Clinical

Practice Guideline
Vitamin D Supplementation for Pregnancy and Lactation

Background and Rationale for Supplementation:
• Vitamin D deficiency during pregnancy affects up to 33% of pregnant females in the
United States.1
• Maternal vitamin D deficiency has been linked to increased risk of pre-eclampsia and
gestational diabetes, indicating a need for Vitamin D supplementation during
pregnancy.2
• Newborn infants depend solely on their mothers’ nutrient stores during gestation, and
are at a higher risk of vitamin D deficiency if they are born to deficient mothers.1,3
• Human breastmilk is low in Vitamin D. Research indicates that breastfed infants are at a
higher risk for vitamin D deficiency during their early stages of life.3
• Postpartum supplementation in breastfeeding mothers is associated with beneficial
outcomes, including decreased risk of rickets in breastfed infants and osteomalacia in
mothers.3,4
Vitamin D Activation and Metabolism2
There are 2 major forms of vitamin D:
• Calcidiol or 25(OH)D: non-active form
• Calcitriol or 1,25(OH)2D: active form
Activation of vitamin D occurs in a 2-step process involving the liver and the kidneys, through a
a double hydroxylation process.2 Activated Vitamin D works in conjunction with parathyroid
hormone (PTH) in the body to maintain calcium and phosphorus homeostasis, via absorption in
the intestines and reabsorption in the kidneys. Through these mechanisms, vitamin D status
impacts cellular processes and bone mineralization in mothers, fetuses, and infants during and
after pregnancy.4
Current DRI’s for Vitamin D5
Age 0-12 months 400 units/day
*While these are the current recommendations,
Pregnancy 600 units/day emerging research suggests these levels may not be
Lactation 600 units/day sufficient during pregnancy and lactation.


Vitamin D Needs During Pregnancy

Increased vitamin D needs during pregnancy are associated with changes in maternal stores
and calcium metabolism necessary for fetal growth.
• Maternal stores
o Physiologically higher levels of maternal 1,25(OH)2D are observed during the 2nd
and 3rd trimesters of pregnancy.4
o Maternal 25(OH)D stores cross the placenta to the fetus during pregnancy. Due
to this transfer of vitamin D in the womb, neonatal 25(OH)D concentrations are
approximately 2/3 of maternal 25(OH)D concentrations during pregnancy.6
• Calcium metabolism
o Enhanced calcium absorption occurs in the intestines during pregnancy.4
o Increased calcium needs are related to fetal calcium requirements (250 mg/d
during the 3rd trimester) for optimal bone growth prior to birth.4
Vitamin D Supplementation During Pregnancy
Supplementation is necessary to meet and maintain maternal 25(OH)D needs during
pregnancy.
Recommended maternal serum 25(OH)D levels during pregnancy:
The Institute of Medicine2 >20 ng/ml or >50 nmol/L
Principi et. al, 20137 >32 ng/mL and below 50-60 ng/mL

More research is necessary to determine fetal and neonatal benefits of maintaining higher
maternal 25(OH)D levels during pregnancy. Research has shown the following benefits of
supplementation on maternal stores during pregnancy:
• Daily supplementation of 2,000 units of 1,25(OH)2D3 is associated with increased
vitamin D content in breastmilk produced 2 months postpartum.6
o However, infants were not able to achieve their recommended Adequate Intake
of vitamin D (200 units/day) when fed this breastmilk alone.6
• A meta-analysis of 15 clinical trials found that:
o Daily supplementation of 1,25(OH)2D3 increased serum 25(OH)D levels more
effectively compared to weekly, monthly, or single megadoses.2


