Articles published on this blog are my opinion only, and may not necessarily reflect the views of any organisations with which I am associated. Please be aware that articles posted on this blog are not intended as a substitute for professional medical advice. If you have a medical problem relating to breastfeeding, please seek further advice from a Lactation Consultant (IBCLC) or trained Breastfeeding Counsellor.

Friday, 14 January 2011

As easy as ACD?

Getting the facts straight about vitamins for breastfed babies over 6 months old

Suggest that my breastmilk is in some way deficient, that it does not contain every nutrient my baby needs, I can feel my hackles rising. One such occasion was the moment I was ‘reliably informed’ that I should be giving vitamin supplements to my baby because ‘breastmilk hasn’t got enough “stuff” in after the first 6 months’.

“Stuff”? “Stuff”?! What “stuff” exactly…?

Well, it appears that the latest “stuff” in question is vitamins A, C and D. According to the Healthy Start website, “the UK Department of Health recommends a daily dose of vitamins A, C & D for breastfed infants from 6 months” (1) because “young children may not get enough vitamin A, C and D from their food” (2). Hmm...

Elsewhere though, the information is different: For the vast majority of healthy, full term breastfed babies, vitamin supplements are unnecessary (3). “There are certain cases where a vitamin supplement may be needed for a breastfed baby during the first year, but these cases are the exception, not the rule” (4).

So what’s all this fuss about vitamins A, C and D then?
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A

Vitamin A, according to Healthy Start, can be obtained from:


  • whole cows' milk
  • orange, red and dark green vegetables such as carrots, red peppers, tomatoes, sweet potato, pumpkin, apricots, mangoes, broccoli
  • oily fish (2)

Hang on a minute… isn’t there something pretty vital missing from this list?

“Breastmilk is a natural, excellent source of vitamin A” (4).

When a baby reaches 6 months of age, it is a myth that breastmilk changes and is no longer enough for a baby’s needs. What actually changes is the baby’s need for certain nutrients (5). Very gradually, a baby begins to need more from his diet than breastmilk (5), so “complementary foods are needed to provide enough vitamin A” (6). However, “breastmilk continues to be a major source of vitamin A to 24 months and beyond” (6). Breastmilk is also an important source of fat, which must be consumed to ensure good uptake of vitamin A by the body (6).

In fact, NOT breastfeeding increases the risk of:
  • vitamin A deficiency
  • infections that can reduce a baby’s vitamin A stores.
A large study in Bangladesh found “a 74% reduction in the risk of vitamin A deficiency among breast fed children” (7) aged between 6 months and 3 years compared to non-breastfed children. “Vitamin A deficiency is rare in breastfed babies even in areas of the world where vitamin A deficiency is widespread” (4).

So why does Healthy Start recommend a vitamin A supplement for breastfed babies from 6 months?

“In the UK, 1 in 2 children under 5 do not have enough vitamin A in their diet” (8). It’s worth noting here that the survey quoted by Healthy Start did not include any breastfed babies aged 0-18 months; in fact it did not look at any children under 1.5 years old.

That said, some breastfed babies are more at risk of vitamin A deficiency, such as those babies born to mothers who were deficient in vitamin A during pregnancy (6), but this is rare in higher income countries such as the UK.
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C

Vitamin C, according to Healthy Start, can be obtained from:
  •  “fruit and vegetables, especially blackcurrants, kiwi fruit, citrus fruits, tomatoes, peppers and strawberries. Potatoes, sweet potatoes and mangoes are also good sources” (2).

Again there’s something missing:

breastmilk contains high levels of vitamin C (3).

So why does Healthy Start recommend a vitamin C supplement for breastfed babies from 6 months?

“The role vitamin C plays in iron absorption is particularly important in children under 4 years old” states the Healthy Start website (1).

Aha! Do I spot the myth that breastmilk cannot provide a baby with enough iron after 6 months?

“Those who don't know very much about breastmilk will tell you how low it is in iron compared to breastmilk substitutes” (9). It is now generally accepted that giving breastfed babies iron supplements can cause more harm than good: “the baby’s delicately balanced use of iron may be jeopardised and digestive problems […] may result” (3).

Hmm, so iron supplements are out, then. Hey, vitamin C aids iron absorption, so how about promoting vitamin C as another line of defence against those pesky low levels of iron in breastmilk?

That might seem logical, but the way breastfeeding works is far, far cleverer than it first appears. Comparing iron levels in breastmilk with breastmilk substitutes isn’t helpful because looking at the amount of iron alone doesn’t explain what actually happens to the iron once it reaches the baby’s gut. Although the amount of iron in breastmilk is small, it is highly bioavailable, meaning it is well absorbed (3). Only around 4% of the iron in iron-fortified formula is absorbed (3), meaning that the amount of iron in formula has to be much higher to begin with (9), resulting in a lot of leftover iron that can cause problems in the baby’s gut. By comparison, around 50% of the iron in breastmilk is absorbed (9). But that’s not all: “high lactose and vitamin C levels in human milk aid in the absorption of iron” (3).
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D

Vitamin D is the one everybody’s talking about.

