Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics

revised

  • 111(4):908
FROM THE AMERICAN ACADEMY OF PEDIATRICS

Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents

Carol L. Wagner, Frank R. Greer and ; and the Section on Breastfeeding and Committee on Nutrition
Pediatrics November 2008, 122 (5) 1142-1152; DOI: https://doi.org/10.1542/peds.2008-1862
Carol L. Wagner
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Frank R. Greer
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • Comments
Loading
Submit a Response to This Article
Compose eLetter

More information about text formats

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

  • Medication hyperosmolarity may limit adherence to Vitamin D dosing recommendations in VLBW neonates
    Jason B. Sauberan, PharmD
    Published on: 09 March 2009
  • vitamin D supplementation for formula fed infants
    David L Eenigenburg
    Published on: 06 February 2009
  • Published on: (9 March 2009)
    Medication hyperosmolarity may limit adherence to Vitamin D dosing recommendations in VLBW neonates
    • Jason B. Sauberan, PharmD, Infant Special Care Center
    • Other Contributors:

    We would like to caution neonatal providers attempting to follow the Vitamin D dosing recommendations of Wagner, Greer, and the AAP Section on Breastfeeding and Committee on Nutrition.1 The potential for hyperosmolar stress on the premature gut from multiple vitamin preparations should be taken into consideration when initiating vitamin D supplementation in VLBW infants being fed breastmilk. The osmolality of Poly-Vi-Sol®...

    Show More

    We would like to caution neonatal providers attempting to follow the Vitamin D dosing recommendations of Wagner, Greer, and the AAP Section on Breastfeeding and Committee on Nutrition.1 The potential for hyperosmolar stress on the premature gut from multiple vitamin preparations should be taken into consideration when initiating vitamin D supplementation in VLBW infants being fed breastmilk. The osmolality of Poly-Vi-Sol® is known to be approximately 11,000 mOsm/kg and that of Tri-Vi-Sol® is 7,000 mOsm/kg.2 When 1 mL of these supplements is added to a typical volume of breastmilk for a VLBW infant, the final osmolality of the milk can be significantly increased to beyond the 450 mOsm/kg safe limit set by the AAP for commercial formula.3 Ernst et al demonstrated many years ago that 1 mL of Poly-Vi-Sol® added to 30 mL of preterm formula increases the final osmolality of the feeding to 744 mOsm/kg.4 This high value will be even higher in ELBW infants receiving smaller volumes of feedings. For example, in a 1 kg infant receiving enteral breastmilk (295 mOsm/kg)2 at 18 mL per feeding every 3 hours (150 mL/kg day), 1 mL of Poly-Vi-Sol® added to the feedings would increase the calculated milk osmolality to 858 mOsm/kg.

    Recently, a 720 gram birthweight, 24-week gestational age male neonate in our care experienced an acute gastrointestinal emergency consistent with modified Bell’s stage 1a necrotizing enterocolitis (NEC). Symptoms developed within 6 hours of initiating 1 mL of Poly-Vi-Sol® added to his feedings once daily. The child had a postnatal age of 21 days and was only receiving approximately half of his total fluids from gavage-fed breastmilk. In reviewing his disease history, we estimated that the osmolality of the feeding containing the Poly-Vi-Sol® was approximately 1,300 mOsm/kg. Hyperosmolar feedings was thus considered a likely contributor to his NEC.

    Hyperosmolar stress has long been known to be a risk factor for NEC in premature infants.5 Among the Vitamin D preparations available in the U.S.,1 ergocalciferol drops have the highest osmolality (16,277 mOsm/kg) followed by Poly-Vi-Sol® and Tri-Vi-Sol®,3 However, the dosing volume of ergocalciferol is only 0.05 mL per 400 units. This means that the calculated osmolality after adding a dose of ergocalciferol to the same amount of breastmilk as in our case would only be 340 mOsm/kg. Ergocalciferol is thus the safest choice based on osmolality alone, but it is not without safety hazards. Wagner et al correctly identified the potential for overdosing with ergocalciferol due to its extremely small dosing volume.1 Multivitamin preparations are easier to prepare and to dose but should be avoided in VLBW babies until full feedings are achieved in order to avoid hyperosmolar GI stress. When they are initiated, we recommend that the 1 mL dose be divided twice daily. Tri-Vi-Sol® has a lower osmolality than Poly-Vi-Sol® and it may be preferred. We estimate that the minimum volume of unfortified breastmilk required to maintain an osmolality < 450 mOsm/kg after adding either 0.5 mL of Tri-Vi-Sol® or Poly-Vi-Sol® is 22 mL and 35 mL, respectively. An alternative strategy that requires further research is the possibility of circumventing the need for infant vitamin D supplementation by using high dose maternal supplementation of vitamin D (>= 2,000 IU daily) to meet the same nutritional goals by generating higher vitamin D levels in their milk.6

