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.