1. National WIC Association Conference, April 2017
Infant Vitamin D Supplementation: Practices of Mothers Participating in a Local WIC Program
National WIC Association Conference, April 2017
Sina Gallo, RD, PhD1
Amara Channell Doig, MPH1
Jennifer Brady, BS2
David Goodfriend, MD, MPH2
Janine Rethy MD,MPH2
1Nutrition & Food Studies, George Mason University, Fairfax, VA
2Loudoun County Health Department, Leesburg, VA; J

2. Funding
1. Community Partnerships for Healthy Mothers & Children National WIC Association & Centers for Disease Control
To develop and implement community-driven plans to reduce and prevent chronic disease in high-risk areas
2. Preventive Health and Health Services Program
Virginia Department of Health
Preventing and Controlling Obesity and Chronic Disease Through Evidence Based Programming

3. Loudoun County Health Department Obesity & Chronic Disease Prevention Division
Community based prevention model to create a culture of health in Loudoun County
David Goodfriend, MD, MPH - Health Director
Janine Rethy, MD, MPH, FAAP, FABM - Physician Advisor
Jennifer Brady, BSc - Health Educator
Internship/Practicum students
Collaboration with George Mason University since 2014
Team Meeting with Community Partnerships for Healthy Mothers and Children Program Managers, Sept

4. Sina Gallo, RD-PhD chhs.gmu.edu/faculty-and-staff
Dr. Sina Gallo, RD, is an Assistant Professor in the Department of Nutrition and Food Studies. She earned her Ph.D. in Human Nutrition from McGill University in Montréal, Québec, Canada. She is a registered dietitian with active membership in the US Academy of Nutrition and Dietetics. 
Dr. Gallo’s research explores the role of early life nutrition in chronic disease prevention. Specific interests in Vitamin D supplementation and prevention of bone diseases and family based interventions aimed at preventing obesity during the critical periods of life.
chhs.gmu.edu/faculty-and-staff

5. Objectives By the end of the session, participants will be able to:
Participants will be able to define the American Academy of Pediatrics' infant vitamin D supplementation recommendations.
Participants will be able to identify 2 benefits of vitamin D supplementation for infants.
Participants will be able to list 2 strategies to improve vitamin D supplementation adherence in WIC mothers.

6. Outline Vitamin D Adherence with infant vitamin D supplementation
Sources, functions, recommendations, risks for deficiency
Adherence with infant vitamin D supplementation
WIC and provider survey results
Practice guidelines
Parent education, selection of products, Medicaid coverage

7. Part 1
Vitamin D

8. Vitamin D =
Sunshine vitamin

9. Vitamin D
Vitamin D
Adapted from Hollick. J Nutr, 2005.

10. Photosynthesis of Vitamin D
SKIN
UVB (SUN)
PRE-VITAMIN D3
CHOLESTEROL
7-DEHYDROCHOLESTEROL
THERMAL ISOMERIZATION
VITAMIN D3
(CHOLECALCIFEROL)
DIETARY SOURCES

11. People with increased skin melanin requires longer exposure to sunlight
Lightly pigmented white subjects (skin type II)
Heavily pigmented black subjects (skin type V)
Clemens et al. Lancet, 1982.

12. Sunscreen with a sun protection factor (SPF) of 8
reduces skin capacity to make vitamin D
Holick, MF. Am J Clin Nutr, 2004.

13. Factors Affecting Endogenous Synthesis of Vitamin D
Skin pigmentation
Sunscreen
Season
Latitude
Time of day
Clothing
Cloud cover
Pollution

14. Sun Safety Recommendations – AAP, 2014
Keep infants less than 6 months out of direct sunlight to reduce the risk of skin cancer
Begin effective sun protection early in life including sun screens
Minimize sun exposure from 10 am to 4 pm
AAP: American Academy of Paediatrics (

15. Can be found in the D3 or D2 forms
Vitamin D
Can be found in the D3 or D2 forms
Fortified Milk or Juices
Salmon
Supplementation
Vitamin D
Adapted from Hollick. J Nutr, 2005.

16. Vitamin D Recommendations
Good Housekeeping 1934.
Good Housekeeping 1940.

17. AAP Recommendation 400 IU/d supplemental vitamin D
Breastfed and partially breastfed infants beginning in the first few days of life until they start receiving at least 1 litre of formula per day.
Non-breastfed & older children consuming <32 oz (1 L) / day of vitamin D- fortified formula or milk
Adolescents who do not get 400 IU of vitamin D/d through foods
Wagner & Greer. Pediatrics, 2008.