    1. Wagner CL, Greer FR. Prevention of rickets and vitamin d deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-1152. 2. Jew RK, Owen D, Kaufman D, Balmer D. Osmolality of commonly used medications and formulas in the neonatal intensive care unit. Nutr Clin Pract 1997;12(4):158-163. 3. Commentary on breast-feeding and infant formulas, including proposed standards for formulas. Pediatrics. 1976;57(2):278-285. 4. Ernst JA, Williams JM, Glick MR, Lemons JA. Osmolality of substances used in the intensive care nursery. Pediatrics. 1983;72(3):347-352. 5. Kliegman RM, Fanaroff AA. Necrotizing enterocolitis. N Engl J Med. 1984;310(17):1093-1103. 6. Taylor SN, Wagner CL, Hollis BW. Vitamin D supplementation during lactation to support infant and mother. Journal of the American College of Nutrition. 2008;27(6):690-701.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (6 February 2009)
    vitamin D supplementation for formula fed infants
    • David L Eenigenburg, MD

    The article states that any infant not receiving >1 liter of formula/day should be supplemented with vitamin D. This would include nearly every baby under 2 months, and a significant number of 4 month olds. Why does the AAP not include all of these babies in the standard recommendations, rather than considering them on an individual basis? As written, the recommendations rather gloss over the formula fed babies....

    Show More

    The article states that any infant not receiving >1 liter of formula/day should be supplemented with vitamin D. This would include nearly every baby under 2 months, and a significant number of 4 month olds. Why does the AAP not include all of these babies in the standard recommendations, rather than considering them on an individual basis? As written, the recommendations rather gloss over the formula fed babies.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
PreviousNext
Back to top

Advertising Disclaimer »

In this issue

Pediatrics
Vol. 122, Issue 5
November 2008
  • Table of Contents
  • Index by author
View this article with LENS
PreviousNext
Email Article

Thank you for your interest in spreading the word on American Academy of Pediatrics.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
(Your Name) has sent you a message from American Academy of Pediatrics
(Your Name) thought you would like to see the American Academy of Pediatrics web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Request Permissions
Article Alerts
Log in
You will be redirected to aap.org to login or to create your account.
Or Sign In to Email Alerts with your Email Address
Citation Tools
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
Carol L. Wagner, Frank R. Greer
Pediatrics Nov 2008, 122 (5) 1142-1152; DOI: 10.1542/peds.2008-1862

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
Carol L. Wagner, Frank R. Greer
Pediatrics Nov 2008, 122 (5) 1142-1152; DOI: 10.1542/peds.2008-1862
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Print
Download PDF
Insight Alerts
  • Table of Contents

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • BACKGROUND
    • RECOMMENDED DAILY INTAKE OF VITAMIN D FOR INFANTS AND CHILDREN
    • SUNLIGHT EXPOSURE AND VITAMIN D
    • PREGNANCY, VITAMIN D, AND THE FETUS
    • THE EFFECT OF MATERNAL VITAMIN D SUPPLEMENTATION DURING LACTATION ON THE VITAMIN D STATUS OF THE BREASTFED INFANT
    • VITAMIN D SUPPLEMENTATION FOR BREASTFEEDING INFANTS
    • FORMS OF VITAMIN D SUPPLEMENTS
    • FORMULA-FED INFANTS AND VITAMIN D SUPPLEMENTS
    • VITAMIN D SUPPLEMENTS DURING LATER CHILDHOOD AND ADOLESCENCE
    • SUMMARY GUIDELINES
    • COMMITTEE ON NUTRITION, 2007–2008
    • LIAISONS
    • STAFF
    • SECTION ON BREASTFEEDING EXECUTIVE COMMITTEE, 2007–2008
    • LIAISONS
    • STAFF
    • Footnotes
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • Comments

Related Articles

  • Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake
  • PubMed
  • Google Scholar

Cited By...

