3. Because the vitamin D content in hu- supplement, their breastfed infants. TABLE 1 Statements Regarding Vitamin D
Supplementation and Rickets on the
man milk may be relatively low, breast- We were particularly interested in the Practitioner Vitamin D Survey and
fed infants are at risk for rickets un- role that their child’s pediatrician had Parental Survey of Infant Feeding
less they are exposed to adequate in influencing this choice. Before the Practitioner vitamin D survey
amounts of sunshine to produce en- project, we postulated that approxi- In order to practice high quality medicine it is
important to follow AAP practice guidelines.
dogenous vitamin D or receive it from mately one third of infants who were A major limitation of the AAP recommendation
other sources.1–4 For more than a de- breastfed for at least 6 months would that all breastfed infants receive
cade, supplemental vitamin D has been receive supplemental vitamin D and supplemental vitamin D is that the
recommendation is not evidence-based.
recommended for certain infants who that a parent’s decision regarding sup- Routinely recommending vitamin D for
are breastfed to prevent rickets.5 In plementation would be highly influ- breastfed babies may result in some
2003, the American Academy of Pediat- enced by the recommendation of their mothers electing to formula feed instead.
Some of my breastfed patients will likely
rics (AAP) recommended that all child’s pediatrician.
develop rickets if they don’t receive
breastfed infants receive at least 200 supplemental vitamin D.
IU/day of supplemental vitamin D; METHODS Parental survey of infant feeding
I think that giving vitamins to babies and young
in 2008, the recommendation was A prospective observational study was children is important for their overall
changed to at least 400 IU/day.2,6 conducted by the Puget Sound Pediat- health.
Estimates of physician adherence to ric Research Network (PSPRN), a re- Vitamins may be needed to prevent rickets or
other bone diseases in some babies.
the AAP recommendations regarding gional practice-based network of pri- It is inconvenient to give vitamins to young
vitamin D supplementation vary. A mary care pediatric practices in the babies.
1999 survey of North Carolina pediatri- Seattle, Washington, area. For this When my baby was less than 6 months old,
he/she didn’t need any extra vitamins
cians found that 44.6% recommended project, 44 PSPRN practitioners from 7 because the breast milk or formula that
the supplement for all breastfed in- private practice offices and 1 inner- he/she took had everything my baby needed.
fants, and 38.6% recommended it for city pediatric clinic participated. The If babies are out in the sunlight and fresh air
they don’t need extra vitamins.
some infants.7 These results are simi- study consisted of 2 surveys, including
My child’s doctor recommended that I give my
lar to a study of Las Vegas, Nevada, a practitioner vitamin D survey and an baby vitamins.
pediatricians in which 48% recom- infant-feeding survey completed by
mended vitamin D for breastfed in- parents. Survey data were collected
fants.8 Recently, it was reported that between July 2006 and June 2008. responses to statements by pedia-
89% of responding pediatricians in the Before collecting data on infants, the tricians who indicated that they rec-
US military recommended supplemen- practitioner vitamin D survey was dis- ommended vitamin D for all breastfed
tation for all, or some, infants fed hu- tributed to 44 PSPRN pediatricians. The infants were compared with the re-
man milk.9 More important, however, pediatricians were asked about their sponses of those who had some other
there have been few data on whether current recommendation regarding vi- practice regarding supplementation.
