No increase in meeting vitamin D intake guidelines since 2009

Less than 40% of U.S. infants met American Academy of Pediatrics (AAP) guidelines for daily vitamin D intake, according to an analysis national data, and levels were particularly low for breastfed babies.

In the study of National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2016, 27.1% (95% CI 24.3% to 29.8%) of infants (ages 0 to 11 months) met vitamin D intake guidelines, reported Alan E. Simon, MD, of the NIH in Rockville, Md., and Katherine A. Ahrens, PhD, of the University of Southern Maine in Portland.

Additionally, non-breastfeeding infants were more likely to meet guidelines than breastfeeding infants at 31.1% (95% CI 27.6% to 34.5%) versus 20.5% (95% CI 15.4% to 25.5%, P<0.01), they stated in Pediatrics, adding that the findings held true in most demographic subgroups.

The authors wrote that “we observed no increase in meeting AAP vitamin D intake guidelines since 2009 [(P>0.05)]… These findings suggest renewed consideration of how to best meet vitamin D intake guidelines.”

In 2008, the AAP revised its guidelines for infant vitamin D intake from 200 IU daily to 400 IU daily. By 2010, all guidelines published worldwide suggested infant vitamin D intake should be 400 IU/day.

For the study, the authors “estimated the percentage of infants meeting the 2008 AAP vitamin D guidelines on a given day, defined as either consuming at least 1 L of infant formula or receiving a supplement of at least 400 IU vitamin D or both….Breastfeeding was identified…if an infant consumed any breast milk on either of the 2 possible days of dietary recall. Breastfeeding included both exclusive (breast milk only) and partial (breast milk plus formula, other liquid, and/or solid food).”

They pointed out that a limitation of the study was the lack of data on vitamin D supplementation or formula intake for days other than the single day intake assessed in the NHANES dietary recall, along with recall bias by parents.

Also, the analysis did not assess food or cow’s milk as vitamin D sources. Though the AAP recommends cow’s milk not be given to infants age <1 year, nearly 13% of infants in the dietary recall records used in the investigation consumed regular non-formula milk products, Simon and Ahrens noted.

They reviewed 1,435 NHANES dietary recall records, including breastfeeding status. The breastfeeding (37.4%) and non-breastfeeding (62.6%) groups were compared across multiple demographic subgroups of age, sex, race or ethnicity; recipient of federally funded supplemental nutrition (WIC), income as a percentage of the federal poverty level, education level, and health insurance status.

The authors found that breastfeeding infants were more likely to be younger (ages 0 to 5 months vs 6 to 11 months); non-Hispanic white; living in families with higher income and whose household head was a college graduate; and were more likely to have private insurance (P<0.01). Breastfeeding infants were also less likely to have received WIC benefits.

However, the breastfeeding group were also less likely to meet vitamin D intake guidelines than their non-breastfeeding (27.1% versus 31.1%) counterparts, although households with a family income ≥400% of the federal poverty level were twice as likely to meet guidelines as those in any other income group.

Available data from 2015 to 2016 demonstrated that 20.8% (95% CI 13.5%-29.8%) of breastfeeding infants met guidelines, while 35.3% (95% CI 26.9%-44.2%) of non-breastfeeding infants did the same (P<0.05).

Younger (0 to 5 months) non-breastfeeding infants were more likely to meet vitamin D intake guidelines than those 6 to 11 months (36.1% versus 27.7%, P<0.05).

Demographic race and ethnicity analysis showed that non-Hispanic white infants seemed to have more socioeconomic advantages versus ethnicities, vitamin D intake was not one of them.

“In unadjusted analyses, across all infants 0 to 11 months of age, non-Hispanic white infants were less likely than non-Hispanic black and non-Hispanic other infants to meet vitamin D intake guidelines,” the authors noted (23.4% versus 33.1% and 37.7%, respectively, P<0.05 and P<0.01, respectively). They investigators attributed this to the higher intake of formula by the non-Hispanic white groups.

Only one demographic subgroup had more than 40% of its infants meet the guidelines: non-Hispanic other race and/or ethnicity, which comprises only 6% of the U.S. infant population, Simon and Ahrens reported. This group includes Asian, American Indian and Alaska native, Native Hawaiian or Pacific Islander, and other (including multiracial) infants.

“Probable impediments to meeting the AAP guidelines include a combination of inconsistent prescribing by clinicians and poor adherence to the use of a supplement by parents of infants, and this is further complicated by a lack of awareness of the consequences of vitamin D deficiency in infants among the public,” stated Jaspreet Loyal, MD, and Annette Cameron, MD, both of Yale University in New Haven, Conn., in a commentary accompanying the study.

They also pointed out that previous research advocated for vitamin D support in breastfed infants, either with dissolving filmstrips or liquid drops. “Data suggest that supplementing mothers of exclusively breastfed infants with vitamin D can provide adequate levels of vitamin D in infants in the first month of life, but more research is needed,” they wrote.

Simon and Ahrens said their findings support incorporating breastfeeding and socioeconomic status into the design considerations of future efforts to help U.S. infants meet vitamin D intake guidelines, an idea that was backed by Loyal and Cameron: “The study is a call to action for the pediatric community to rethink and to reassess its approaches to optimizing vitamin D supplementation for infants.”

  1. Less than 40% of nearly all demographic subgroups met American Academy of Pediatrics vitamin D intake guidelines.

  2. Among breastfeeding infants, lower socioeconomic status was associated with failing to meet the guidelines.

Shalmali Pal, Contributing Writer, BreakingMED™

Simon, as well as Loyal and Cameron, reported no relationships relevant to the contents of this paper to disclose.

Ahrens reported support from the Maine Economic Improvement Fund and the NIH.

Cat ID: 138

Topic ID: 85,138,730,138,94,925