Rebecca B. Saenz, MD, IBCLC, FABM Mississippi Breastfeeding

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Whats the Big Deal about Vitamin D?

• Rebecca B. Saenz, MD, IBCLC, FABM
• Mississippi Breastfeeding Medicine Clinic, PLLC
• Madison, Mississippi

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In the news
And on the Web
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What is Vitamin D?

• 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

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Vitamin D synthesis

• Vit D from skin or diet gt
• Metab in liver to 25-OH-Vit D gt
• 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

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What Vitamin D does--

• 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)

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Disease States

• Skeletal rickets, osteopenia, osteoporosis,
  osteomalacia, fracture
• Muscular weakness, twitches
• Skin -- psoriasis
• Cardiac hypertension, CHF, inc. CRP
• Pulmonary wheezing illnesses
• Immune diabetes, MS, Crohns, RA, OA
• Psychiatric schizophrenia, depression
• Other prostate, colon, breast cancers, and
  non-Hodgkins lymphoma

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Vitamin D levels

• (measured as serum 25-OH-Vit D levels)
• Deficiency lt 20ng/ml
• Insufficiency 21-29ng/ml
• Sufficiency gt30ng/ml
• Preferred range 30-60ng/ml
• Intoxication gt150ng/ml

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Sources of Vitamin D

• 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)

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A word about sunshine . . .

• Its 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!

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It is virtually impossible to get enough
sunshine from November to Februaryabove 35
degrees latitudeto stay sufficient.
35 degrees latitude is the north border of
Georgia, Alabama, and Mississippi, and cuts
Arkansas in half just north of Little Rock
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Sources of Vitamin D

• 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

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Sources of Vitamin D

• 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

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Sources of Vitamin D

• 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

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Sources of Vitamin D

• Dietary (Infants)
• Human Breast Milk Vitamin D content varies based
  on Moms Vitamin D status,
• which varies based on her
• sunlight exposure and dietary intake.
• Range 5-20 IU / liter, if mom unsupplemented
• Up to gt800 IU / liter if mom on high-dose Vit D

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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
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Human Breast Milk is not deficient in Vitamin
DModern life is deficientin sunshine!
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Risk Factors for Vit D Deficiency

• Reduced skin synth
• Sunscreen
• Pigment
• Aging
• Season/latitude/time
• Skin grafts

• Dec. bioavailability
• Malabsorption
• Cystic fibrosis
• Celiac disease
• Crohns disease
• Gastric Bypass surgery
• Cholesterol lowering meds
• Obesity

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Risk Factors for Vit D Deficiency

• 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

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Risk Factors for Vit D Deficiency

• 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

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Risk Factors for Vit D deficiency in infants

• 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

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Recommendations Breastfeeding Babies

• 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

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Supplementation of the nursing infant with oral
vitamin D . . . does not address the issue of why
the antirachitic activity of the mothers 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.
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Correlation of Maternal and Infant 25-OH-Vit D
levels

• Maternal Infant Maternal
  Infant
• Vit D Vit D serum
  serum
• Suppl Suppl 25(OH)D
  25(OH)D
• 2000IU/day 0 36.1 27.8
• 4000IU/day 0 44.5 30.8
• 6400IU/day 0 58.8 46
• 400IU/day 300IU/day 38.4 43
• From 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 80Suppl
  61752S-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.

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We understand more fully now that this
deficiency is not caused by something that is
inherently wrong or missing in mothers milk but
rather by inadequate maternal dietary vitamin D
intake and the resultant low concentrations in
the mothers milk. Wagner CL, Taylor SN, and
Hollis BW. Does Vitamin D Make the World Go
Round? Breastfeeding Medicine 2008
3(4)239-250.
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Supplementation of Breastfeeding Mothers

• 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 infants 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 80Suppl 61752S-1758S.

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Recommendations Lactating Mothers

• 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.

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Summary

• 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.

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Summary

• 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.

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Mississippi Breastfeeding Medicine Clinic, PLLC

• Rebecca B. Saenz,
• MD, IBCLC, FABM
• 111-A Depot Drive
• Madison, MS 39110
• 601-898-7979
• Fax [phone]
• drbecky_at_msbfmedclinic.com
• And on Facebook!