Quite rightly, Healthy Start states that:
“Summer sunshine, not food, is the main source of vitamin D in the UK” (1).

Although around 80-90% of our vitamin D comes from sunlight (10), some vitamin D is found in foods:
  • oily fish such as sardines, kippers, salmon, eel, pilchards and trout
  • meat
  • eggs
  • food fortified with vitamin D, such as margarine and some breakfast cereals (1) (please note that milk is not fortified with vitamin D in the UK)

Sorry if I’m disappointing anyone, but this time I’m not going to pick on Healthy Start for missing anything vital.


On the other hand, I’m not going to start harping on about how breastmilk is deficient in vitamin D either. Because those that do entirely miss the point:

Breastmilk is naturally low in vitamin D.

OK, let’s get this straight: breastmilk is a food. Human beings are not designed to get most of their vitamin D from food, but from sunlight exposure.

With this in mind, “Health professionals and lactation consultants are challenged to counsel all mothers on prevention of vitamin D deficiency without undermining the breast-feeding relationship.” (11)

It’s worth pointing out here that fruit and vegetables are poor sources of vitamin D. Yet would anyone give out advice to stop giving fruit and vegetables to children simply because they lack vitamin D? Why is this? Because depriving a child of all the other vitamins and nutrients in fruit and vegetables would have a potentially catastrophic effect upon that child’s health. It’s a no-brainer really.

Similarly, human breastmilk is naturally low in vitamin D. So why undermine a mother’s confidence in breastfeeding, or advise her to stop altogether? What would the impact be of depriving a child of a major source of highly bioavailable vitamins, minerals and nutrients? What would the impact be of depriving a baby of antibodies, anti-viral and anti-inflammatory components and other immune factors (see 12), particularly at a time when that baby’s gut is potentially being exposed to an increased number of pathogens through the introduction of solid foods? All of these components and more are found in breastmilk - a baby’s normal food. What are the risks of depriving a child of breastfeeding? Think about it!

The good news is that the small amount of vitamin D which is present in breastmilk comes in a highly bioavailable form which is very easily used by the baby (13). However, this amount alone is too small to prevent rickets (a disease caused by vitamin D deficiency) (3).  In fact, because of the way vitamin D works inside our bodies (you may be surprised to find out that it's actually not really a vitamin - it's a prohormone with a bit of an identity crisis), an increasing body of research is indicating that vitamin D deficiency may be linked to a vast range of other diseases (see 1, 10 & 14), not just rickets. This is why adequate sunlight exposure is important.

Adequate sunlight exposure, according to Healthy Start, could be achieved through spending about 15-30 minutes outside a few days each week in the summer (April-September) between 10am and 3pm with some skin exposed (1). However, other sources dispute whether this is really enough (10). 

Although “research has shown that breastfed infants can maintain sufficient vitamin D status solely through adequate sunlight exposure” (14), “international organisations like La Leche League International and UNICEF acknowledge that vitamin D supplementation is necessary when sunlight exposure is inadequate and that some infants have a higher risk of vitamin D deficiency than others” (15).

Risk factors for vitamin D deficiency in the UK include:


  • babies whose mothers are vitamin D deficient during pregnancy/lactation (1, 3, 11, 13, 15)
  • darker skin (1, 2, 3, 10, 11, 13, 15) Darker skin needs to be exposed to sunlight for much longer in order to make sufficient vitamin D.
  • staying indoors during daylight hours (10, 11, 13, 15)
  • living at more northerly latitudes (1, 11, 13, 15)
  • living in areas where sunlight is blocked by buildings/pollution (3, 15)
  • using sunscreen (3, 11, 13, 15)
  • covering most of the body when outside (1, 2, 3, 11, 13, 15)
  • frequent substantial cloud cover (10, 11)
  • lead exposure (15)

As you can see, there is no 'one size fits all' answer to whether breastfed babies (or indeed mothers) should choose vitamin D supplementation. Ask yourself:
Does your baby receive an adequate amount of sunlight exposure?
Do any of the above risk factors apply to you and your baby?