these recommendations influence pa- tamin D supplementation for breastfed Likert-scale responses were trans-
rental behavior and how many breast- infants. Possible responses included formed to an ordinal scale for the anal-
fed infants actually receive supple- recommend vitamin D for all breastfed ysis. Regression analysis was used to
mental vitamin D. In a study on the patients; recommend for “high-risk” chil- assess differences; generalized esti-
prevalence of hypovitaminosis D in dren; discuss pros and cons of supple- mating equation techniques were used
young children in the Boston, Massa- mentation with parents; and do not rou- to account for the clustering of pedia-
chusetts, area, Gordon et al10 reported tinely discuss vitamin D with parents. tricians in different practices.11
that only 2% of breastfed infants re- Pediatricians were asked to indicate The infant-feeding survey was distrib-
ceived supplemental vitamin D. their level of agreement with 4 state- uted to parents of children 6 to 24
We conducted a study to determine the ments regarding supplemental vitamin months old at the time of an office visit
rate of supplemental vitamin D usage D by using a 6-point Likert scale, with to a PSPRN practice. This survey was
among a group of infants from the Se- possible responses to each statement anonymous; no identifying health in-
attle, Washington, area who were pre- ranging from “completely agree” to formation was collected. Surveys were
dominantly breastfed for at least the “completely disagree.” The statements available in both English and Spanish
first 6 months of life. We were inter- on vitamin D usage are shown in Table 1. and were distributed by a research as-
ested in identifying the reasons par- For the analysis of data in the prac- sistant who visited practices on a reg-
ents choose to supplement, or to not titioner vitamin D surveys, the ularly scheduled basis. Surveys were
106 TAYLOR et al
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4. ARTICLES
also distributed to parents by office mula daily during the first 6 months of garding supplementation and use of
staff in participating practices during life and “never” or “almost never” re- vitamin D in study patients was as-
multiple data-collection periods that ceived 16 oz of formula in 1 day. Be- sessed. Parental agreement with
ranged from 1 to 3 months. cause commercial formula contains statements regarding vitamin D use
For the infant-feeding survey, parents 400 IU/L,12 the infants who were de- was dichotomized; responses of “com-
of age-eligible children provided the fined as being predominantly breast- pletely agree” or “agree” were com-
current age of their child and were fed received 100 IU of vitamin D from pared with all other responses for
asked the initial type of feeding for him formula on a routine basis and never each item. Similarly, the response to
or her (breast milk or infant formula). or almost never received 200 IU daily. the item in the infant-feeding survey in
On the basis of the recommendation which parents were asked how im-
Parents of those infants who were ini-
for 200 IU of supplemental vitamin D portant their child’s pediatrician’s
tially breastfed were asked how long
daily that was in place when the study recommendation was regarding sup-
their child received human milk, how
data were collected,2 none of these plemental vitamin D was dichotomized
much formula their child received on a
predominantly breastfed, unsupple- by comparing responses of “very im-
routine basis, and how often the child
portant” or “important” to other
received 16 oz of formula in a single mented study children received 50%
responses.
day (possible responses included of the recommended vitamin D dose
“never or almost never,” “a few days from infant formula on a daily basis Each individual characteristic or belief
each week,” “almost every day,” or and virtually never received all of the was compared with the use of vitamin
“every day,”). Parents were asked recommended dose from this source. D in predominantly breastfed study pa-
whether their child routinely received The rate of supplemental vitamin D use tients. Those characteristics and be-
in the children who were predomi- liefs statistically associated with vita-
a multivitamin (all containing vitamin
min D use in univariate analyses,
D) during the first 6 months of life. The nantly breastfed for at least 6 months
defined as an odds ratio (OR) with a
parent was also asked to provide the was calculated. The rate of breast-
95% CI that did not include 1.0, were
name of his or her child’s pediatrician feeding, prolonged breastfeeding,
included in a multivariate model to
during the child’s first 6 months of life and vitamin D use was also com-
identify factors independently associ-
and to indicate how important this puted for children from different ra-
ated with vitamin D use in breastfed
physician’s recommendation was re- cial and ethnic groups; 95% confi-
children.
garding the decision of whether to give dence intervals (CIs) around point
his or her infant vitamins; responses estimates were calculated. Finally, during the study period, there
were categorized with a 5-point Likert was increasing publicity regarding vi-
Characteristics and parental beliefs tamin D deficiency in children and
scale that ranged from “very impor- associated with supplemental vitamin adults.13,14 To protect the anonymity of
tant” to “very unimportant.” Parents D use in children who were predomi- study children and their parents, we
were also asked to provide the race nantly breastfed for at least 6 months did not collect data on the date that
and ethnicity of their child. were assessed with the use of logistic infant surveys were completed (these
Six statements regarding vitamin D regression. Generalized estimating dates corresponded to dates of physi-
supplementation were listed on the equation techniques were used in cian visits, which is considered to be
survey. As with the practitioner survey, these analyses to account for the clus- identifiable health information).15 How-
parents indicated their level of agree- tering of patients in different prac- ever, information on the surveys was
ment with each statement by using a tices.11 Characteristics assessed in- entered into databases as they were
6-point Likert scale. The statements on cluded race, ethnicity, and age. Data on collected. To assess the effects of sec-
the infant-feeding survey are listed in the infant-feeding surveys regarding ular trends in vitamin D use during the
Fig 1. the child’s pediatrician during the first study period (2006 –2008), we catego-
Much of the analysis of data in the 6 months of life were linked to re- rized study patients into tertiles on the
infant-feeding surveys was focused on sponses on the practitioner vitamin D basis of the chronological order of
those children who were predomi- surveys. On the basis of this linkage, when their data were entered into the
nantly breastfed for at least the first 6 the association between having a pedi- study databases.
