Ask Busca: Iron and Vitamin D suppplementation for infants?

Ali, a nursing student, asked:

[The teacher of my nutrition class said] that babies who are breast fed will likely need an iron and vitamin d supplement. This makes absolutely no sense to me, because breast is supposed to be best, so why would anything need to be supplemented. The teacher said because the baby stops living off of it mothers iron stores at four months, and so that is why, but do they not get enough from the breast milk. I would just think that if the mother was eating healthy that the baby would not need to be supplemented on anything.

Busca's (excessive) babble:

Thanks for your question, Ali. So sorry it has taken me nearly 6 months to finally give you a response! I'm not a doctor, nurse, dietician, or nutrition expert, but I do love to dig around and see what I can find to help my readers out. So here's what I dug up in regard to iron and vitamin D supplementation...

Iron Supplementation

I knew kellymom.com would probably have something to say about it. And, indeed, she does. In fact, she has so much great info over there, that I'm just going to direct you to her site where you will find just about everything you could possibly want to know on the subject of iron supplementation. Here's a brief excerpt:

Healthy, full-term infants who are breastfed exclusively for periods of 6-9 months have been shown to maintain normal hemoglobin values and normal iron stores. In one of these studies, done by Pisacane in 1995, the researchers concluded that babies who were exclusively breastfed for 7 months (and were not give iron supplements or iron-fortified cereals) had significantly higher hemoglobin levels at one year than breastfed babies who received solid foods earlier than seven months. The researchers found no cases of anemia within the first year in babies breastfed exclusively for seven months and concluded that breastfeeding exclusively for seven months reduces the risk of anemia.

The original recommendations for iron-fortified foods were based on a formula-fed baby's need for them and the fact that breastmilk contains less iron than formula (doctors didn't know then that the iron in breastmilk is absorbed much better). Also, a few babies do have lower iron stores and will need extra iron at some point. . . .

La Leche League recommends that babies be offered foods that are naturally rich in iron, rather than iron-fortified foods. . . .

Note: Additional iron intake by the mother will not increase iron levels in breastmilk, even if the mother is anemic. Iron supplements taken by mom may produce constipation in baby. Anemia in the nursing mother has been associated with poor milk supply, however.

Learning about baby-led weaning really changed the way I saw iron supplementation. My first two daughters had iron-fortified rice cereal before 6 months of age, but my son was exclusively breastfed without any supplementation for 6 months. Afterward, he simply ate whatever offered foods he managed to get into his mouth. But I never worried about his iron levels.

Vitamin D Supplementation

As for Vitamin D, there was a recent news article on the subject that caught my eye and prompted me to finally tackle your question. USA Today reported on a couple of studies published in the journal Pediatrics related to infants and vitamin D. Nicolas Stettler, a pediatrician interviewed in the article, acknowledges, "Because humans originated in equatorial areas with year-round sunshine, babies in the distant past wouldn't have needed to get vitamin D from breast milk," but, according to the second study from Pediatrics, 58% of infants today have deficient vitamin D blood levels. It also reported that "Getting lots of sunlight helped raise vitamin D levels in moms, but not in their newborns." (It was unclear to me whether they meant that the mother and baby were both exposed to sunlight or whether they meant that sunlight didn't improve the vitamin d levels of breast milk.)

I have to wonder when I hear that breast milk is "low in Vitamin D," whether that really just means that mothers themselves have been low in Vitamin D for decades leading researchers to conclude that breast milk is always low. I've read elsewhere that Vitamin D supplementation will increase the Vitamin D content of breastmilk, so I think that's worth exploring. Maybe breast milk isn't inherently low after all?

