Rebecca B. Saenz, MD, IBCLC, FABMMississippi Breastfeeding Medicine Clinic,

PLLCMadison, Mississippi

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• Actually, a hormone• Receptors in many organ systems –

– Bone, skeletal muscle, brain, prostate, breast, colon, pancreas, immune cells

• Vitamin D2 = calciferol – about 30% activity of D3

• Vitamin D3 = cholecalciferol

• Vit D from skin or diet > • Metab in liver to 25-OH-Vit D >• Metab in kidneys to 1,25-diOH-Vitamin

D3• Regulated by parathyroid hormone

and serum calcium and phosphorus • Excess 25-OH-Vit D and 1,25-diOH-Vit

D are catabolized into inactive calcitroic acid and excreted in bile

• Increases calcium and phosphorus absorption

• Enhances bone mineral density• Increases insulin production in pancreas• Decreases renin production in kidneys• Immunomodulatory• Anti-inflammatory• Role in preventing genetic expression of

some cancers (local effect)

Skeletal – rickets, osteopenia, osteoporosis, osteomalacia, fracture

Muscular– weakness, twitches Skin -- psoriasis Cardiac – hypertension, CHF, inc. CRP Pulmonary – wheezing illnesses Immune – diabetes, MS, Crohn’s, RA, OA Psychiatric – schizophrenia, depression Other – prostate, colon, & breast

cancers, and non-Hodgkins lymphoma

(measured as serum 25-OH-Vit D levels)

Deficiency < 20ng/ml Insufficiency = 21-29ng/ml

Sufficiency >30ng/ml Preferred range = 30-60ng/ml Intoxication >150ng/ml

Sunshine – ultraviolet B radiation (290-315nm) 0.5 “minimal erythemal dose”* gives about 3000IU of vitamin D3

*0.5 minimal erythemal dose = about 5-10** minutes of exposure of arms and legs to direct sunshine,

**Depending on time of day, season, cloud cover, extent of air pollution, latitude, body mass, amount of exposed skin, UVB protection, and skin sensitivity (complexion & genetics)

It’s GOOD in moderation!

• 10-15 minutes daily• Short sleeves and pants• Without hat or sunscreen

– SPF 15 or higher blocks 99% of UVB• What about risk of skin cancer?

– Apply sunscreen after those first 10-15 minutes!

*35 degrees latitude is the north border of Georgia, Alabama, and Mississippi, and cuts Arkansas in half just north of Little Rock

Dietary (Adults) Salmon 100-1000 IU Sardines 300 IU Mackerel 250 IU Tuna 230 IU Cod liver oil 400-1000 IU Shitake mushrooms 100-1600

IU Egg yolk 20 IU

Dietary (“Fortified”) Milk, OJ, yogurt, 100 IU/8oz Infant formula 100 IU/8oz Butter 50 IU/3.5oz Margarine 430 IU/3.5oz Cheeses 100 IU/3oz Breakfast cereals 100

IU/serving

Dietary Supplements Prescription

• Vitamin D2 (ergocalciferol)50,000IU/cap

• Drisdol liquid vit D2 8,000IU/ml Over the Counter

• Multivitamin / Prenatal 400IU• Vitamin D3 400, 800,

1000, or 2000 IU

• Infant drops 400IU/dose

Dietary (Infants)

Human Breast Milk Vitamin D content varies based on Mom’s Vitamin D status,

which varies based on her sunlight exposure and dietary intake.

Range: 5-20 IU / liter, if mom unsupplemented

Up to >800 IU / liter if mom on high-dose Vit D

DATE: August 29, 2008

It is clear that vitamin D content of human milk is variable and directly related to maternal vitamin D status. Human milk is not deficient in vitamin D per se; rather, it is deficient in vitamin D when mother is deficient. Vitamin D transfer into mothers’ milk is predictable: a deficient woman has little to transfer to her infant via her milk; if her status improves, transfer of vitamin D in her milk to the baby will also. Maternal vitamin D deficiency and resultant nutritional rickets in her nursing infant is preventable: supplementation of the infant with vitamin D will ameliorate deficiency in that age group, but does not address maternal needs. Adverse effects associated with vitamin D deficiency affect bone development and innate immunity such that no woman and her baby should be deficient. We must prescribe a safe intervention that will achieve sufficiency in both mother and infant and not blame human milk as the culprit, but rather, see the problem as the larger public health issue that it is.