  • Pearls & Oy-sters: Focal hypocalcemic seizures secondary to severe vitamin D deficiency/rickets
  • Neonatal Hypocalcemia in the Infant of a Diabetic Mother
  • Vitamin D in Children: Can We Do Better?
  • Adherence to Vitamin D Intake Guidelines in the United States
  • Population-specific sequence and expression differentiation in Europeans
  • Vitamin D During Pregnancy and Infant Growth: A Long Shot
  • Question 2: Vitamin D intake for preterm infants: how much do they really need?
  • Vitamin Excess and Deficiency
  • Vitamin D, the placenta and early pregnancy: effects on trophoblast function
  • Updates in Infant Nutrition
  • Suboptimal vitamin D status in Korean adolescents: a nationwide study on its prevalence, risk factors including cotinine-verified smoking status and association with atopic dermatitis and asthma
  • Vitamin D deficiency in adolescents in a tier 4 psychiatric unit
  • Trends in the Diagnosis of Vitamin D Deficiency
  • Maternal Preferences for Vitamin D Supplementation in Breastfed Infants
  • High-Dose Monthly Maternal Cholecalciferol Supplementation during Breastfeeding Affects Maternal and Infant Vitamin D Status at 5 Months Postpartum: A Randomized Controlled Trial
  • Response to commentary by D Roth
  • Vitamin D Status and Dental Caries
  • Maternal postpartum high-dose vitamin D3 supplementation (6400 IU/day) or conventional infant vitamin D3 supplementation (400 IU/day) lead to similar vitamin D status of healthy exclusively/fully breastfeeding infants by 7 months of age
  • Maternal Vitamin D Supplementation for Breastfeeding Infants
  • The predictive value of serum 25-hydroxyvitamin D and dietary intake during adolescence: timing matters
  • Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial
  • Maternal Vitamin D Supplementation for Breastfeeding Infants: Will it Work?
  • Vitamin D Deficiency in School-Age Children Is Associated with Sociodemographic and Lifestyle Factors
  • Improved Vitamin D Supplementation in Hospitalized Breastfed Infants Through Electronic Order Modification and Targeted Provider Education
  • Rapid Normalization of Vitamin D Levels: A Meta-Analysis
  • Consumption of non-cow's milk beverages and serum vitamin D levels in early childhood
  • Vitamin D in the Newborn, Part II: Bases for Current Dietary Recommendations in Term and Preterm Neonates
  • Vitamin D in the Newborn, Part I: Assessment of Status and Deficiency Risk Factors
  • NICU Follow-up: Medical and Developmental Management Age 0 to 3 Years
  • Dental Complications of Rickets in Early Childhood: Case Report on 2 Young Girls
  • Trial of Daily Vitamin D Supplementation in Preterm Infants
  • Vitamin D status of early preterm infants and the effects of vitamin D intake during hospital stay
  • Higher Vitamin D Intake in Preterm Infants Fed an Isocaloric, Protein- and Mineral-Enriched Postdischarge Formula Is Associated with Increased Bone Accretion
  • Is vitamin D deficiency an underreported issue in refugee health?: Two cases of infants presenting with vitamin D-deficiency rickets
  • Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants
  • Osteopenia in preterm infants
  • Vitamin D status of exclusively breastfed infants aged 2-3 months
  • The Change in Plasma 25-Hydroxyvitamin D Did Not Differ between Breast-Fed Infants That Received a Daily Supplement of Ergocalciferol or Cholecalciferol for 3 Months
  • The Relationship Between Cow's Milk and Stores of Vitamin D and Iron in Early Childhood
  • Vitamin D Status of Exclusively Breastfed 4-Month-Old Infants Supplemented During Different Seasons
  • The Association of Vitamin D Status With Pediatric Critical Illness
  • Efficacy of Fat-Soluble Vitamin Supplementation in Infants With Biliary Atresia
  • Vitamin D Deficiency in Critically Ill Children
  • Vitamin D Deficiency in Critically Ill Children: A Roadmap to Interventional Research
  • Maternal Vitamin D Status: Effect on Milk Vitamin D Content and Vitamin D Status of Breastfeeding Infants
  • MECHANISMS IN ENDOCRINOLOGY: Vitamin D and fertility: a systematic review
  • Impact of Maternal Nutritional Status on Human Milk Quality and Infant Outcomes: An Update on Key Nutrients
  • Question 2 What is the ideal dose of vitamin D supplementation for term neonates?
  • Breastfeeding and the Use of Human Milk
  • Care of the Well Newborn
  • 25-Hydroxyvitamin D Levels and Vitamin D Deficiency in Children with Rheumatologic Disorders and Controls
  • Vitamin D: A D-Lightful Solution for Health
  • Preventable but no strategy: vitamin D deficiency in the UK
  • New Insights About Infant and Toddler Skin: Implications for Sun Protection
  • Vitamin D Status in Abused and Nonabused Children Younger Than 2 Years Old With Fractures
  • Vitamin D and Diabetes
  • Ultraviolet Radiation: A Hazard to Children and Adolescents
  • Ultraviolet Radiation: A Hazard to Children and Adolescents
  • Vitamin D requirements in adolescents: what is the target?
  • Dietary Guidelines for Calcium and Vitamin D: A New Era
  • Cord-Blood 25-Hydroxyvitamin D Levels and Risk of Respiratory Infection, Wheezing, and Asthma
  • Randomised controlled trial analysing supplementation with 250 versus 500 units of vitamin D3, sun exposure and surrounding factors in breastfed infants
  • An Inflection Point of Serum 25-Hydroxyvitamin D for Maximal Suppression of Parathyroid Hormone Is Not Evident from Multi-Site Pooled Data in Children and Adolescents
  • Vitamin D Status of Inuit Preschoolers Reflects Season and Vitamin D Intake
  • Vitamin D Insufficiency in Children With Epilepsy
  • Predictors of vitamin D status and its association with parathyroid hormone in young New Zealand children
  • Vitamin D Status Is Modestly Associated with Glycemia and Indicators of Lipid Metabolism in French-Canadian Children and Adolescents
  • Maternal Serum 25-Hydroxyvitamin D Concentrations Are Associated with Small-for-Gestational Age Births in White Women
  • Widespread Vitamin D Deficiency in Urban Massachusetts Newborns and Their Mothers
  • 25-Hydroxyvitamin D Status of Healthy, Low-Income, Minority Children in Atlanta, Georgia
  • Adherence to Vitamin D Recommendations Among US Infants
  • Incorporating Type 1 Diabetes Prevention Into Clinical Practice
  • Diagnosis and management of vitamin D deficiency
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods
  • Vitamin D Needs of Preterm Infants
  • Potential Interactions of Vitamins With Medications
  • Vitamin D Levels in Subjects With and Without Type 1 Diabetes Residing in a Solar Rich Environment
  • Vitamin D: An Evidence-Based Review
  • Defining Vitamin D Deficiency in Children: Beyond 25-OH Vitamin D Serum Concentrations
  • Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004
  • US Vitamin Use: Too Much By Too Many
  • Dietary Reference Intakes for vitamin D: justification for a review of the 1997 values
  • Vitamin D Recommendations: They Change Again!
  • Google Scholar