I am partial to Vitamin D expert, Michael F. Holick, who has been researching Vitamin D for more than three decades. The home page of his website has some great info on Vitamin D:

Vitamin D is not a vitamin but a hormone. It is unique in that it is made in the skin as a result of exposure to sunlight. Photosynthesis of vitamin D has been occurring on earth for more than 750 million years. Some of the earliest life forms that were exposed to sunlight for their energy requirement were also photosynthesizing vitamin D. Both children and adults have in the past depended on adequate sun exposure to satisfy their vitamin D requirement. It is well documented that at the turn of the last century upwards of 80% of children in the industrialized, polluted cities of northern Europe and northeastern United States suffered from the devastating consequences of vitamin D deficiency rickets. The skin has a large capacity to make vitamin D. Exposure of a person in a bathing suit to a minimal erythemal dose of sunlight, which is typically no more than 15-20 minutes on Cape Cod in June or July at noon time, is the equivalent to taking 20,000 IU of vitamin D orally. It is now well documented that in the absence of any sun exposure 1,000 IU of vitamin D3 a day is necessary to maintain healthy levels of 25-hydroxyvitamin D in the circulation. An analysis of the NHANES III data has demonstrated that neither children nor adults are receiving an adequate amount of vitamin D from their diet or from supplements.

Holick is a strong proponent of sensible sun exposure. And so am I. I feel fortunate that I live in the Valley of the Sun where my children and I can go outdoors at any time of year most days and receive more than enough Vitamin D in ten minutes to keep our levels adequate. Even so, during times of the year when the weather keeps us indoors more often, I have mixed safe amounts of liquid vitamin D into my kids' yogurt or juice to keep their immune systems functioning and prevent illness.

(Getting a few minutes of backyard Vitamin D at lunchtime in February)

The American Academy of Pediatrics is opposed to exposing infants to direct sunlight. Personally, I think their recommendation is counter-intuitive. Human beings have been living with the sun for thousands of years (and without chemical sunscreens). We even took my newborn son outside for a few minutes every day (at my midwives' recommendation) because of his slight jaundice. Even after his slight yellow tinge had disappeared, I still took him with me outside in the early April morning sunshine while I watered my vegetable garden. He absolutely loved it. As soon as the sun's warm rays would fall on his face, his facial muscles would relax and take on a look of total peace and serenity. He always turned to face the sun no matter where I put him. And my instincts told me it was good for him. My gut tells me newborns need a few minutes of sunlight every day, just like the rest of us.I love the sun. I really think that human beings need regular sunlight exposure to survive. I don't generally use much sunblock on myself or my children unless we are in the sun for an extended period of time. I remember asking our pediatrician about the safety of sunscreens for infants when my first daughter was about 6 months old. He encouraged us to use hats, clothing, and shade rather than chemical suscreens. At the time, I was slow to take his advice and continued to use sunscreen. As I learned more about Vitamin D and safe sun exposure, my sunscreen use has decreased dramatically. Now we rely on hats, clothing, and shade to prevent sunburn (as our pediatrician recommended all those years ago). We all try to wear shirt-style swimming suits to keep our backs and shoulders protected. When we do use sunscreen, I focus on the areas most likely to sunburn--the nose, cheeks, ears, tops of feet, etc.While I wouldn't advocate spending large stretches of time in direct sunlight, I do advocate spending a few minutes every day (sunscreen-free) with some of your skin exposed to the sun, even babies. In places where sunlight is minimal in winter months, I also advocate taking Vitamin D supplements. I'm convinced that widespread Vitamin D deficiency is largely responsible for the "cold and flu season" phenomenon.

So what am I trying to say with all this Vitamin D babble? Yes, babies need vitamin D. How they get it is a personal decision mothers should discuss with their pediatricians. Personally, I'll echo what the Vitamin D council has to say:

Infants and children under the age of one should obtain a total of 1,000 IU (25 mcg) per day from their formula, sun exposure, or supplements. As most breast milk contains little or no vitamin D, breast-fed babies should take 1,000 IU per day as a supplement unless they are exposed to sunlight. The only exception to this are lactating mothers who either get enough sun exposure or take enough vitamin D (usually 4,000–6,000 IU per day) to produce breast milk that is rich in vitamin D. Formula fed babies should take an extra 600 IU per day until they are weaned and then take 1,000 IU a day, as advised below.