months of life. Children were consid- atrician who recommended vitamin D The study was approved by the Seattle
ered to be predominantly breastfed if for all breastfed infants versus having Children’s Hospital’s institutional re-
they routinely received 8 oz of for- a provider who had another policy re- view board.
PEDIATRICS Volume 125, Number 1, January 2010 107
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5. RESULTS 2433 completed surveys
-69 surveys on children <6 mo or >25 mo old
A total of 44 PSPRN pediatricians com-
2364 surveys on eligible children (97.2%)
pleted the practitioner vitamin D sur-
vey. At the time that the survey was
completed, 16 pediatricians (36.4%) in-
dicated that they routinely recom- 1945 initially breastfed (82.6%) 411 formula fed (17.4%) 8 missing
mended supplemental vitamin D for all
of their breastfed patients. Fourteen
respondents (31.8%) recommended 1456 infants breastfed for ≥6 mo (75%)
supplemental vitamin D for breastfed 4 missing
infants who were at high risk for de-
veloping rickets. Six pediatricians
- 287 infants who took ≥8 oz/d formula on
(13.6%) responded that they discussed routine basis and/or 16 oz formula a few
the pros and cons of supplementation d/wk or more (20.1%)
-29 with missing data
with parents of breastfed infants, and
8 (18.2%) indicated that they did not
routinely discuss vitamin D supple-
1140 infants predominately
mentation with parents. breastfed for ≥6 mo
(58.6% of those initially breastfed)
Physicians who did not recommend vi-
tamin D for all breastfed infants had FIGURE 1
Survey completion and breastfeeding practices in study children.
significantly higher levels of agree-
ment with the statement, “A major lim-
itation of the AAP recommendation TABLE 2 Rate of Initial Breastfeeding Among Study Infants of Different Racial and/or Ethnic Groups
and Rates of Being Predominately Breastfed for at Least 6 Months
that all breastfed infants receive sup-
Race/Ethnicity No.a % Initially % Predominantly
plemental vitamin D is that the recom-
Breastfed Breastfed for 6 mo
mendation is not evidence based,”
Black 120 62.5 24.2
than pediatricians who recommended American Indian/Alaskan Native 42 88.1 52.4
vitamin D for all breastfed infants (39 Asian/Pacific Islander 427 81.5 44.8
total responses; P .011). Those prac- White 1695 85.1 52.4
Hispanic ethnicityb 232 73.7 41.0
titioners who were not universally rec- a Data on children whose parents indicated that they were of multiple races are included in more than 1 race category.
ommending vitamin D also had higher b Includes children from all racial groups.
