Breast milk is a close-to-perfect food for infants, but it is lacking in vitamin D, putting exclusively breast-fed children at risk for developing rickets. Photo courtesy of Kewulay H. Kamara.

CHICAGO—The Centers for Disease Control is expected to issue a recommendation this Spring calling for universal vitamin D supplementation for all breast-fed infants.

The reason? Rickets.

CDC epidemiologists are seeing a rise in this archaic nutritional deficiency, which they attribute to a nationwide increase in breast-feeding over the last decade, combined with public health efforts to keep kids out of the sun as a way of preventing malignant melanoma.

Breast milk supplies only about 4 percent of the daily (vitamin D) requirement, said Susan Baker, MD, professor of pediatrics, State University of New York, Buffalo.

Breast milk may be a close-to-perfect food for infants, but when it comes to vitamin D, it is lacking. Adequate infant levels cannot be achieved by giving vitamin D supplements to lactating mothers without giving toxic doses.

Humans manufacture needed vitamin D by exposing their skin to the sun; limiting a child’s time in the sun reduces levels of vitamin D. Combined, the movements toward reduction of sun exposure and favoring breast milk over vitamin D-fortified infant formulas increases the risk of vitamin D deficiency, the cause of rickets, in early childhood, said Dr. Baker at the annual meeting of the American Academy of Pediatrics.

Recent reports about a resurgence of rickets has prompted the CDC to convene a special consensus panel next spring to draft a recommendation for universal vitamin D supplementation of all breast fed infants, said CDC epidemiologist Dr. Kelley Scanlon.

Rickets was a scourge of the 18th and 19th century that was largely vanquished midway through the 20th century through the widespread use of cod liver oil and vitamin D-fortified dairy products, said Dr. Baker, chair of the AAP nutrition committee. But like a number of seemingly-conquered diseases, rickets is showing signs of a comeback.

In the last year, studies have confirmed 6 cases of children hospitalized with severe rickets. Dr. Scanlon was co-author of a recent CDC study that reported on six cases of “hospitalized rickets in Georgia from January 1997 to June 1999,” she said.

She admitted that 6 cases seems very minimal, but these are hospitalized cases, meaning that they were quite advanced. Given the fact that reporting of rickets is not mandatory, and many sub-acute cases escape clinical detection, she and others at CDC believe the actual incidence of the disease is much higher. She added that the pediatric community has heard about her surveillance, and is beginning to send in more reports.

A second study in North Carolina described 30 cases over a 10-year-period, with 18 of the 30 (60%) occurring in the last 18 months. Dr. Baker said the risk of rickets is particularly high for African-American infants and other darker-pigmented children, because dark pigmentation is a natural filter for sunlight. In both Georgia and North Carolina all cases were among African-Americans. Almost all of the reported cases of rickets so far have been in exclusively breast-fed children.

The North Carolina state health department responded to the case reports by issuing a mandate to physicians to prescribe vitamin D supplementation for all breast-fed infants. Dr. Scanlon said that Alaska also recently mandated vitamin D supplementation for nursing infants. The recommendation is for supplementation with 400 IUs of vitamin D.

Because infant formula is fully fortified, North Carolina tells parents to stop vitamin D supplements if an infant is taking even a single bottle of formula.

One problem with supplements, says Dr. Baker, is that there is no single liquid vitamin D supplement available for infants. The best choice, she said, is one of the liquid infant multivitamin formulas such as Tri-Vi-Sol.

While the recommendation is reasonable, it has raised some concern among breast-feeding advocates. “The biggest concern is that this recommendation is saying that breast milk is not a complete food,” said Lawrence Gartner, MD, professor emeritus of pediatrics and ob.gyn, University of Chicago, and a medical advisor to La Leche League International, the world’s largest breast-feeding advocacy group.

“We must emphasize that this is not really a breast feeding problem. There is nothing wrong with breast milk so long as the baby is getting adequate sunshine,” said Dr. Gartner in an interview with Holistic Primary Care.

Why, then is CDC focusing on breast-feeding instead of sun exposure? Possibly, CDC officials are trying to avoid running counter to their strong, and highly successful melanoma prevention recommendations. It may also be an attempt to avoid potential racial discrimination issues since a sun exposure solution would require differential recommendations for darker versus lighter pigmented individuals.

La Leche League spokeswoman Kim Cavaliero said her organization is not likely to embrace a vitamin D supplementation recommendation. “If a mother has concerns about vitamin D, she should ask her physician. We do not want to make blanket statements.”

Although the proposed new CDC guideline will be limited to breast-fed infants, Dr. Baker believes physicians should also consider vitamin D supplements for toddlers, especially those whose parents believe their children are lactose intolerant or have some other aversion to dairy.

Obviously, children who drink a lot of Kool-Aid, Gatorade and soda need supplements (not to mention dietary changes), but those who exclusively drink soy and rice milk products that are not fortified may also be vitamin D deficient, said Dr. Baker. She strongly advises parents who insist on using these milk substitutes to only buy fortified products.

THE REDUX: Rickets, secondary to vitamin D deficiency, is on the rise, a trend CDC attributes to increased breast-feeding and decreased sun exposure. Next spring, CDC is planning to issue recommendations for vitamin D supplementation (400 IU/day) for all breast-fed infants. Breast-feeding advocates point out that while breast milk is low in vitamin D, this is only a problem if an infant is not getting enough sunlight.