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Breastfeeding and Vitamin D Supplementation 2014 Pediatric Continuity Clinic Curriculum Created by: Trang Bui.

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Presentation on theme: "Breastfeeding and Vitamin D Supplementation 2014 Pediatric Continuity Clinic Curriculum Created by: Trang Bui."— Presentation transcript:

1 Breastfeeding and Vitamin D Supplementation 2014 Pediatric Continuity Clinic Curriculum Created by: Trang Bui

2 Objectives Understand the clinical presentation of vitamin D deficiency in the neonatal period Describe current recommendations for vitamin D supplementation in breastfeeding Learn anticipatory guidance regarding Vitamin D supplementation

3 Case #1 A 12-day-old girl born in October presents to clinic with new-onset focal seizures. In the previous 5 days, she has had right-sided arm and leg twitching, left-sided head turning and lip smacking. These episodes lasted for approximately 30 s, and their frequency had increased to eight times per hour. There is no history of fever, trauma, sick contacts or neonatal sepsis risk factors. The baby is breastfed and supplemented with formula. He is found to have hypocalcemia. What is the relationship between an acute versus chronic presentation of Vitamin D deficiency? What are risk factors for Vitamin D deficiency?

4 What is the presentation? Acute Acute presentations occur in period of rapid growth with increased metabolic demand such as neonatal period An unsupplemented infant will reach deficient state more rapidly than infant whose mother had adequate vitamin D state Associated signs and symptoms: Hypocalcemia (including seizures) More likely in infants of diabetic or preeclamptic mother May occur in infants born to mothers with hyperparathyroidsm Lethargy Irritability Predisposition to respiratory infections in infancy

5 What is the presentation? Chronic State of deficiency occurs months before findings are apparent on physical exam Rickets/ decreased bone mineralization: Lab findings: normocalcemia or asymptomatic hypocalcemia Rickets: peak incidence between mo

6 What are the risk factors? Vitamin D deficiency rickets among breastfed infants is rare, but it can occur if an infant does not receive additional vitamin D from a vitamin supplement or from adequate exposure to sunlight. A number of factors decrease vitamin D level. These factors include: Decreased synthesis from sunlight. Living at high latitudes, particularly during winter months Air quality conditions such as high levels of air pollution Skin pigmentation as in darker skin types Weather conditions such as dense cloud covering The degree to which clothing covers the skin Use of sunscreen Decreased GI absorption from chronic disease: Fat malabsorption (e.g. cystic fibrosis) Anticonvulsant medication use (induce cytochrome p450 and other enzymes)

7 Stages and Clinical Signs

8 Case #2 A young mother in your practice presents for the 2 week newborn exam for her second child whom she is breastfeeding. She would like to breastfeed exclusively until she returns to work at which time she would like to start supplementing with formula. What is the MOST appropriate advice to give this mother about her child’s nutrition? How would your advice change if she were want to transition completely to formula?

9 Recommendations for Vitamin D Supplementation in Breastfed and Partially Breastfed Infants The American Academy of Pediatrics (AAP) recommends a daily intake of vitamin D of 400 IU/day for all infants and children beginning in the first few days of life (and continued into childhood) Human milk typically contains a vitamin D concentration of 25 IU per liter or less. When maternal vitamin D status is deficient, particularly in winter, the unsupplemented infant 25-OH-D concentration is very low *Though rare, a breastfed infant may need vitamin B12 supplements before age 6 mo if mother is vitamin B12 deficient.

10 Recommendations for Vitamin D Supplementation in Breastfed and Partially Nonbreastfed Infants All infant formulas in the U.S. must have a minimum 40 IU/100 kcal and a maximum concentration of 100 IU/100 kcal Most formula-fed infants with feed 1 L of formula per day after the first month of life Any infant who receives <1 L or 1 qt of formula per day requires an alternative way to obtain 400 IU/day of vitamin D An infant receiving Vitamin-D fortified formula (>1 L per day) or a child one year of age or older who is weaned to vitamin-D fortified milk, then further supplementation is not necessary.

11 Case #3 You are addressing a group of expectant mothers at a local health clinic as part of a community education program. You explain that exclusive breastfeeding is the best nutrition for most infants after birth. You also explain these infants should receive Vitamin D supplementation. What Vitamin D formulations are available? How are we doing as pediatricians with making recommendations for supplementation with Vitamin D while breastfeeding?

12 Forms of Vitamin D Supplements Adequate amounts of vitamin D can be achieved by currently available multivitamin products containing 400 IU of vitamin D per mL or the newly available preparations that contain 400 IU/mL vitamin D alone without other vitamins. These products are available over the counter. Prescription preparations of vitamin D have very high vitamin D concentration and are not for routine home use.

13 Oral Vitamin D Preparations

14 How are we doing? A minority of breastfed infants receive vitamin D supplementation. Vitamin D use is strongly linked to physician recommendations Many parents believe breastmilk has all the needed nutrition. Educational efforts directed at physicians and parents are needed to increase compliance with Vitamin D supplementation guidelines.

15

16 PREP Question You are seeing an infant in the newborn nursery who was born this morning to a woman who has hepatitis C virus (HCV) infection. The infant is healthy. The mother wants to know if she should breastfeed her infant. Of the following, the MOST appropriate information to share with this mother is that:

17 PREP Question A. breastfeeding is contraindicated if the mother has evidence of liver dysfunction B. breastfeeding is contraindicated when a mother has HCV infection C. breastfeeding is recommended if the mother does not also have hepatitis B virus infection D. breastfeeding is recommended if the mother does not also have human immunodeficiency virus infection E. breastfeeding is recommended only if viral cultures of human milk show no evidence of HCV

18 PREP Question A. breastfeeding is contraindicated if the mother has evidence of liver dysfunction B. breastfeeding is contraindicated when a mother has HCV infection C. breastfeeding is recommended if the mother does not also have hepatitis B virus infection D. breastfeeding is recommended if the mother does not also have human immunodeficiency virus infection E. breastfeeding is recommended only if viral cultures of human milk show no evidence of HCV

19 References and Future Reading – Breastfeeding: More Than Just Good Nutrition. RM Lawrence and RA Lawrence; Pediatrics in Review 2011; 32: ; doi: /pir – AAP Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics Vol. 129 No. 3 March 1, 2012 pp. e827 -e841 (doi: /peds ) – PREP 2012, Question 13 – Wagner CL, Freer FR; Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122: Institute of Medicine, Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 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


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