levels of agreement than those who
universally recommended supplemen-
tation for breastfed children with the breastfeeding practices of their chil- As shown in Fig 1, surveys were com-
statement indicating that recommend- dren are summarized in Fig 1. Among pleted by parents of 1140 children who
ing supplementation might lead some the 2364 eligible children whose par- were predominantly breastfed for at
mothers to choose to not breastfeed ents completed surveys, 1945 (82.6% least the first 6 months of life. The rest
their infants (P .042). There were no [95% CI: 81.0%– 84.1%]) were mainly of the analysis was focused on these
significant differences in levels of fed with human milk during their first 1140 study infants and toddlers. Over-
agreement for the statement regard- month of life. The race and ethnicity of all, 181 of 1139 of these children
ing the importance of following AAP eligible children are shown in Table 2 (15.9% [95% CI: 13.8%–18.1%]) were
guidelines and the statement regard- along with the rates of initial breast- routinely given supplemental vitamin D
ing the possibility of rickets in breast- feeding and the proportion who were during the first 6 months of life. Infor-
fed children who were not supple- predominantly fed human milk for at mation on vitamin D use for 1 child was
mented between those pediatricians least 6 months. The mean age of the missing. Use of supplemental vitamin
who routinely recommended vitamin D infants and toddlers at the time their D in predominantly breastfed infants
and those who had another policy re- parents completed the survey was 12.1 varied according to race, with val-
garding supplementation. months (SD: 4.8 months); 25% were ues ranging from 14.2% (95% CI:
Data on completion of the infant- aged 8 months or younger, and 25% 11.9%–16.6%) among white children to
feeding survey by parents and on were aged 16 months or older. 27.1% (95% CI: 20.9%–34.0%) among
108 TAYLOR et al
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6. ARTICLES
TABLE 3 Univariate Association Between Vitamin D Use and Patient Characteristics, Parental tamin D supplementation and that vita-
Beliefs, and Policy of the Child’s Pediatrician Among Study Children Who Were
Predominantly Breastfed for at Least the First 6 Months of Life mins are important for a child’s over-
Variable ORa 95% CI No.b all health were the only variables that
White 0.63 0.44–0.90 1089 were positively and significantly asso-
Nonwhite race and/or Hispanic ethnicityc 1.67 1.22–2.27 1089 ciated with the use of vitamin D. Con-
Black 1.12 0.49–2.62 1089 versely, parental agreement that sup-
Asian/Pacific Islander 2.02 1.43–2.87 1089
Hispanic ethnicity 0.93 0.56–1.54 1084 plementation is unnecessary because
Child’s age 1.00 0.97–1.03 1139 breast milk has all needed nutrition
Parent agrees: vitamins important for overall health 5.22 3.45–7.90 1101 and that giving vitamins is inconve-
Parent agrees: vitamins needed to prevent rickets/other diseases 2.77 1.93–3.98 1020
Practitioner survey: child’s doctor recommends vitamin D for all 3.88 2.23–6.73 926 nient were both significantly associ-
breastfed infants ated with not using vitamin D. Addi-
Parent agrees: child’s doctor recommended vitamin D 19.52 10.61–35.93 1083 tional models that included all racial
Parent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.07 0.04–0.13 1109
Parent agrees: giving vitamins inconvenient 0.59 0.42–0.84 1087
variable terms and/or data on the
Parent agrees: vitamins not needed if infant is out in sunlight 0.29 0.17–0.49 1074 child’s pediatrician’s recommendation
Child’s doctor’s recommendation regarding vitamin D important in 2.88 1.65–5.03 1037 regarding supplementation were ana-
parent’s decision about vitamin D supplementation
a
lyzed. The results of every analysis
OR was calculated by using logistic regression after accounting for clustering of children into different practices.
b No. indicates number of valid responses to each item. were similar. Parental agreement that
c Of the study children, 335 of 1090 (30.7%) were nonwhite race and/or Hispanic ethnicity; information on vitamin D
vitamin D was recommended by the
supplementation was collected for 1089 of these children.
child’s physician (adjusted ORs rang-
ing from 7.76 to 8.93 in different analy-
Asian/Pacific Islander children. A total tritional rickets are nonwhite and/or ses) and agreement that vitamins are
of 29 black patients were predomi- Hispanic,16 only 1 race variable (non- good for overall infant health (ad-
nantly breastfed for at least 6 months; white race and/or Hispanic ethnicity, justed ORs: 1.98 –2.23) were signifi-
6 of these children (20.7%) received or non-Hispanic white race) was in- cantly associated with providing sup-
supplemental vitamin D. The rate of vi- cluded in the model. In addition, be- plementation; agreement that breast
tamin D usage among Hispanic chil- cause 213 predominantly breastfed milk had all needed nutrition (adjusted
dren who were breastfed for at least 6 study children had an initial primary ORs: 0.10 – 0.12) and agreement that
months without significant formula care provider who was not a member giving vitamins is inconvenient (ad-
supplementation was 15.8% (95% CI: of PSPRN and did not complete the justed ORs: 0.45– 0 .46) were statisti-
9.1%–24.7%). practitioner survey, data on the child’s cally associated with not giving vita-
The univariate association between vi- pediatrician’s vitamin D recommenda- min D.