o Daily supplementation of 4,000 units of vitamin D for 6 months (after 12 weeks

gestation) effectively achieved serum 25(OH)D levels >20 ng/ml and was safe
during pregnancy.2
o Lower doses of 400-2,000 units/day were not as effective.2
• Further research is necessary to determine the upper tolerable limit for vitamin D
supplementation. Current research suggests that supplementation of 4,000-10,000
units/day may be safe during pregnancy.4
Vitamin D Needs During Lactation
Mothers planning on breastfeeding their children require vitamin D supplementation for the
following reasons:
• Human milk contains low levels of vitamin D. Breastmilk from vitamin D sufficient
mothers provides <100 units of total vitamin D activity, and less if mothers are
vitamin D insufficient.3,6
• Higher incidence of rickets have been observed among breastfed infants, regardless
of maternal vitamin D status.8
Vitamin D Supplementation During Lactation
Ongoing research suggests that vitamin D supplementation in lactating mothers is associated
with increased levels of vitamin D in breastmilk and in breastfed infants.
• Daily supplementation of 2,000-4,000 units/day of 1,25(OH)2D3 during lactation was
associated with increased vitamin D content in breastmilk. Greater increases were
observed with the higher dose 4,000 units/day.6
• Daily supplementation of 400-6,400 units/day of 1,25(OH)2D3 was associated with
increased serum 25(OH)D concentrations in infants after 7 months. However, the lower
supplementation of 400 units/day did not improve maternal serum 25(OH)D
concentrations.9
• Monthly supplementation of 50,000 units and 100,000 units of 1,25(OH)2D during
lactation significantly improved maternal 25(OH)D levels for 5 months postpartum.8


• Monthly supplementation of 100,000 units 1,25(OH)2D during lactation significantly

improved serum 25(OH)D levels in exclusively breastfed infants for up to 5 months
postpartum.8
Vitamin D Recommendations
Children up to 1 year of age 400 units/day
Pregnancy 600 units/day (first 12 weeks, DRI recommendation)
4,000 units/day (after 12 weeks gestation)
Lactation 4,000 units/day (improves vitamin D content of breastmilk)
6,400 units/day (improves infant serum vitamin D levels)
*Note: Additional infant supplementation may be necessary to
achieve 400 units/day, depending on individual differences in
maternal baseline vitamin D levels
Safety Upper Limit: 4,000-10,000 units/day has appeared safe
during pregnancy

References
1. Dawodu A, Davidson B, Woo JG, et al. Sun exposure and vitamin D supplementation in
relation to vitamin D status of breastfeeding mothers and infants in the global
exploration of human milk study. Nutrients. 2015;7(2):1081-1093.
doi:10.3390/nu7021081.
2. Palacios C, De-Regil LM, Lombardo LK, Peña-Rosas JP. Vitamin D supplementation during
pregnancy: Updated meta-analysis on maternal outcomes. 2016.
doi:10.1016/j.jsbmb.2016.02.008.
3. Ballard O, Morrow AL. Human Milk Composition: Nutrients and Bioactive Factors.
doi:10.1016/j.pcl.2012.10.002.
4. Mithal A, Kalra S. Vitamin D supplementation in pregnancy. Indian J Endocrinol Metab.
2014;18(5):593-596. doi:10.4103/2230-8210.139204.
5. Ross AC, Taylor CL, Yaktine AL, Valle HB Del. Dietary Reference Intakes for Calcium and
Vitamin D. National Academies Press (US); 2011. doi:10.17226/13050.
6. Wall CR, Stewart AW, Camargo CA, et al. Vitamin D activity of breast milk in women


randomly assigned to vitamin D 3 supplementation during pregnancy 1,2. 10AD.

doi:10.3945/ajcn.115.114603.
7. Principi N, Bianchini S, Baggi E, Esposito S. Implications of maternal vitamin D deficiency
for the fetus, the neonate and the young infant. Eur J Nutr. 2013;52(3):859-867.
doi:10.1007/s00394-012-0476-4.
8. Wheeler BJ, Taylor BJ, Herbison P, et al. High-Dose Monthly Maternal Cholecalciferol
Supplementation during Breastfeeding Affects Maternal and Infant Vitamin D Status at 5
Months Postpartum: A Randomized Controlled Trial. J Nutr. 2016;146(10):1999-2006.
doi:10.3945/jn.116.236679.
9. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-Dose Vitamin D 3
Supplementation in a Cohort of Breastfeeding Mothers and Their Infants: A 6-Month
Follow-Up Pilot Study. Breastfeed Med. 2006;1(2):59-70. doi:10.1089/bfm.2006.1.59.