Children over the age of 1 year should take 1,000 IU per every 25 pounds of body weight per day, depending on latitude of residence, skin pigmentation, and sun exposure. On the days they are outside in the summer sun, they do not need to take any; in the winter they will need to supplement accordingly.

I hope that helps!

Speaking of loving the sun, this is one of my new favorite songs. I was introduced to it over our Spring break trip to CA when I attended a prenatal yoga class taught by my book collaborator, Felice. Love it! It's definitely going on my next birthing c.d.

This is why I carry on

I've been feeling somewhat discouraged since my last post. Wondering whether I'm wasting my time making a big fuss about nothing with this blog and all the time and energy I put into birth advocacy. Does it really matter as much as I think/feel it does?

Then I got an email from a friend-of-a-friend that made my day yesterday. She had discovered, two weeks before her due date, that a certain medication she was taking would prevent her from having an epidural. So she was scrambling to prepare herself for an unexpected drug-free birth at the last minute. A couple of friends alerted me to her predicament, and I quickly whipped-up an email with attachments and links and tips.

Her baby came early, before she felt as prepared as she would have liked to be, but her birth went beautifully. She had a very fast (2.5 hour) labor and arrived at the hospital ready to push. She said the thing that got her through was remembering this post relating running to birth. She was a runner in high school so she could relate. And, while coping with labor, she imagined herself doing 200 meter sprints with a running friend by her side, cheering her on. In the end, she said:

We were really blessed and I cried. To be truthful, labor was a lot easier than I expected. I suppose I was waiting for a feeling of daggers and swords all through my lower region. Thankfully, it wasn't quite like that. . . . It's very likely I will have to do natural birth every time from here on out, but if it is similar to what I just experienced, it won't be so bad. It was beautiful!

I don't know whether the birth process matters as much as I think it does. Perhaps it matters little for most women. But once in a while I have the privilege of helping a woman discover the strength and beauty of giving birth. I can't help everyone or change everything. But I can help one. And then another one. And then another. And hearing them say, one by one...

"I feel so much more informed and empowered to deliver naturally and feel strongly that I can absolutely make it!"

"You have inspired me!"

"I know now that I can do so much more than I thought I could... that my body is capable of so much more."

"I have never felt so much love before. I knew that this was one of those life changing and life affirming moments that couldn't be experienced any other way."

"It was beautiful!"

Those are the moments when I know birth matters... even if just for a few women. And they are the reason I carry on.

Misunderstandings

I just finished a conversation with a friend who recently found out she's pregnant with her third baby. This baby will be born via planned c-section (her first was born by cesarean after she got stuck at 7 cm, her second a planned c-section). She also mentioned an insensitive comment one of her acquaintances had made about cesareans, and it got me thinking. We are all guilty of misunderstanding each other once in a while. Unfortunately those misunderstandings and hurt feelings abound in the birthing world. It reminded me of this post from a year ago where I angrily lamented the rising cesarean rate and unwittingly hurt a reader's feelings (and felt awful about it).

It got me thinking about how tricky it is to balance advocacy and compassion. An advocate is, by nature, a fighter. We aren't content to accept the status quo. We feel driven to change things. But we can't change things unless we raise awareness about the problems we see. And, it seems, we can't raise awareness about the problems we see without pricking a few hearts here and there. Or can we?

Is it possible to talk about unnecessary cesareans without hurting the feelings of those who have given birth by cesarean? Is it possible to talk about the beauties and bliss of normal birth without those cesarean moms feeling that we're telling them their experiences were "less than" or failures? Is it possible to balance advocacy and compassion in such a way that everyone feels heard and validated and no one takes offense?

What do you think?