tamin D use in predominantly breast- tion policy were not included in the When asked to identify their child’s
fed children and several variables, in- larger model. The results of the multi- main doctor during the first 6 months
cluding race, ethnicity, age, parental variate analysis are shown in Table 4. of life, parents of 927 patients listed a
beliefs, and the policy of the child’s pe- Of the variables assessed in the full PSPRN pediatrician who had com-
diatrician regarding supplementation, model, parental agreement that the pleted the practitioner vitamin D sur-
are summarized in Table 3. In the child’s pediatrician recommended vi- vey (81.3% of those infants who were
unadjusted analyses, most of the vari-
ables assessed were statistically asso-
ciated with supplementation. To iden- TABLE 4 Multivariate Analysis to Identify Patient Characteristics, Parent Beliefs, and Provider
tify characteristics and beliefs that Policies Associated With Vitamin D Supplementation in Predominantly Breastfed Infants
were independently associated with vi- Variable ORa 95% CI
tamin D use in breastfed infants, an Nonwhite race and/or Hispanic ethnicity 1.29 0.81–2.06
analysis including those variables sig- Parent agrees: vitamins important for overall health 1.98 1.17–3.34
Parent agrees: vitamins needed to prevent rickets/other diseases 1.37 0.81–2.31
nificantly associated with supplemen- Parent agrees: child’s doctor recommended vitamin D 7.76 4.11–14.64
tation in univariate comparisons was Parent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.12 0.07–0.23
conducted. Because of both the over- Parent agrees: giving vitamins inconvenient 0.45 0.26–0.76
Parent agrees: vitamins not needed if infant is out in sunlight 0.94 0.42–2.10
lap between several racial and ethnic Child’s doctor’s recommendation regarding vitamin D important in 1.83 0.77–4.39
groups and evidence that 90% of decision about vitamin D supplementation
children in the United States with nu- a OR calculated using logistic regression after accounting for clustering of children into different practices.
PEDIATRICS Volume 125, Number 1, January 2010 109
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7. predominantly breastfed). Among this secular trend, there were no sig- tific and lay press, has likely increased
these 927 study children, 218 (23.5%) nificant changes in the results; 4 vari- interest in providing vitamin D to
were seen by a health care provider ables (agreeing that the child’s doc- breastfed infants. In our study, we
who indicated that he or she routinely tor recommended supplementation, found that vitamin D use increased sig-
recommended supplemental vitamin D agreeing that vitamins are important nificantly during the final third of our
for all breastfed infants. Parents of for overall infant health, agreeing that study period (roughly covering the pe-
children whose provider universally breast milk has all needed nutrition, riod of late 2007 to mid-2008) when
recommended vitamin D for breastfed and agreeing that giving vitamins is in- there was publicity about vitamin D.13,14
infants were significantly more likely convenient) remained significantly as- However, even during this most recent
to agree that the provider recom- sociated with vitamin D use. period, fewer than one quarter of the
mended this supplement than those of responding parents of predominantly
children whose pediatrician had an- DISCUSSION breastfed infants reported giving vita-
other policy (64.7% and 22.7%, respec- Our results indicate that only a minor- min D to their children. The same fac-
tively; OR: 3.10 [95% CI: 1.95– 4.91]). ity of study children who were predom- tors (their child’s doctor’s recommen-
Parents of nonwhite and/or Hispanic inantly breastfed for 6 months re- dation and a belief that breast milk has
children were also more likely to agree ceived supplemental vitamin D. This all needed nutrition) remained signifi-
that their child’s provider recom- rate of usage is explained, to a large cantly associated with a parent’s deci-
mended vitamin D than those of white degree, by 2 conflicting influences. sion regarding supplementation.