You may like to undertake some further research before you feel you can make an informed decision about whether or not to supplement your breastfed baby with vitamin D. The following information sources are a good place to start:

Bonyata, K (1998) Does my baby need vitamin D supplements? http://www.kellymom.com/nutrition/vitamins/vitamin-d.html

La Leche League International resources on Breastfeeding and Vitamins

Gillie, O (2004) Sunlight Robbery: Health benefits of sunlight are denied by current public health policy in the UK http://www.healthresearchforum.org.uk/reports/sunlightrobbery.pdf

(please remember that research and medical information change over time, and that some of these sources provide information primarily aimed at mothers and babies who do not live in the UK)


Should you decide to supplement your breastfed baby with vitamin D, here are some questions worth considering:


  • Do the benefits of vitamin D outweigh the fact that vitamins A and C in the Healthy Start drops are unnecessary for nearly all breastfed babies?
  • Are there any other ingredients in the vitamin A, C & D supplement that you want to know about before giving it to your baby?
  • Is there a vitamin D only supplement available for your baby?

As much as the comment that ‘breastmilk doesn’t have enough “stuff” in after the first 6 months’ made my inner rebel bristle, I realise that mothers and babies do need vitamin D, either through positive changes to diet and lifestyle to ensure sunlight exposure, or by supplementing with vitamin D.


Right, sardines on toast, anyone?


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References & Bibliography

(1)          Healthy Start: Vitamin Supplement Recommendations http://www.healthystart.nhs.uk/en/fe/vitamin_supplement_recommendations.html (accessed 11/12/10)

(2)          Healthy Start: Healthy Start Vitamins http://www.healthystart.nhs.uk/en/fe/healthystart_vitamins.html (accessed 11/12/10)

(3)          Mohrbacher, N & Stock, J (2003) The Breastfeeding Answer Book La Leche League International p604-7

(4)          Bonyata, K (1998) Does my baby need vitamins? http://www.kellymom.com/nutrition/vitamins/vitamins.html

(5)          Rapley, G & Murkett, T (2008) Baby-led Weaning (London: Vermillion), p54

(6)          Rehydration Project (2001) Facts for Feeding. Breastmilk: A Critical Source of Vitamin A for Infants and Young Children http://rehydrate.org/breastfeed/facts-breastmilk.htm

(7)          Mahalanabis D (1991) Breast feeding and vitamin A deficiency among children attending a diarrhoea center in Bangladesh: A case-control study. BMJ; 303:493-496. (found at http://www.bmj.com/content/303/6801/493.abstract)

(8)          Gregory JR Collins DL et al (1995) National Diet and Nutrition Survey: children aged 1½ to 4½ years London HMSO in Healthy Start: Vitamin Supplement Recommendations http://www.healthystart.nhs.uk/en/fe/vitamin_supplement_recommendations.html (accessed 11/12/10)

(9)          Thomas, C (2010) Ask The Armadillo - follow on con? http://www.analyticalarmadillo.co.uk/2010/08/breastfeeding-q-ask-armadillo.html

(10)       Gillie, O (2004) Sunlight Robbery: Health benefits of sunlight are denied by current public health policy in the UK http://www.healthresearchforum.org.uk/reports/sunlightrobbery.pdf

(11)       Hottya, M (2004) Sunlight and Vitamin D: Exposing the Benefits New Beginnings, Vol. 21 No. 4, July-August 2004, p. 124 http://www.llli.org/NB/NBJulAug04p124.html

(12)       Thomas, C (2010) Ask the Armadillo – what’s in breastmilk? http://www.analyticalarmadillo.co.uk/2010/10/ask-armadillo-whats-in-breastmilk-but.html

(13)       Bonyata, K (1998) Does my baby need vitamin D supplements? http://www.kellymom.com/nutrition/vitamins/vitamin-d.html

(14)       Will, H et al. (2009) Vitamin D Requirements During Infancy: Reading Between the Lines Leaven, Vol. 45 No. 1, 2009, pp. 2-6. http://www.llli.org/llleaderweb/LV/LVIss1-2009p2.html

(15)       Good Mojab, C (2002) Sunlight Deficiency and Breastfeeding BREASTFEEDING ABSTRACTS, November 2002, Volume 22, Number 1, pp. 3-4. http://www.llli.org/ba/Nov02.html

2 comments:

  1. Here is a link to a great study that found that supplementing moms with adequate amounts of vitamin D was as effective as a Vit D supplement in maintaining babies vitamin D levlels: http://www.liebertonline.com/doi/abs/10.1089/bfm.2006.1.59

    ‎"Infant levels achieved exclusively through maternal supplementation were equivalent to levels in infants who received oral vitamin D supplementation. Thus, a maternal intake of 6400 IU/day vitamin D elevated circulating 25(OH)D in both mother and nursing infant. "

    If mom takes adequate amounts of vit D, there will be no need to supplement breastfed infants. :-)

    ReplyDelete
  2. Great article & thanks also to Mellanie - I was just wondering about that, as I don't get out often enough!

    ReplyDelete

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