Katherine Barber and Mishawn Purnell-O'Neal
Issue 117, March/April 2003
As early as the spring of 2003, the American Academy of Pediatrics (AAP) may recommend that all breastfed babies receive a daily supplement of vitamin D, based on the belief that breastmilk is deficient in vitamin D and can lead to rickets in babies who are exclusively breastfed. Such a recommendation is paradoxical: While breastmilk is supposedly the best form of infant nutrition (as mothers, physicians, and even infant-formula companies agree), it is somehow lacking in sufficient amounts of vitamin D. This policy could have far-reaching, potentially harmful implications for the work of breastfeeding advocates across the country, particularly in the African American community.
Nutritional rickets is a disease characterized by weak bones, poor bone development, and bowed legs, and is caused by a deficiency in vitamin D. (It can also be caused by cystic fibrosis, metabolic disorders, and celiac disease.) The human body needs vitamin D for proper bone growth and calcium absorption. Our primary source of adequate amounts of vitamin D is sunlight, or Ultraviolet B (UVB) exposure. Vitamin D is also found in such foods as salmon and egg yolks. Nutritional rickets is rare in the US, though over the past few years there have been new cases around the country. It's so uncommon, in fact, that until recently there was no national monitoring system to track and study the disease; the Centers for Disease Control (CDC) is just beginning to monitor it. Signs of rickets in infants include slow growth, seizures, the inability to stand or walk, curved bones, large joints, and bowed legs. In the 1920s, researchers discovered that the root of the disease was vitamin D deficiency; since then, many foods, including cow's milk, have been fortified with extra vitamin D.
Vitamin D-deficiency rickets is a public health issue that warrants attention, but not at the expense of breastfeeding. Media attention has mainly focused on exclusive breastfeeding as a cause of rickets; however, an increase in rickets cases may result from the reduced amount of time that people spend in the sun and from women who do not have adequate stores of vitamin D during pregnancy.
It is true that breastmilk has low amounts of vitamin D, but those low amounts are just what breastfed babies need. In rare cases, vitamin D supplements may be appropriate for some breastfed babies, such as those not exposed to the sun because of their parents' religious beliefs and those who live in regions where there is little sunlight.
Experts say that darker skin makes children more susceptible to rickets. This is because darker tones tend to protect the skin from a certain amount of ultraviolet rays, causing an almost natural deficiency in vitamin D. Michal Young, MD, a noted neonatologist and prominent breastfeeding advocate in Washington, DC, told us, " 'Dark-skinned' is a relative term and given to far too many variations. Also, climate conditions, such as cities with a lot of air pollution, can make sunlight a challenge for persons who are not as deeply pigmented."
Are African American or darker-skinned babies as susceptible to rickets as those who live in areas where sunlight is diminished? "Most babies with light-medium skin tones just need a little outdoor time, while darker-skinned babies need more outdoor time. Let's get the kids outside more, instead of giving them vitamin D," says Katherine Dettwyler, PhD, Adjunct Professor of Anthropology and Nutrition at Texas A&M University.
A natural alternative to vitamin D supplementation is exposure to sunlight, but how much sunlight? To make enough vitamin D, a baby in a diaper needs a total of only 30 minutes of sunlight a week-less than five minutes a day. Fully clothed and without a hat, a baby would need two hours of sunlight a week, or about 20 minutes a day. Medium to darker skin tones need a little more time in the sun.
Becky Saenz, MD, IBCLC, Associate Professor of Family Medicine at the University of Mississippi Medical Center, believes the AAP may have concerns about recommending sunlight exposure because of the danger of skin cancer. She points out, "There is a vast difference between recommending that it's okay for baby to sit in the grocery buggy while mom puts the groceries into the car in the early morning or late afternoon, and recommending nude sunbathing at noon."
Maternal Diet: Another Possible Alternative?
Maternal vitamin D status is crucial to the vitamin D status of the breastfed infant. The amount of vitamin D stores a newborn baby has is directly related to its mother's vitamin D stores. Several studies have documented that the vitamin D status of the mother can be raised by increased exposure to UVB rays, supplements, and increased consumption of food with vitamin D. For instance, healthy individuals who eat two to three servings of salmon per week have met all their vitamin D needs. Salmon is also an excellent source of docoshexanoic (DHA), the long-chain polyunsaturated fatty acid essential to visual and brain development, which is found in human milk but is absent from most infant formula. The amount of DHA in breastmilk also varies with the maternal diet. And just as there are those looking to cash in by adding DHA to infant formula, there is the same danger with the issue of vitamin D supplementation. Fortification of infant formula with DHA has a potential value of $300 to $400 million for the science and technology industry.1 Just as the March of Dimes promotes the pre-conception use of folic acid as a way to reduce the risk of birth defects, public-awareness campaigns could promote the importance of women's vitamin D status in their childbearing years.
