Nutritional rickets, a childhood disease caused by vitamin D deficiency, continues to be a public health problem in a vast number of countries around the world. Despite medical awareness and advances in developed countries, the disease continues to represent an issue among infants and children. Infants of darker skin, infants who are exclusively breastfed, and those who are prevented from adequate ultraviolet light exposure due to climate conditions, social and/or religious customs, are at higher risk of developing this disease. During lactation, the maternal vitamin D insufficiency that is caused by a lack of sun exposure and a diet low in vitamin D correlates to low levels of the vitamin through breast milk, resulting in infant nutritional rickets. Not only does Vitamin D deficiency remain the major cause of rickets among infants around the globe; the recent resurgence has resulted in the causation of other diseases, making the compliance of health care providers and pediatricians a crucial aspect to avoid its emergence in modern society.
Vitamin D is necessary for the normal formation of skeletal structure and teeth enamel, for general fetal growth, as well as for the appropriate absorption of calcium and phosphorus from the bowels. It also plays an important role in immune function. According to nurse practitioner and researcher Julia Delcour (2011), “Preliminary research has linked vitamin D to multiple sclerosis, type 1 diabetes mellitus, cancers, respiratory illness, and psychiatric conditions.” This fat-soluble vitamin can be naturally found in some foods in small quantities, and is also synthesized by the integumentary system cells on the skin in response to ultraviolet light exposure. Therefore, vitamin D holds an inactive, and an active state. When a vitamin D deficiency occurs in the human body, the intestinal absorption of calcium and phosphorous is not aided. As a result, the already existing calcium in the bones is pulled out in order to complete specific bodily functions that require this mineral. This leads to the obstructed growth of young children, by softening and weakening long bones that will bend and deform under the infant’s weight when starting to walk. Nutritional rickets is therefore often characterized by bowlegs, and hypocalcaemia.
Since rickets has been documented in medical records as early as the first and second century, advances have been made to treat and prevent the disease that has caused the death of many infants. Autopsies made during a research conducted in 1909 provided “proof of rickets in 96% of deceased infants aged 18 months or younger” (Delcour, 2011). The treatment and prevention of rickets, also known as antirachitic, was practiced during decades by using cod-liver oil supplementation and sunlight exposure. Later on in time, it was discovered that the vitamin D component in cod-liver oil was responsible for the protection against the disease. This led to the discouragement of breast milk as the essential method to protect infants from diseases, and the promotion of cod-liver oil supplementation instead. Consequentially, the infant formula production surfaced and the government made the decision to fortify the breast milk supplement with vitamin D to prevent rickets. Yet a vast number of studies and research during the past decades have returned breastfeeding to favor, pointing out its health benefits for infants, and mothers alike.
In the United States, breastfeeding had been reintroduced in the 1980s. Health providers and pediatricians encourage breastfeeding again, especially exclusive breastfeeding for at least the first six months. Since infant nursing’s prominent return, nutritional rickets has also reemerged in the infant population in today’s society. Several studies and observational reports have determined that “in vitamin D deficient infants, up to 95% with clinical rickets are breastfed” (Delcour, 2011). This has respectively prompted the use of vitamin D supplementation, not only in infant formula, but also for breastfeeding mothers. “The Food and Drug Administration requires fortification of formula concentrations to be between 40 and 100IU/100kcal” (Delcour, 2011). On the other hand, mothers are not forced to take vitamin D supplementation during pregnancy, neither during lactation. Thus, it is crucial for primary care providers (PCP) to educate families about the role of vitamin D in their child’s development, and screen infants at high risk, to establish adequate levels of vitamin D in pediatric patients.
Breastfed infants and children are the most susceptible to nutritional rickets, but exclusive breastfeeding is not the sole risk factor. “Other factors that may lead some babies to an even higher risk for deficiency are prenatal conditions, geographic location, phenotype, and social and economic environment” (Delcour, 2011). Women are advised and encouraged to take prenatal vitamins during pregnancy, although it does not always guarantee proper vitamin levels that will be sufficient for the child, while in utero and even after birth. The climate conditions represent an important factor in vitamin D production, as it is synthesized by ultraviolet light that penetrates the skin and activates the metabolite. Young children with a darker skin are more prone to have nutritional rickets “because of their skin’s solar-reflective qualities” (Delcour, 2011), compared to those that are fair-skinned. The same accounts for mothers with higher levels of pigmentation. Furthermore, populations living in regions where the weather has more resemblance to the winter season, and sunlight is not available for vast amounts during the day, are at risk of vitamin D deficiency. This does not exclude vitamin D deficiency from sun-rich environments though, where cultural and economic considerations are responsible. People, who are always wearing clothes that cover most of the body, whether it is due to religious beliefs or fashion style, are also at risk.