Caroline Chantry, MD Karla Shepard Rubinger President Executive Director Academy of Breastfeeding Medicine Academy of Breastfeeding Medicine 140 Huguenot Street, 3rd floor New Rochelle, NY 10801-5215

Reduced skin synth Sunscreen Pigment Aging Season/latitude/

time Skin grafts

Dec. bioavailability Malabsorption

Cystic fibrosis Celiac disease Crohn’s disease Gastric Bypass

surgery Cholesterol lowering

meds Obesity

Increased catabolism Anticonvulsants Glucocorticoids Others

Increased urinary loss of 25-OH-D Nephrotic syndrome

Decreased synthesis of 25-OH-D Liver failure

Decreased synthesis of 1,25-diOH-D Chronic kidney

disease

• Heritable Disorders – (Rickets)

– Vit D dependent rickets – type 1

– Vit D resistant rickets– Vit D dependent

rickets – type 3– AD hypophosatemic

rickets– X-linked

hypophosphatemic rickets

Acquired disorders Tumor-induced

osteomalacia Primary

hyperparathyroidism

Granulomatous disorders (sarcoid, TB)

Hyperthyroidism

• Mom who is “insufficient” or “deficient” during pregnancy or lactation

• Baby is both exclusively breastfed• AND sheltered / protected from

sunlight.– Babies born in fall/winter– Babies in full-time daycare– Living above 35 degrees N latitude

• Babies born prematurely

Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!

AAP: 400 IU vitamin D3 / day Sensible sun exposure 1000-2000 IU vitamin D3 / day is safe,

if necessary to treat deficiency

Supplementation of the nursing infant with oral vitamin D . . . does not address the issue of why the antirachitic activity of the mother’s milk is low --- namely, that her vitamin D status is poor.

Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.

Maternal Infant Maternal Infant Vit D Vit D serum serum Suppl Suppl 25(OH)D

25(OH)D

2000IU/day 0 36.1 27.84000IU/day 0 44.5 30.86400IU/day 0 58.8 46 400IU/day 300IU/day 38.4 43From: Hollis BW, Wagner CL. Vitamin D requirements during lactation:

high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.

Wagner C, Hulsey TC, Fanning D, et al. 2006. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month follow-up pilot study. Breastfeeding Medicine 1(2):59-70.

“We understand more fully now that this deficiency is not caused by something that is inherently wrong or missing in mother’s milk but rather by inadequate maternal dietary vitamin D intake and the resultant low concentrations in the mother’s milk.”

Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.

“Lactating women given 4000 IU of vitamin D3 per day not only had an increase in the level of 25-OH vitamin D to more than 30 ng/ml, but were able to transfer enough vitamin D3 into their milk to satisfy an infant’s requirement.”

Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant.

Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.

Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!

1000 – 4000 IU vitamin D3 / day 50,000 IU vitamin D2 q 2 weeks to treat

deficiency Up to 4000 IU vitamin D3/day is safe for 5

mos Up to 6400 IU / day has been used for 3

months without problems.

• Vitamin D deficiency is much more widespread than previously thought

• Vitamin D deficiency is a factor in many diseases, not only rickets and osteoporosis.

• Modern life is deficient in sunshine, and thus in vitamin D.

• Some form of vitamin D supplementation may be appropriate for many breastfeeding mothers / babies.

• “In the future, we expect that by treating the mother with a sufficient dose of vitamin D, both mother and her recipient infant will achieve normal vitamin D status.”

• Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):239-250.

Rebecca B. Saenz,MD, IBCLC, FABM

111-A Depot DriveMadison, MS 39110

601-898-7979Fax 601-898-7989

drbecky@msbfmedclinic.comAnd on Facebook!