non-Hispanic children (44.6% and Parents who reported that their child’s
27.8%, respectively; OR: 1.75 [95% CI: As expected, we found a high rate of
pediatrician recommended vitamin D
1.37–2.27]). Overall, 33.3% of respond- breastfeeding in this population of in-
were 8 times more likely to provide
ing parents indicated that their child’s fants seen in primary care pediatric
the supplementation than parents
provider recommended vitamin D practices in the Seattle area. In 2002, it
whose child’s pediatrician did not
supplementation. Among these par- was estimated that 71% of US children
make this recommendation. However,
ents, 44.6% gave the supplement to had ever been breastfed and that
only one third of the parents of breast-
their child versus 2.8% of those 63.2% were breastfed at 1 month of
fed infants indicated that the pediatri-
whose child’s provider did not rec- age. The Pacific region of the country
cian recommended vitamin D. In addi-
ommend vitamin D (OR: 19.52 [95% CI had the highest reported rates of
tion, and perhaps the most striking
10.61–35.93]). breastfeeding, with 76.4% of infants
finding of this study, fewer than half
from this region reportedly being
Among the responding parents of chil- (44.6%) of the parents who responded
dren who were predominantly breast- that vitamin D was recommended by breastfed at 1 month of age.18 We found
fed for at least 6 months, 743 of 1110 their child’s pediatrician actually ad- that 82.6% of the children in our study
(67.0%) agreed with the statement ministered the supplementation. This were mainly breastfed during the first
that vitamin D supplementation is not counterintuitive result is partially ex- month of life. We also found that
required because breast milk has all plained by our finding that 67% of the breastfeeding among black infants
needed nutrition. Only 3.0% of children parents believed that supplementation was more common in our population
of these parents received supplemen- is unnecessary because breast milk than nationally. However, breastfeed-
tal vitamin D. has all needed nutrition. Parents who ing rates in Hispanic infants in our
had this belief were 9 times less study were comparable to US rates for
There was an increase in the use of
likely to give supplemental vitamin D Hispanic infants.18 Perhaps more sur-
vitamin D in predominantly breastfed
than those who did not agree with this prising was the finding that 1140 of the
infants during the 2-year study period.
During the first third of the period, statement. 2364 infants in the study (48.2%) were
10.8% of these children received sup- Initially, vitamin D supplementation breastfed with little or no formula sup-
plemental vitamin D; 12.7% received was recommended for breastfed in- plementation for at least 6 months.
the supplement during the middle fants as a method to prevent rickets.2 This is substantially higher than the
third and 24.0% during the last third of However, there is emerging evidence 35.1% of infants nationally who are
the study period (OR: 1.60 [95% CI: that vitamin D may play an important breastfed for at least 6 months.18
1.10 –2.32] for comparison between role in mitigating other disease pro- It is possible that the high rate of
the final and first third of the study pe- cesses in children.1,17 Information breastfeeding in study children was
riod). However, after controlling for about this evidence, both in the scien- linked to the reticence of the respond-
110 TAYLOR et al
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8. ARTICLES
ing pediatricians to recommend vita- man and Svec reported among 128 fants among participating pediatri-
min D in at least 2 ways. Pediatricians military pediatricians.9 cians. Our results suggest that vitamin
who did not universally recommend A potential limitation of this study is D use is strongly linked to physician
supplementation had a belief that rec- that parents of children up to 2 years recommendations. Efforts to increase
ommending vitamin D might cause old were asked to report whether vita- physician acceptance of vitamin D rec-
some parents to not breastfeed their mins were given during the first 6 ommendations should lead to more
infant. Perhaps these practitioners months of life and the reasons for this use in infants and increase compli-
were wary of any intervention that choice. It is possible that some parents ance with AAP guidelines.6 However,
would alter the high prevalence of did not recollect correctly. To some ex- the results of our study also suggest
breastfeeding. Conversely, pediatri- tent, our finding that significantly that there is a strong belief by parents
cians may have been hesitant to bring more parents of study children whose that breast milk has all needed nu-
up supplementation to parents who pediatricians universally recommend trition. To a large degree, this belief
have strong beliefs about the nutri- vitamin D indicated that the practitio- supersedes physician recommenda-
tional advantages of human milk. We ner recommended supplementation tion. Thus, to substantially increase vi-
found that 68.2% of responding pedi- than those whose child’s pediatrician tamin D use in predominantly breast-
atricians recommended vitamin D did not tend to validate the accuracy of fed infants, public health educational
supplementation for some or all parental reporting on the surveys. campaigns should also directly target
breastfed infants. Although this is parents.