In order to achieve appropriate vitamin D levels, it is of great value to keep the risk factors in mind and know when these apply, and to whom. To achieve adequate levels, women who choose to breastfeed should be encouraged to take prenatal vitamins, consume foods rich in vitamin D through diet – such as oily fish, organ meats and egg yolks – and expose to sunlight. “Sunlight accounts for roughly 90% of most people’s vitamin D production” (Delcour, 2011), yet dermatologists and cancer experts advise caution in sun exposure, and recommend the regular use of sunscreen because of the rise of skin cancer concerns (Black et al., 2003). This contributes to a slippery slope that can drive health care providers to contradictions. Since infants that are six months and younger should not be directly exposed to the sun, and should always be protected with sunscreen, the American Academy of Pediatrics (AAP) favors the direct supplementation of infants from 2 months of age, and onwards. The prevention methods for the risk of skin cancer should not be overridden, which drastically impedes the potential for infant’s to synthesize vitamin D, thus requiring another source.
Direct infant supplementation is preferred and recommended for exclusively breastfed, partially breastfed, and formula-fed young children. The guidelines started off with 200 IU per day of vitamin D supplementation, but the AAP doubled the amount in 2008. As a result, “a number of countries now recommend that all breastfed infants receive a daily supplementation of 400 IU per day” (Thiele, Senti, & Anderson, 2013), with the main goal to reduce rickets in the infant population.
The sufficiency of vitamin D is not only linked to the prevention of rickets, but to accomplish long-term health benefits. Several studies have shown that vitamin D is extremely important for the protection against chronic diseases. Research by Saathoff, Hanson, Anderson-Berry, Lyden and Fernandez (2014) points out how a correlation was established between “vitamin D supplementation during infancy and bone mineral mass in prepubertal girls”, as well as “an 80% decrease in the risk of diabetes mellitus type 1 in infants who received at least 2000 IU per day for the first year of life”. The researchers further explain how vitamin D is “involved in the regulation of genes that control cell proliferation and differentiation, apoptosis, and angiogenesis.” According to these results, other diseases such as asthma, cancer or cardiovascular disease can represent a risk factor for the deficiency of this specific vitamin.
Vitamin D sufficiency is clearly necessary in pursuance of a healthy life, starting as early as in the mother’s womb. Hence it is important to keep the vitamin D levels balanced during pregnancy and lactation, towards assuring the wellbeing of the newborn child, and its future developing stages of life. A woman should breastfeed her child as long as it is possible, but should also make sure that the infant is receiving the adequate amount of nutrients necessary to successfully grow in a healthy manner. Yet first, PCP should be trained and educated, so that they can properly educate and advise those responsible for their pediatric patients. Based on several surveys of physicians, “The most common reason for not supplementing infants with vitamin D was the belief that breastfed infants received adequate sunlight” (Saathoff, Hanson, Anderson-Berry, Lyden & Fernandez, 2014). Furthermore, “17% of physicians felt that breast milk had sufficient vitamin D.” As a consequence, a vast number of parents have believed, and still believe that breast milk can be an exclusive nutritional source for infants, without the need of any supplementation.
Primary care providers are capable of, and responsible for improving compliance with current guidelines. Both health care professionals and families should be informed about the importance of vitamin D, its functions, overall health, and the diseases that vitamin D deficiency can cause; including the fact that although breastfeeding is the most favorable nutrition for infants, they do also require a second source of vitamin D. Delcour (2011) claimed, “While direct infant supplementation is preferred, maternal supplementation has shown promising results.” Therefore, mothers should also be encouraged to take vitamin supplements during pregnancy and after delivery, to achieve optimum health for the baby and herself. Women who live in regions where the climate is not favorable for vitamin D synthesis, and for those who have religious practices that create a barrier in reaching a balance should be especially motivated. Equilibrium should be found among the controversy between exposure to the sun and skin cancer concerns as well. This will make it easier, and less confusing for PCP and parents to provide a good health foundation for their children.
American Academy of Pediatrics. (n.d.). AAP.org. Retrieved October 16, 2014, from http://www.aap.org/en-us/Pages/Default.aspx
Black, L. S., Eidelman, A. I., Gartner, L. M., Lawrence, R. A., Naylor, A. A., O’Hare, D., & Schanler, R. J. (2003, April). Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. (Clinical Report). Pediatrics, 111(4), 908+. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA100171681&v=2.1&u=nu_main&it=r&p=AONE&sw=w&asid=dcbac21658114be9141d94ec574cfb69
Delcour, J. (2011, April). Reversing vitamin D deficiency in infants: with fortified formula being shunned in favor of breastfeeding, rickets is making a comeback. Supplementation is the surest means of prevention. Clinical Advisor, 14(4), 68+. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA263519792&v=2.1&u=nu_main&it=r&p=AONE&sw=w&asid=7f3c9f24ed1ceb32fe51aaa486aa5622
Saathoff, M., Hanson, C., Anderson-Berry, A., Lyden, E., & Fernandez, C. (2014). Vitamin D Supplementation Practices in Breastfed Infants in Outpatient Pediatric Clinics. ICAN: Infant, Child, & Adolescent Nutrition, 6(2), 122-126. Retrieved October 18, 2014, from the SAGE journals database.
Thiele, D. K., Senti, J. L., & Anderson, C. M. (2013). Maternal Vitamin D Supplementation to Meet the Needs of the Breastfed Infant: A Systematic Review. Journal of Human Lactation, 29(2), 163-170.