More in this TOC Section

  • Ethical Considerations in Pediatricians’ Use of Social Media
  • 2021 Recommendations for Preventive Pediatric Health Care
  • Recommended Childhood and Adolescent Immunization Schedule: United States, 2021
Show more From the American Academy of Pediatrics

Similar Articles

Subjects

  • Endocrinology
    • Metabolic Disorders
    • Endocrinology
  • AAP Policy Collections by Authoring Entities
    • Committee on Nutrition
  • Journal Info
  • Editorial Board
  • Editorial Policies
  • Overview
  • Licensing Information
  • Authors/Reviewers
  • Author Guidelines
  • Submit My Manuscript
  • Open Access
  • Reviewer Guidelines
  • Librarians
  • Institutional Subscriptions
  • Usage Stats
  • Support
  • Contact Us
  • Subscribe
  • Resources
  • Media Kit
  • About
  • International Access
  • Terms of Use
  • Privacy Statement
  • FAQ
  • AAP.org
  • shopAAP
  • Follow American Academy of Pediatrics on Instagram
  • Visit American Academy of Pediatrics on Facebook
  • Follow American Academy of Pediatrics on Twitter
  • Follow American Academy of Pediatrics on Youtube
  • RSS
American Academy of Pediatrics

© 2021 American Academy of Pediatrics