at: www.pediatrics.
org/cgi/content/full/115/1/e31

REFERENCES
1. Misra M, Pacaud D, Petryk A, Collett-Solberg
PF, Kappy M; Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Vitamin D deciency in children and its management: review of
current knowledge and recommendations.
Pediatrics. 2008;122(2):398 417
2. Gartner LM, Greer FR; American Academy of
Pediatrics, Section on Breastfeeding and
Committee on Nutrition. Prevention of rickets and vitamin D deciency: new guidelines
for vitamin D intake. Pediatrics. 2003;
111(4):908 910
3. Reeve LE, Chesney RW, DeLuca HF. Vitamin D
of human milk: identication of biologically
active forms. Am J Clin Nutr. 1982;36(1):
122126
4. Hollis BW, Roos BA, Draper HH, Lambert PW.
Vitamin D and its metabolites in human and
bovine milk. J Nutr. 1981;111(7):1240 1248
5. Committee on Nutrition. Vitamins. In: Pediatric Nutrition Handbook. 4th ed. Elk Grove
Village, IL: American Academy of Pediatrics;
1998:275276
6. Wagner CL, Greer FR; American Academy of
Pediatrics, Section on Breastfeeding and
Committee on Nutrition. Prevention of rickets and vitamin D deciency in infants, chil-

PEDIATRICS Volume 125, Number 1, January 2010

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

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111

Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods

James A. Taylor, Leah J. Geyer and Kenneth W. Feldman
Pediatrics 2010;125;105-111; originally published online Nov 30, 2009;
DOI: 10.1542/peds.2009-1195
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