Re-post: Defining Female Empowerment

The feminism chatter on CJane's blog has got my head spinning. Now I'm all befuddled and not really sure where I stand, but it brought my mind back to this post from last August, so here it is again in case you missed it...

The whole battle between the two camps is due to the faiure [sic] of women in the country to fight for real empowerment. They take up an 'easy' cause, child birth and child raising, to fight for with the enemy that does not exist, other women. Rather than fight men for equal pay (the ERA is STILL not ratified in this country!), equal opportunity, fight sexism, fight discrimination, they pick easy 'battles' with no true winners. My partner calls the breast-home birth-epidural-vaccination battles 'Hen Chatter'. No real substance or results. These arguments do nothing to better the lives and livelihoods of women or our daughters. Filled with hystrionics [sic] and personal anecdotes they are just busy work, like darning once was, for women. Keeps the little women busy and from tackling the real fights. Keep it up ladies and we will remain in the 1960's for another half century. Empowering women is not about how you have a baby!

-Ali (excerpt from her comment in response to "Pushing Back: Has the natural childbirth movement gone too far?" by Lisa Selin Davis)

I linked over to Lisa Selin Davis' essay from the Citizens for Midwifery blog. Initially I expected the article itself to get me riled up. But it turned out to be fairly balanced. Just a few painful jabs. Then I started reading the comments. Why do I let myself read the comments? The essay's title is quite fitting, in fact. Except Jennifer Block's title was making reference to the way women as a whole are "pushed" into less than ideal maternity care. This essay refers to the way women "push" each other. And, after reading the comment by "Ali" above, I certainly did feel as though I had been violently shoved to the ground.

My immediate reaction was... I have to write a blogpost! So I opened-up this window, poised to spill my reaction on the blank screen with gusto. But I stopped myself. I knew I needed to take a breather so I could express myself with a level head.

So I folded our (massive) piles of laundry while my husband and kids scrubbed the toilets and cleaned the bathrooms. Then we all put our piles of clothes away. And we put more loads of laundry in the washer. Now, with my sweet babe napping, and my husband getting lunch ready, I think I'm ready to say what's on my mind. I do my best thinking while completing seemingly brainless tasks, I think--showering, housework, etc. Multi-tasking is fun, no?

Here's what I've been thinking about today...

4.3 million births were registered in the United States in 2006 (source). And the vast majority of women worldwide will give birth at some point in their lifetimes. That translates to a mind-boggling number of births. So, in my view, what happens to women in childbirth is an issue that should matter to all women everywhere.

But, of course, we are all in different stages of life. The issues that matter to each of us are usually those most pertinent to our circumstances. I happen to be in my childbearing years. I have spent the past six+ years totally immersed in childbirth and childrearing. That is where my head is. So I am well-versed in the abuses toward women (and babies) occurring within that sphere. On the flip side, most of my female age-mates have spent the last six years in graduate school and the workforce, building their careers. They would be well-versed in the abuses toward women within their spheres.

Doesn't it make sense for all women to work within their own spheres of influence? What good would I do championing the cause of females in the corporate world if I have absolutely no idea what it's like to be in their shoes? What good does it do for any woman to say, in essence, "What matters to you is meaningless! My crusade is so much better than yours!" It reminds me of the similar sentiment that my work as a "stay-at-home" mother is menial or pointless, or that my career choice is somehow harming the progress of womankind. It is attitudes such as these that have led me to eschew the "feminist" label.

"Ali" accuses me and other birth advocates of fighting with "the enemy that does not exist, other women." But what has she just done? Is she not attacking me and women like me? I have always tried to make it clear that I do what I do to educate, inspire, and empower other women. Not ever to attack them. And, yes, I said empower.

Let's talk about empowerment. I can't tell you how many times I've heard women say, following the birth of their child, "That was the most empowering experience of my life!" I would love to see the day that childbirth is empowering for every woman, and never disempowering, as it is for too many. "Ali" may not be aware just yet, but women across the country are abused daily by their maternity care providers (many of them males). Can't we agree that needs to change?