What's a Mother to Do?
Among experts in the pediatric and breastfeeding fields, there is a lack of consensus about the issue of vitamin D-deficiency rickets. Many breastfeeding advocates have a problem with a "one size fits all" approach to vitamin D supplementation. Some headlines have claimed that, with a growing number of African American women choosing to breastfeed, there has been an increase in the number of reported cases of vitamin D-deficient rickets. This misleading statement in effect questions the confidence of African American women and their ability to provide quality nutrition for their infants. It also perpetuates the myth that technology and science are needed to complement and improve breastmilk.
Another potential result of this type of recommendation is that women may choose not to initiate breastfeeding at all. Among African American women, breastfeeding rates are often 20 percent or more lower than those of whites and Hispanics. Breastfeeding promotion in this community has long been a challenge, and this recommendation may actually deter African American women from breastfeeding. Consequently, both mother and infant would miss all the benefits associated with the breastfeeding experience. Katherine Dettwyler says, "It makes it more of a hassle to breastfeed, and it makes it sound as though breastmilk is lacking while formula is perfect. Already, too many people think formula is a risk-free option to breastfeeding, when it clearly isn't. I'd like to see some side-by-side comparison of the risks of rickets from lack of vitamin D in breastmilk to the risks of everything else from [the] lack of pretty much everything in formula."
Breastmilk is the only form of nutrition designed to meet a baby's specific needs. Some babies have circumstances that warrant medications and/or supplements; but this should be on a case-by-case basis. If experts begin to say that breastmilk is best, but that all breastfed babies need a supplement, of any sort, a Pandora's box is opened. Formula companies will heartily feast on this information. Their marketing may include taglines like, "Formula X has everything your baby requires, so there's no need to worry about rickets." In fact, formula manufacturer Mead Johnson has already capitalized on the belief that breastmilk isn't quite enough. Advertising for its product Di-Vi-Sol (vitamin D drops) says, "With Breast-feeding and D-VI-SOL Baby's Nutrition is Complete. D-VI-SOL-A daily dose of peace of mind. You know that breast-feeding is the best form of feeding you can give your baby. However, even the superbly balanced nutrition of breast milk contains only about 10% of the recommended daily intake of Vitamin D for infants."
This ad tells the consumer and the general public that breastmilk alone is not good enough for babies. Formula manufacturers will gain in a number of ways from this kind of recommendation, and their marketing will begin to send subtle messages that their product is more complete than breastmilk. Sales resulting from a universal recommendation of vitamin D would also provide more residual income for the formula companies at the expense of exclusive breastfeeding. We need to be very cautious when professional organizations make broad policy statements that have huge health implications. Not all babies are at risk of developing rickets; too much vitamin D, in fact, can cause an excess amount of calcium in a baby's system, potentially leading to kidney or brain damage, lethargy, seizures, coma, pancreatitis, and cardiac arrhythmias. What happens if a baby is given an overdose of vitamin D drops? What if a mother chooses not to give the drops?
Who will pay for the drops? What if a mother can't afford to buy them? Medical doctors will also be affected by this recommendation. Some will prescribe the drops across the board rather than on an individual basis. For those doctors who don't promote breastfeeding to their patients, this may reinforce the doctors' lack of confidence in breastfeeding as the most viable option.
Many unanswered questions regarding the supplementation issue remain. What are the short- and long-term health consequences of providing vitamin D to infants who are not vitamin D-deficient? What are the psychological and physiological impacts on breastfeeding? Have the risks been weighed against the benefits? Clearly, there is a need for additional research on breastmilk, vitamin D, rickets, and the disease's causes and means of prevention.
1. Doris De Guzman, "DHA Poised to Enter the Food and Beverage Market," Chemical Reporter (April 2002).
Katherine Barber, CLEC, is the Founder and Executive Director of the African American Breastfeeding Alliance (AABA), a national organization whose mission is to educate African American women and families about the importance of breastfeeding and to provide support to African American women who choose to breastfeed. Katherine is married and the mother of a three-year-old daughter and a five-year-old son.
Mishawn Purnell-O'Neal, MPH, is an independent health consultant and President of the Chicago Chapter of the African American Breastfeeding Alliance. She is the author of Breastfeeding Facts Over Fiction: Health Implications on the African American Community, which she self-published in 2001. Mishawn and her husband are the parents of four-month-old and three-year-old sons.