18. Maternal Supplementation: Not Evidence-Based
Breastfeeding mothers and infants (n=334) from SC & NY randomized at 4-6 weeks postpartum x 6 months:
Group 1: 400 IU / d mothers IU / d infants
Group 2: 2,400 IU / d mother + No infant vitamin D -- Arm Stopped
Group 3: 6,400 IU/d + No infant vitamin D
Hollis et al. Pediatrics, 2015.

19. Maternal Supplementation: Not Evidence-Based
Breastfeeding mothers and infants (n=334) from SC & NY randomized at 4-6 weeks postpartum x 6 months:
Group 1: 400 IU / d mothers IU / d infants
Group 2: 2,400 IU / d mother + No infant vitamin D -- Arm Stopped
Group 3: 6,400 IU/d + No infant vitamin D
Baseline
7 months
Hollis et al. Pediatrics, 2015.

20. Can be found in the D3 or D2 forms
Vitamin D
Can be found in the D3 or D2 forms
Fortified Milk or Juices
Salmon
Supplementation
Vitamin D
Liver
25(OH)D
CYP27A1
Calcium regulation
Intestinal absorption
Bone resorption
Renal excretion
Classical
1,25(OH)2D
CYP27B1
“Biologically Active”
Kidney
Adapted from Hollick. J Nutr, 2005.

21. Nutritional Rickets
Metabolic bone disease which causes bones to demineralize resulting in soft weak bones, which can become bowed or curved.
Vitamin D deficiency is the leading cause.
Diagnosis between 4 months to 4.5 years.

22. ~1900s Exposure to sun lamps effective treatment for rickets

23. ~1930s Fortification of milk with vitamin D to 100 IU / cup

24. Cases of Rickets in the U.S.
National prevalence is unknown as rickets is not included as part of pediatric surveillance
24 per 100,000 from in Olmsted County, MN1
Black children highest risk: ~220 per 100,0001
Breastfed without supplementation2
Enrolled in WIC3
Worldwide re-emergence noted particularly among ethnic minority children4
Does not account for asymptomatic vitamin D deficiency
1Thacher et al. Mayo Clinic Proceedings, 2013; 2Weisberg et al. Am J Clin Nutr, 2004; 3Mylott et al. Wisconsin Medical J, 2004;
4Ladhani et al. Arch Dis Child, 2004

25. Long Term Benefits to Bone
Vitamin D supplementation during infancy is associated with higher bone mass at 7-9 years among girls
Zamora et al. Clin Endocrinol Metab, 1999. 25

26. Can be found in the D3 or D2 forms
Vitamin D
Can be found in the D3 or D2 forms
Fortified Milk or Juices
Salmon
Supplementation
Noncalcemic functions
Type I diabetes
Asthma
Autism
Multiple Sclerosis
Heart Disease
Vitamin D
Liver
25(OH)D
CYP27A1
Non-classical
Calcium regulation
Intestinal absorption
Bone resorption
Renal excretion
Classical
1,25(OH)2D
CYP27B1
“Biologically Active”
Kidney
Adapted from Hollick. J Nutr, 2005.

27. Incidence of type 1 diabetes per 100,000 men
by latitude in 51 regions worldwide
Mohr et al. Diabetologia, 2008.

28. Benefits Beyond Bone Type I diabetes Respiratory tract infections2-3
Finnish children given 2,000 IU / day vitamin D from 1 year of age showed 80% decreased risk of developing type 1 diabetes throughout the next 20 years1
Vitamin D improves ability of the pancreas to produce insulin and decrease insulin resistance
Respiratory tract infections2-3
Asthma4
1Hyppönen et al. Lancet, 200; 2Christensen et al. Pediatr Infect Dis J. 2017; 3Feng et al. J Allergy Clin Immunol. 2016.
4Wolsk et al. J Allergy Clin Immunol. 2017.

29. Our current vitamin D recommendations are not based on non-bone outcomes.

30. Vitamin D deficiency: Who is at risk?
Maternal vitamin D deficiency
Mothers with dark skin and without sufficient storage of vitamin D
Limited sun exposure or residing in latitudes far from equator
(>40° North or South)
Exclusively breastfeed infants without supplementation
“It is inappropriate to actively promote breastfeeding for a vulnerable patient population, but not encourage use of vitamin D supplementation.”
Mylott et al. Rickets in the Dairy State. Wisconsin Medical J, 2004

31. Knowledge Gaps
Are infants receiving supplemental vitamin D?

32. Part 2
Adherence with infant vitamin D supplementation.

33. Adherence in the U.S.
Using data from NHANES , % of infants (0-11 mo) meeting the AAP vitamin D recommendation
1 L (32 oz.) of formula per day or 400 IU/d from supplement
27%
31%
19%
1Ahrens et al. Clin Pediatr, 2016.