Women can be empowered in a multitude of ways. Having a salary equivalent to a male executive is only one of them. Shouldn't "feminism" be about what matters to all women, not just about what matters to one small niche of them? Who is Ali to decide what ought to be empowering to other women? Aren't we all entitled to decide that for ourselves?

The fact of the matter is that the childbirth experience is a huge, often life-changing rite of passage for women. And what happens during that special experience matters deeply to many women, and rightly so. How does it harm the progress of womankind for us childbirth advocates to focus our efforts on maximizing the empowerment of that pivotal, life-changing experience? Can "Ali" and her partner really believe these issues are "hen chatter" or "histrionics"? Or that our efforts "do nothing to better the lives and livelihoods of women or our daughters." It is, in large part, because of my love for my daughters that I continue my crusade.

Furthermore, I happen to believe that darning is a valuable lost art--one I very much wish I had. Oh how many hole-filled socks I could have made wearable again!

So, "Ali" wants to get women away from their "needlework" and out fighting the "real fights" in the feminist agenda. I'm glad there are women like her fighting for equality in their realm of experience. But if you imagine all of womankind as a whole, perched on a tabletop, doesn't it make sense that we can't just raise one corner? Shouldn't we all "stand close together and lift where we stand" and improve every aspect of women's lives simultaneously, each exerting our efforts in the areas most suited to us? You work over there, I'll work over here, and together we'll all make a difference? Isn't that how it should be?

Thank you, ABC News

For raising awareness about the many problems with our maternity care system in this country and the rising maternal death rate.

Now let's change things.

Ripples

Last night I was talking with my husband as we finished-off the last of the apple pie we made on Sunday. He's grown accustomed to my nearly constant birth chatter (poor guy). I was talking about how crazy it was that the maternity care system in this country changed so fast.

My great-grandmother, Margaret, gave birth to my grandmother at home into the hands of a short little English immigrant midwife. My grandmother gave birth to all of her children in the hospital, flat on her back, drugged-up to the point of being virtually unconscious (probably twilight sleep), having her babies pulled out of her by the doctor (probably with forceps), and not remembering a bit of it. Which is why I'm sketchy on the details... she didn't know the details herself! She also had a very difficult time nursing her babies and her milk "dried up" after a short time--probably a result of the sugar water they were given in the hospital and afterward. (Magaret is seated in the photo above, with my father on her lap and my grandmother standing.)

I love my grandmother. She was a mother-figure to me when I was a traumatized and motherless toddler, and we've had a special mother-daughter bond ever since. She's one of the most important people in my life. I love, honor, and respect her greatly. But she's also the woman who told me over and over, when my first-born was a baby, that I was going to spoil her by holding her so much, that I should put her down more, and that I should just let her cry (as a tiny newborn baby) at night and eventually she'd give up and sleep. It was extremely difficult to sort through all the advice and figure out what to do. In the end, I felt strongly that I should go against her advice and follow my instincts. So I did.

I can't help but wonder whether my grandmother's views about mothering were somehow ripple effects of the way she gave birth. Did the disconnected birthing process lead to a more disconnected way of responding to her babies? Or was it simply the way her mother had taught her to care for infants?

This morning, I was reading an article by Pam Udy in Midwifery Today called "Emotional Impact of Cesareans." This part really struck me, in light of last night's conversation with my husband:

When a woman gives birth, she has to reach down inside herself and give more than she thought she had. The limits of her existence are stretched. There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife, a doula or her mom to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.

Do you think there's some truth to this? Does the way we give birth have ripple effects in our mothering styles? Would my grandmother have been a different type of mother if she had been conscious during her children's births? Or does it have more to do with how we were parented ourselves or our maternal instincts giving each unique child the style of parenting they need?

Please share your thoughts!