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PEDIATRICS Vol. 113 No. 1 January 2004, pp. 179-180

Pediatrician Patterns of Prescribing Vitamin Supplementation for Infants: Do They Contribute to Rickets?

Marsha L. Davenport, MD
Aysin Uckun, MD
Ali S. Calikoglu, MD
Division of Endocrinology Department of Pediatrics University of North Carolina Chapel Hill, NC 27599-7039, USA

To the Editor.—

There seems to be a resurgence of vitamin D (vitD) deficiency rickets in the United States.^1–3 Decreasing sunlight exposure,⁴ an increasing number of women breastfeeding, and increasing maternal vitD deficiency^1,5 are certainly some of the factors responsible for this resurgence. We postulated that a decline in the number of pediatricians who recommend vitD supplementation for breastfed infants might be another contributing factor.

A questionnaire was mailed to all active members of the North Carolina Chapter of American Academy of Pediatrics (AAP) to determine their vitD supplementation practices in October, 1999. Of the 1040 questionnaires, 417 (40.1%) were returned, and 383 were suitable for analysis. Most respondents were primary care physicians (86.4%) and practiced in private offices (68.1%). They averaged 19.2 ± 10.4 years of experience (4–55 years) and graduated from medical school between 1944 and 1995. Of these, 25.8% reported seeing 1 cases of vitD deficiency rickets within the previous 3 years.

There was no consensus about vitD supplementation for infants. Some (13%) never recommended vitD supplementation, and a few (9%) always recommended supplementation. Most, however, recommended supplementation for selected groups (for example, breastfed, dark-skinned, premature, or undernourished infants).

When asked specifically about breastfed infants, 44.6% recommended vitD supplementation for all, 38.6% recommended it for some, and 16.5% never recommended it. The majority of pediatricians who did not recommend vitD supplementation for breastfed infants (83.1%) believed that human milk already has sufficient vitamins. Others were concerned about its cost (3.1%), the risk of hypervitaminosis (4.2%), decreasing the likelihood of breastfeeding (2.1%), or other problems (14.7%).

For those who recommended vitD supplementation, the ages for initiating and ending vitD varied tremendously. Although many pediatricians preferred initiating supplementation at birth or in the first month of life, one fourth suggested starting after 6 months; 38% continued it until weaning, 10% to <1 year of age, and 44% to 1 year, and 8% used other criteria. Pediatricians who graduated in the 1990s were less likely to recommend vitD supplementation than those who graduated before 1990 (Fig 1 a). They were also more likely to initiate supplementation after 6 months of age (P < .001; Fig 1 b).

View larger version (29K): [in this window] [in a new window]   Fig 1. Percentage of pediatrician practices for breastfed infants grouped by decade(s) of graduation from medical school. a, Recommending vitamins for none (black bar), some (gray bar), or all (white bar) infants. Note the high percentage of pediatricians graduated before 1970 that recommend vitamins for all breastfed infants compared to those graduated more recently. b, Recommended age at initiation (in months). Graduation from medical school before 1990 (white bar) and in the 1990s (black bar) is shown. Note that those graduated in the 1990s recommend that vitamins be initiated at later ages.

 
These data confirm anecdotal evidence that many pediatricians do not recommend vitD supplementation for breastfed infants, and those that do may recommend it late or terminate its administration early. Factors that may be responsible for the decreasing number of pediatricians recommending vitD supplementation include less education about rickets in medical school and residency and vagueness of the AAP guidelines concerning vitD supplementation. In 1963, the AAP recommended that all infants receive 400 IU of vitD daily,⁶ but policy statements in the past 25 years have been weaker, for example, recommending vitamin D as a possible supplement for breastfed infants whose mothers are vitD-deficient or for infants that do not receive adequate sunlight.⁷ In the face of increasing reports of rickets, the AAP developed new vitD intake guidelines for healthy infants, children, and adolescents to prevent vitD deficiency and rickets in April 2003.⁸ They propose that all infants receive 200 IU of vitD supplementation unless at least 500 ml (16 ounces) of vitD-fortified formula or milk are consumed daily. Breastfed infants are at risk for vitD deficiency because human milk contains only 15 to 50 IU/L of vitD,^9,10 which is insufficient to prevent rickets when sunlight exposure is limited.¹⁰

The consequences of vitD deficiency rickets can be profound. Even more disturbing, however, are other long-term consequences of vitD deficiency that we have recently begun to appreciate such as increased risks of type I diabetes, cancer, and osteoporosis. Pediatricians and other primary care providers, therefore, should assume leadership roles in educating families about vitD and should insure that every infant and child is vitD-sufficient.

REFERENCES

1. Kreiter SR, Schwartz RP, Kirkman HN Jr, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr.2000; 137 :153 –157[CrossRef][Web of Science][Medline]
2. Welch TR, Bergstrom WH, Tsang RC. Vitamin D-deficient rickets: the reemergence of a once-conquered disease. J Pediatr.2000; 137 :143 –145[CrossRef][Web of Science][Medline]
3. Tomashek KM, Nesby S, Scanlon KS, Cogswell ME, Powell KE, Parashar UD. Nutritional rickets in Georgia [commentary]. Pediatrics.2001; 107(4) . Available at: http://www.pediatrics.org/cgi/content/full/107/4/e45
4. Daaboul J, Sanderson S, Kristensen K, Kitson H. Vitamin D deficiency in pregnant and breast-feeding women and their infants. J Perinatol.1997; 17 :10 –14[Medline]
5. Thomas MK, Demay MB. Vitamin D deficiency and disorders of vitamin D metabolism. Endocrinol Metab Clin North Am.2000; 29 :611 –27, viii[CrossRef][Web of Science][Medline]
6. American Academy of Pediatrics, Committee on nutrition. The prophylactic requirement and the toxicity of vitamin D. Pediatrics.1963; 31 :512 –530[Abstract/Free Full Text]
7. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics.1997; 100 :1035 –1039[Abstract/Free Full Text]
8. American Academy of Pediatrics, Gartner LM, Greer FR, Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics.2003; 111 :908 –910[Abstract/Free Full Text]
9. Specker BL, Tsang RC, Hollis BW. Effect of race and diet on human-milk vitamin D and 25-hydroxy vitamin D. Am J Dis Child.1985; 139 :1134 –1137[Abstract/Free Full Text]
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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