34. Loudoun County, Virginia
Median household income ~$118,000
20% born outside the United States
Increasingly diverse
17% Asian
14% Hispanic
~40% increase in a decade
7% Black
4% living below federal poverty line
12% Hispanic / Latinos
Individuals living below the Federal Poverty Line

35. WIC Survey
Ethnic minority children at risk for vitamin D deficiency and rickets more common among those enrolled in WIC
There is a paucity of data on vitamin D adherence among infants enrolled in WIC
Objective
To describe vitamin D supplementation practices of mothers of infants participating in a WIC program
Explore the determinants and barriers to supplementation

36. Methods
Self-administered online survey using tablets (via Qualtrics) at both Loudoun County WIC clinics
Available in English and Spanish
5 sections, 58 questions
Vitamin D intake and knowledge
~25 min. to complete
Anonymous and de-identified, 18 years +
IRB approval from George Mason University and VDH
Completed between July - August 2016

37. Participant Characteristics
Race / Ethnicity
74% Latino / Hispanic
90% Spanish speaking
14% Black / African American
5% Asian
Primary Language
68% Spanish

38. Participant Characteristics cont’d
Maternal age: 30 ± 7 years
No. of Children: 2 ± 3
Education
45% did not complete high school
66% earned less than the federal poverty line
WIC income criteria <185% of federal poverty line

39. Maternal Vitamin D Supplementation
95% of women took a prenatal supplement (multivitamin/mineral)
~400 IU / d
27% took additional vitamin D
Of which, 19% took more than 800 IU / d

40. Infant Supplemented with Vitamin D
Overall, 37 infants (27%) were supplemented
with vitamin D
*Analysis limited to child <5 years

41. Infant Met AAP Vitamin D Recommendation
Overall, 21 infants (24%) met AAP vitamin D
recommendation
*Analysis limited to child <5 years

42. Comparison: Met AAP Recommendation
Feeding Type
WIC sample,
3 months
(Loudoun co, VA)
US sample,
0-12 months
(Ahrens et al., 2016)
Exclusively Breastfed
21%
19%
Mixed Feeding
30%
Formula Fed 8%
31%
26%
Data presented as %.

43. Comparison: Met AAP Recommendation
Feeding Type
WIC sample,
3 months
(Loudoun co, VA)
US sample,
0-12 months
(Ahrens et al., 2016)
Canadian sample, 6 months
(Gallo et al., 2010)
Exclusively Breastfed
21%
19%
74%
Mixed Feeding
30%
51%
Formula Fed 8%
31%
36%
26%
64%
Data presented as %.

44. Age Started Vitamin D Supplement

45. Age Stopped Vitamin D Supplement

46. Age Stopped Vitamin D Supplement
Average duration of supplementation:
3.6 months

47. Vitamin D Preparations
Supplement
n (%)
D-Vi Sol
16 (59)
Tri-Vi-Sol
7 (26)
Baby Ddrops
4 (15)
n=27
D-Vi-Sol
Mead Johnson
400 IU / mL
TRI-Vi-Sol
Mead Johnson
400 IU / mL
Baby Ddrops
Ddrops Company
400 IU / drop

48. Vitamin D Knowledge
17% of parents correctly identified vitamin D supplement as the best source
23% incorrectly believe breast milk provides adequate vitamin D
27% incorrectly believe that sun is the only vitamin D their child needs
41% knew about the daily vitamin D recommendation
38% had a health provider recommend vitamin D
Only 15% recommended by WIC nutritionist or breastfeeding counselor

49. Reasons for Not Supplementing
Having a health care professional recommend predicted a
33-X increased likelihood vitamin D supplementation
(95 %CI: 8, 128, p<0.0001)

50. Knowledge Gaps
Are infants receiving supplemental vitamin D?
Are mothers receiving information about supplemental vitamin D for their infants?

51. Physician Recommendations
North Carolina (35ºN)1 & Nevada (36ºN)2
45-48% health care providers recommended
Seattle, Washington (47ºN)3
36% pediatricians recommended
16% of infants received supplement
Physicians’ knowledge of the AAP recommendations is positively associated with the likelihood of their recommending vitamin D4
1Davenport et al. Pediatr, 2004; 2Shaikh & Alpert. J Hum Lact, 2004; 3Taylor et al. Pediatr, 2010; 4Sherman et al. Mil Med, 2009.

52. Provider Survey
Objectives: To determine practices, attitudes and knowledge regarding infant feeding and vitamin D supplementation among local Loudoun county, VA primary care providers.

