CLINICAL HIGHLIGHTS Vitamin D Supplementation To Prevent Rickets in Breast-Fed Babies Agency for Healthcare Research and Quality • 2101 East Jefferson Street • Rockville, MD 20852

Introduction Forest University School of Medicine, Winston-Salem, and at the University Vitamin D is necessary for proper bone of North Carolina (UNC) School of growth, but it is not found in many Medicine, Chapel Hill. The UNC foods naturally. It is synthesized in the study was part of the work of the UNC skin with exposure to sunlight, but Centers for Education and Research on many babies do not get much exposure Therapeutics (CERTs™) program. to the sun for a number of reasons, www.ahrq.gov CERTs™ are funded and administered such as not spending time outdoors by the Agency for Healthcare Research Key Finding: Dark-skinned infants and children and wearing clothes, hats, or sunscreen. and Quality (AHRQ). who are fed only breast milk should receive The darker an infant’s skin, the more 400 IU of vitamin D supplementation daily, sun exposure is needed to synthesize Methods vitamin D. Although breastfeeding is beginning by at least 2 months of age, In 1999, Wake Forest and UNC set out the ideal form of nutrition for infants, to prevent rickets. to find what changes in the care of it does not supply the vitamin D infants in North Carolina could needed for healthy bone growth. The study “Prevalence of Vitamin D-Deficient account for the increase in the number Nutritional rickets is a condition in Rickets in Minority Infants” was conducted at of cases of nutritional rickets seen in which children’s bones are too soft and Wake Forest University School of Medicine, their two medical institutions. Records do not develop properly. Winston-Salem, and at the University of North on all patients diagnosed with Thanks largely to vitamin D Carolina (UNC) School of Medicine, Chapel Hill. nutritional rickets at the two supplementation of infant formula and It was funded in part by the Agency for institutions during the period 1990-99 recognition of the need for sunlight, were reviewed. Information was Healthcare Research and Quality (AHRQ), the rickets had become largely a thing of obtained on age at diagnosis, infant Federal Government’s lead agency charged with the past in the United States. However, feeding (breastfeeding and other foods), supporting research to improve the quality of cases of nutritional rickets among vitamin D supplementation (if any), health care, reduce its cost, address patient babies have been on the rise recently. racial/ethnic background, and sex, as safety and medical errors, and broaden access For this reason, dark-skinned infants well as x-ray findings, height, and to essential services. and children who are exclusively breast weight. Diagnoses of nutritional rickets fed should receive 400 IU of vitamin D were based on clinical, biochemical, supplementation daily, beginning by at and x-ray findings. least 2 months of age. This is the After diagnosis, all the babies received finding of a study, “Prevalence of vitamin D therapy, and their x-ray and Vitamin D-Deficient Rickets in laboratory abnormalities were resolved U.S. Department of Health Minority Infants,” conducted at Wake and Human Services or resolving by the end of the study. Public Health Service Findings and Discussion infants is a safe, low-cost, and reasonable option. Of 30 babies with nutritional rickets seen at the Wake Forest and UNC Action Taken medical centers, all were black and all As a result of these findings, the North were breast fed. Most of them were Carolina Women’s, Infants and growth retarded—nearly a third, Children (WIC) program now severely so. Except for babies who had distributes a free multivitamin recently begun receiving vitamin supplement for babies 6 weeks of age or supplementation or had begun drinking older who are exclusively breastfeeding. vitamin D-fortified milk, all the babies It also sends out fact sheets on Vitamin had vitamin D deficiency. D supplementation to both parents and Breastfeeding among black women in health professionals. North Carolina has risen dramatically The American Academy of Pediatrics’ in the past few years. Breast milk is the present policy is that vitamin D “may ideal form of nutrition for infants, but need to be given before 6 months of age the amount of vitamin D in breast milk in selected groups of infants” (infants depends on the vitamin D status of the who do not get enough sunlight or mother. Dark-skinned mothers need whose mothers are vitamin D more exposure to sunlight than light- deficient). A recent editorial in The skinned mothers to produce the same Journal of Pediatrics questions the amount of vitamin D. The same is true advisability of limiting supplementation of darker skinned babies. Unless they to high-risk groups of breast-fed infants. receive vitamin supplements, breast-fed The American Academy of Pediatrics is dark-skinned infants are at risk for currently reviewing their guidelines on rickets. vitamin D supplementation. The amount of sun exposure an infant needs to prevent rickets depends on For More Information skin pigmentation, the amount of Study findings are presented in an clothing worn, latitude, time of day, article in the August 2000 issue of The season of the year, amount of smog, Journal of Pediatrics: Kreiter SR, and so on. Moreover, many parents do Schwartz RP, Kirkman HN, et al. not want to expose their babies to too Nutritional rickets in African American much sun for fear of skin cancer. breast-fed infants. J Pediatr Maternal vitamin D status also plays a 2000;137(2):153-7. role in this vitamin deficiency, but it is impractical to test nursing mothers. The editorial on the article is in the Although there is no national reporting same issue of The Journal of Pediatrics: system for rickets that can give statistics Welch TR, Bergstrom WH, Tsang RC. on this condition nationwide, Vitamin D-deficient rickets: the indications are that rickets is on the rise reemergence of a once-conquered throughout the United States. disease [editorial]. J Pediatr 2000; Increasingly, it appears that vitamin 137(2):143-5. supplementation for all breast-fed

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AHRQ Pub. No. 02-P001 November 2001 revised January 2002