by Dr Samantha Ross, General Practitioner and GPwSI in Preschool Growth and Nutrition
Vitamin D is vital for skeletal growth, bone health and development. Most vitamin D is synthesised in skin after exposure to ultraviolet sunlight. In much of the northern hemisphere, significant synthesis is only possible from April to mid-October, and there must be skin exposure to sunlight for this to happen. Outside of these conditions the body can only rely on stored vitamin D or dietary sources. Dietary sources in the UK are limited and oily fish is the main source. Small amounts are also provided by egg yolk, red meat and fortified foods, such as formula milks for infants and toddlers, some breakfast cereals and margarine.
Severe vitamin D deficiency can result in rickets among children and there is concern that rickets may be re-emerging among children in the UK1. Deficiency can also result in osteomalacia among children and adults and hypocalcaemia in children. A recent study suggested supplementation might reduce the risk of respiratory infections2.
It is known that additional risk factors include:
- Lack of skin exposure to sun (eg. due to climate, wearing clothing, use of sunscreens and not going out)
- Dark skin
- Obesity (and includes babies born to obese mothers and babies born to women with gestational diabetes)
A newborn baby’s vitamin D status is determined by the mother’s level of vitamin D during her pregnancy3. Infants who are exclusively breastfed, or have less than 500 ml a day of infant formula, may not get enough vitamin D to meet their needs4, 5 (see below for more information). Infants from Asian families are at particular risk. Up to a third of Indian, Bangladeshi or Pakistani children have been found to have low vitamin D status at age 26.
Antenatal and Postnatal Advice for Mothers
The National Institute for Health and Clinical Excellence (NICE) and the Scientific Advisory Committee on Nutrition (SACN) recommend that pregnant and breastfeeding women take a vitamin D supplement of 10mcg (or 400IU) daily and that health professionals inform all pregnant and breastfeeding women about the importance of this for their health and the future health of their baby.
There are variations in the provision of vitamin supplementation available to pregnant and breastfeeding mothers and their infants across the UK – in some areas Healthy Start maternal vitamins (which provide vitamin D, folic acid and vitamin C) are provided universally to all pregnant women and infants and in other areas this is only provided free to those eligible through the Healthy Start Scheme. Healthy Start maternal vitamins are the supplement recommended for pregnant and breastfeeding women as other supplements may have a different balance of nutrients added.
It is essential that maternal vitamin D deficiency is prevented or corrected during pregnancy to prevent babies being born with depleted stores. In some cases pregnant woman may require a higher dose of vitamin D – this should be discussed with her GP. If a mother has very low vitamin D stores or other risk factors such as malabsorption, consider local guidelines and seeking specialist advice7.
All pregnant women should take a supplement of 10mcg/day vitamin D during pregnancy and continue to take this when breastfeeding
Healthy Start Vitamins
UK health departments5 and NICE8 have issued evidence-based guidance on vitamin D supplements for various at-risk groups and how to distribute free supplements (that contain vitamin D) to eligible families. A report has documented that parents found it difficult to access Healthy Start vitamins, health professionals did not promote the scheme and eligible families were often unaware of it. The distribution system was found to have failings, and mothers were not motivated to take the vitamins or to give them to their children9.
All at-risk groups should be advised how to obtain the vitamins locally and people who may be eligible for the Healthy Start scheme should be advised how they can apply. The scheme provides vouchers that can be used to buy infant formula, cows’ milk and plain fresh or frozen fruit and vegetables. People also receive coupons that can be exchanged for vitamin supplements that include the recommended amounts of vitamin D.
Updated Guidance for Infants
The Scientific Advisory Committee on Nutrition has reviewed requirements for the whole population including new-born babies10.
Everyone over one year of age should take a 10mcg/day vitamin D supplement and, as a precaution, breastfed babies from birth up to one year of age should also be given a supplement of 8.5-10mcg/day vitamin D.
Babies who are formula fed do not require vitamin D if they are having 500ml/day of infant formula or more, as infant formula already has added vitamin D.
Unicef UK Baby Friendly Initiative11 advise there is a risk that messages around vitamin D supplementation might give the impression that infant formula is superior to breast milk because supplementation is not required if a baby is bottle fed. It advises that health professionals consider how the message is communicated to parents:
- Emphasising that the potential problem is related to a lack of sunlight in the UK, not simply dietary insufficiency.