53. Methods Online survey (via Survey Monkey)
Distributed via the Loudoun County Health Department
4 sections, 30 questions
~15-20 minutes to complete
Based on protocol and recommendations from AAP, WHO, and ABM
IRB approval was not necessary
AAP: American Academy of Paediatrics; WHO: World Health Organization; ABM: Academy of Breastfeeding Medicine

54. Provider Responses 16 practices
28% response rate
77% have a vitamin D policy for breastfed infants
33% have a vitamin D policy for all infants
67% correctly identified infant vitamin D supplementation dose recommended by AAP (400 IU)
22% correctly identified amount of formula infants need to obtain sufficient vitamin D (32 oz.)

55. Part 3
Practice Guidelines

56. Recommend Vitamin D for All Infants
A vitamin D supplement of 400 IU daily should be recommended to all breastfed infants in the first few days of life and continued until can obtain through diet
Formula feed infants require 32 oz. (1 L) per day of formula obtain 400 IU of vitamin D
Infants consuming less than 16 oz. of formula need a supplement
Half dose or alternate days
200 IU from formula plus 400 IU/d supplement not excessive
1,000 IU / day is the upper limit

57. Vitamin D Preparations
Consider alternative preparations
                                 
Availability
~2 mile radius WIC
(11 sites)
82% alcohol-based
45% oil-based
Alcohol-based supplement
contains 400 IU per mL
Oil-based supplement contains 400 IU per drop
Cost per dose
~$ 0.22
Supply: 50 days
Cost per dose $
Supply: days

58. Educate on Recommendation and Delivery
Infants 6 week of age randomized:
Control group: Routine 400 IU/d prescribed
Intervention group: Routine 400 IU/d given plus education (pamphlet and demonstration)
Madar et al, Eur J Clin Nutr 2009

59. Vitamin D Supplementation Factsheet for parents and providers adopted by the Virginia Department
of Health

60. Medicaid Coverage for Infant Vitamin D
Vitamin D is an approved Medicaid drug however, health screening and prescription by a provider must be obtained
May not issue infant insurance cards for several weeks or the plan may request “prior authorization”
Cost of vitamin D supplement may be a deterrent for low- or middle-income families

61. Providing Infant Vitamin D to WIC Families
Free prescription program in Montréal without education failed to improve odds of obtaining vitamin D for the infant1
North Carolina example:
In Dec 1999, free 3 month supply of vitamin D supplements provided to all breastfed infants at 6 weeks of age at 87 local WIC agencies2
Adherence was not assessed and cost-effectiveness analysis is difficult to assess as untreated vitamin D deficiency is unknown
1Millette et al. Acta Pædiatrica, 2014; 2Vitamin D Expert Panel Meeting, 2001

62. Conclusions & Recommendations
Prevalence of infant vitamin D deficiency among WIC enrolled infants is unknown yet, likely at high risk particularly ethnic minority infants.
Low adherence with infant vitamin D supplementation among a local WIC agency and not receiving education from health care providers.
WIC nutritionists are an untapped resource for educating, and supporting vitamin D supplementation.
The cost of untreated vitamin D deficiency is unknown and therefore, need more research to support the effectiveness of vitamin D education and possibly provision programs in the WIC setting.

63. Objectives By the end of the session, participants will be able to:
Participants will be able to define the American Academy of Pediatrics' infant vitamin D supplementation recommendations.
Participants will be able to identify 2 benefits of vitamin D supplementation for infants.
Participants will be able to list 2 strategies to improve vitamin D supplementation adherence in WIC mothers.

64. Acknowledgments Funding
Centers for Disease Control and Prevention (CDC)
National WIC Association (NWA)
Loudoun County Health Department
WIC Staff
Study Staff
Graduate & Undergraduate Trainees
Lindi Jones
Julizza Canales
Study Participants

65. Logistic Regression Model: Received Vitamin D Supplement (n=99)
Variables
Odd Ratio
95% Confidence Interval
Maternal age, years
0.98
0.88, 1.10
Number of children
0.67
0.39, 1.15
Education (ref= Completed High school)
Elementary school
1.40
0.20, 9.83
Some high school
1.70
0.41, 7.15
Country of birth North America
0.56
0.13, 2.47
Infant feeding type, 3 months (ref = Mixed)
Breastfed only
1.21
0.28, 5.22
Formula fed
2.08
0.39, 11.21
Health professional recommended
32.6
8.27, 128.4

66. Vitamin D Isoforms 400 IU/d of vitamin D2 vs. D3
T-Test unequal variances (Welch)
Gallo et al. J Nutr, 2013.