higher than rates found in surveys of CONCLUSIONS
providers conducted before the AAP At the time that we began this study in ACKNOWLEDGMENT
recommendation in 2003,7,8 it is 2006, there was significant resistance This study was funded by a grant from
lower than the 89% rate of recom- to the AAP recommendation for sup- the Agency for Healthcare Research
mending supplementation that Sher- plemental vitamin D for breastfed in- and Quality.
REFERENCES
1. Misra M, Pacaud D, Petryk A, Collett-Solberg dren, and adolescents. Pediatrics. 2008; 2007. Available at: www.cbsnews.com/stories/
PF, Kappy M; Drug and Therapeutics Com- 122(5):1142–1152 2007/07/09/health/webmd/main3032600.shtml.
mittee of the Lawson Wilkins Pediatric En- 7. Davenport ML, Uckun A, Calikoglu AS. Pedia- Accessed April 24, 2009
docrine Society. Vitamin D deficiency in chil- trician patterns of prescribing vitamin sup- 14. Collins AT. Kids’ low vitamin D worries doctors.
dren and its management: review of plementation for infants: do they contribute June 18, 2008. Available at: http://abcnews.go.
current knowledge and recommendations. to rickets? Pediatrics. 2004;113(1 pt 1): com/Health/Diet/Story?id 4982913&page 1.
Pediatrics. 2008;122(2):398 – 417 179 –180 Accessed April 24, 2009
2. Gartner LM, Greer FR; American Academy of 8. Shaikh U, Alpert PT. Practices of vitamin D 15. Gunn PP, Fremont AM, Bottrell M, Shugar-
Pediatrics, Section on Breastfeeding and recommendation in Las Vegas, Nevada. J man LR, Galegher J, Bikson T. The Health
Committee on Nutrition. Prevention of rick- Hum Lact. 2004;20(1):56 – 61 Insurance Portability and Accountability Act
ets and vitamin D deficiency: new guidelines privacy rule: a practical guide for research-
for vitamin D intake. Pediatrics. 2003; 9. Sherman EM, Svec RV. Barriers to vitamin D
ers. Med Care. 2004;42(4):321–327
111(4):908 –910 supplementation among military physi-
cians. Mil Med. 2009;174(3):302–307 16. Weisberg P, Scanlon KS, Li R, Cogswell ME.
3. Reeve LE, Chesney RW, DeLuca HF. Vitamin D Nutritional rickets among children in the
of human milk: identification of biologically 10. Gordon CM, Feldman HA, Sinclair L, et al.
United States: review of cases reported be-
active forms. Am J Clin Nutr. 1982;36(1): Prevalence of vitamin D deficiency among
tween 1986 and 2003. Am J Clin Nutr. 2004;
122–126 healthy infants and toddlers. Arch Pediatr
80(6 suppl):1697S–1705S
Adolesc Med. 2008;162(6):505–512
4. Hollis BW, Roos BA, Draper HH, Lambert PW. 17. Liu PT, Stenger S, Li H, et al. Toll-like recep-
Vitamin D and its metabolites in human and 11. Zeger SL, Liang KY. Longitudinal data analy- tor triggering of a vitamin D-mediated hu-
bovine milk. J Nutr. 1981;111(7):1240 –1248 sis for discrete and continuous outcomes. man antimicrobial response. Science. 2006;
5. Committee on Nutrition. Vitamins. In: Pedi- Biometrics. 1986;42(1):121–130 311(5768):1770 –1773
atric Nutrition Handbook. 4th ed. Elk Grove 12. Committee on Nutrition. Cow milk-based in- 18. Li R, Darling N, Maurice E, Barker L,
Village, IL: American Academy of Pediatrics; fant formulas: label claim nutrient contents Grummer-Strawn LM. Breastfeeding rates
1998:275–276 (per L at 20 kcal/oz). In: Kleinman RE, ed. in the United States by characteristics of
6. Wagner CL, Greer FR; American Academy of Pediatric Nutrition Handbook. 6th ed. Elk the child, mother, or family: the 2002 Na-
Pediatrics, Section on Breastfeeding and Grove Village, IL: American Academy of tional Immunization Survey. Pediatrics.