- Vitamin D deficiency affects the whole population, not just breastfed babies.
- Vitamin D has to be added to infant formula, so that is why further supplementation is not needed.
- There is little evidence of significant vitamin D deficiency among breastfed babies but the Government is taking a ‘precautionary’ approach to protect everyone.
Guidance for Professionals Supporting Parents to give their Baby Vitamin D9
Healthy Start vitamins for infants currently contain 7.5mcg of vitamin D per day, as well as vitamin A and vitamin C and are licensed from 4 weeks onwards (correct in April 2017). The new recommended preventative dose is 8.5-10mcg of vitamin D per day from birth. The Department of Health (DH) have confirmed that a new Healthy Start children’s vitamin product will not be available until Autumn 2018, and this will be compliant with the new government advice on vitamin D from birth. The product is likely to be available as a food supplement rather than a licensed medicine to enable ease of availability. Further information will be available in the 6 months preceding the launch of the new product. Until that time, it is advised that the current Healthy Start vitamins are used.
The current Healthy Start vitamins children’s drops are a licensed medicine, and the DH advise that the license is for 5 drops per day from the age of four weeks and upwards. The DH has advised commissioners and others that healthcare professionals are able to use the drops outside of the license if they think an individual case merits that use. As health visitors and other healthcare professionals hold clinical qualifications they are able to make a decision on whether using the drops outside of the licensed conditions is possible (personal communication to the author from Public Health England, April 2017).
Vitamin drops can be given on a sterilised spoon. ‘Droppers’ are hard to sterilise compared to spoons and there are issues with getting the correct number of drops into the dropper- so it is easier to drop the vitamins on to a sterilised spoon. Applying the drops to the breast may also be advised, but there is a risk of breast rejection. Vitamin drops should not be given to breastfed babies via a bottle with water or flavoured drinks or on a dummy.
Healthy Start UK-wide government scheme to improve the health of low-income pregnant women and families with young children on benefits and tax credits. Women who are pregnant or have a child under four years can apply for means-tested vouchers to spend with local retailers. The vouchers can be spent on: plain cows’ milk, plain fresh or frozen fruit and veg (with no added ingredients) and Stage 1 infant formula milk based on cows’ milk. The scheme also gives access to Healthy Start vitamins for pregnant women and children.
Healthy Start: For Health Professionals Simply explains what the Healthy Start scheme is and eligibility criteria.
Healthy Start: Information for Professionals-Your Role Applications for Healthy Start must, by law, be supported by a registered health professional – usually a midwife or health visitor. There should not be a charge applied for this.
Healthy Start: Information for Health Professionals- Vitamins Explains the requirements for vitamin supplementation for women and children and links to UK regional services providing access to Healthy Start vitamins.
The NHS Website: Find Healthy Start Vitamins Services Postcode locator for Healthy Start vitamins services in England
First Steps Nutrition Trust: Healthy Start Includes links to information on the Healthy Start Scheme and a recipe book ‘Making the Most of a Healthy Start’ to support budget cooking and the use of ingredients which can be bought using Healthy Start vouchers.
- Pearce S, Cheetham T. Diagnosis and management of vitamin D deficiency. BMJ. 2010;340(jan11 1):b5664-b5664.
- Martineau A, Jolliffe D, Hooper R, Greenberg L, Aloia J, Bergman P et al. S102 Vitamin d supplementation to prevent acute respiratory infections: systematic review and meta-analysis of individual participant data. Thorax. 2016;71(Suppl 3):A60.2-A61.
- NICE Guideline CG62: Antenatal Care for Uncomplicated Pregnancies Updated January 2017
- NICE Guideline PH11: Maternal and Child Nutrition Updated November 2014
- Department of Health: Vitamin D – advice on supplements for at risk groups, Chief Medical Officers’ report February 2012
- Office for National Statistics: Infant feeding in Asian families, 1994–1996; Waves 1-5
- NICE CKS: Vitamin D deficiency in adults- treatment and prevention November 2016
- NICE Guideline PH56: Vitamin D- increasing supplement use in at-risk groups November 2014
- Department of Health Policy Research Programme: Healthy start- understanding the use of vouchers and vitamins
- SACN (2016) Vitamin D and Health
- Unicef UK Baby Friendly Initiative: Infosheet- Statement on Vitamin D Supplementation For Breastfed Babies