Committee on Nutrition. Prevention of rick- Pediatrics; 2009:1250 –1258 2005;115(1). Available at: www.pediatrics.
ets and vitamin D deficiency in infants, chil- 13. Kids’ bones at risk from low vitamin D. July 9, org/cgi/content/full/115/1/e31
PEDIATRICS Volume 125, Number 1, January 2010 111
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9. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods
James A. Taylor, Leah J. Geyer and Kenneth W. Feldman
Pediatrics 2010;125;105-111; originally published online Nov 30, 2009;
DOI: 10.1542/peds.2009-1195
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![ARTICLES
Use of Supplemental Vitamin D Among Infants
Breastfed for Prolonged Periods
AUTHORS: James A. Taylor, MD,a Leah J. Geyer, AB,a and WHAT’S KNOWN ON THIS SUBJECT: Because of the risk of
Kenneth W. Feldman, MDa,b nutritional rickets, vitamin D supplementation is recommended
aDepartment of Pediatrics, University of Washington, Seattle, for all breastfed infants. There is emerging evidence of other
Washington; and bDepartment of Pediatrics, Seattle Children’s benefits of vitamin D for children.
Hospital, Seattle, Washington
KEY WORDS WHAT THIS STUDY ADDS: The results of this study provide
breastfeeding, vitamin D, infants, rickets insight into the proportion of breastfed infants who receive
ABBREVIATIONS vitamin D supplementation and the reasons parents choose to
AAP—American Academy of Pediatrics provide the vitamin to their children.
PSPRN—Puget Sound Pediatric Research Network
OR— odds ratio
CI— confidence interval
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1195
doi:10.1542/peds.2009-1195
Accepted for publication Jul 30, 2009
abstract
Address correspondence to James A. Taylor, MD, University of
OBJECTIVES: To determine the rate of vitamin D supplementation in
Washington, Child Health Institute, Box 354920, Seattle, WA predominantly breastfed children. To identify patient characteristics,
98195. E-mail: uncjat@u.washington.edu parental beliefs, and practitioner policies associated with supplemen-
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). tation.
Copyright © 2009 by the American Academy of Pediatrics METHODS: A prospective observational study was conducted in a
FINANCIAL DISCLOSURE: The authors have indicated they have practice-based research network. Network pediatricians completed a
no financial relationships relevant to this article to disclose.
survey regarding their policy on vitamin D supplementation for breast-
fed infants. Parents of children 6 to 24 months old completed a survey
on the initial type of feeding given to the child, length of breastfeeding,
formula supplementation, and use of multivitamins. Parents indicated
their level of agreement with statements regarding vitamin D supple-
mentation.
RESULTS: Among 44 responding pediatricians, 36.4% indicated that
they recommended vitamin D supplementation for all breastfed in-
fants. A total of 2364 surveys were completed on age-eligible children;
1140 infants were breastfed for at least 6 months with little or no
formula supplementation. The rate of vitamin D use for these infants
was 15.9%. Use of vitamin D was significantly associated with parental
agreement that their child’s pediatrician recommended supplementa-
tion (odds ratio [OR]: 7.8), and that vitamins are unnecessary because
breast milk has all needed nutrition (OR: 0.12). Among parents of pre-
dominantly breastfed infants who indicated that their child’s doctor
recommended vitamin D, 44.6% gave the supplementation to their
child. Conversely, 67% of parents agreed that breast milk has all
needed nutrition, and only 3% of these parents gave vitamin D to their
children.
CONCLUSIONS: A minority of breastfed infants received vitamin D sup-
plementation. Educational efforts directed at both physicians and par-
ents are needed to increase compliance with vitamin D supplementa-
tion guidelines. Pediatrics 2010;125:105–111
PEDIATRICS Volume 125, Number 1, January 2010 105
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