Trip Answers

Question answered:01/02/08 Warning! this question is over two years old.

We searched the NLH Guidelines, TRIP and Medline databases but found no guidelines on the treatment of vitamin D deficiency in breast feeding patients.

 

However, the PatientPlus web site contains an article on vitamin D deficiency and in relation to pregnant and breast feeding notes:

 

“If you are pregnant or breastfeeding
Vitamin D is especially important for pregnant or breastfeeding women, and their babies, because it is needed for growth…

 

Treatment - if you are diagnosed with vitamin D deficiency
Doses of up to 1000 units (25 micrograms) daily of vitamin D can be used. (In some situations, higher doses have been used to treat pregnant women.)

 

Important note: if you are pregnant or breastfeeding you should not use high doses of vitamin D (the injections and high dose tablets/liquids described above). This is because of uncertainty about whether these doses are too high for the baby. Doctors tend to be cautious about the dose of vitamin D given to pregnant or breastfeeding women, and will often limit the dose to 1,000 units daily. This is a safe dose. It is likely that higher doses are safe for pregnant women, but we are waiting for more guidance on this subject.”

 

Little information is given on monitoring and following up the patient being treated for vitamin D deficiency, and seem to apply to patients on high doses, simply says:

 

“Some guidelines advise that people taking high vitamin D doses should have their calcium levels checked during the first few weeks. In practice, this is not usually done unless you have symptoms of high calcium as described above.”

 

“Follow up
Most people who are treated for vitamin D deficiency will need to be reviewed a few weeks or months after starting treatment - depending how severe their symptoms are. A further review after one year is advised.” [1]

 

The article also discusses possible complications from vitamin D deficiency in general:

 

“Mild or short-lived vitamin D deficiency usually causes no symptoms. With prolonged deficiency, the risk of getting osteoporosis (bone thinning and fractures in old age) is probably increased. The risk of getting other diseases might also be increased. This is uncertain, but it is possible that vitamin D helps to prevent some conditions such as diabetes, heart disease and cancer.

 

Prolonged, severe deficiency can cause medical problems, which are:
Softening of the bones. This leads to rickets in children and osteomalacia in adults. See separate leaflets on 'Rickets' and 'Osteomalacia'.

 

With severe deficiency, there may be low levels of calcium in the blood. If calcium levels get very low, this can cause muscle spasms (cramps) or seizures. Babies may get breathing difficulties. These symptoms need urgent treatment.
Very rarely, severe deficiency has been reported to cause heart muscle weakness, which was cured by vitamin D treatment.” [1]

 

GPNotebook has an entry on treatment of vitamin D deficiency, but please note it does not specifically discuss the treatment of breast feeding women:

 

• “in adults with confirmed primary vitamin D deficiency.
o need a minimum daily dose of oral vitamin D of 20µg (800 IU)
? with this dose, it takes at least a year for bone to normalise
? in some cases higher doses of vitamin D, to a maximum of 55µg (2,200 IU) daily, may be needed to achieve adequate repletion with vitamin D, especially in older patients, and in 'at risk' ethnic minorities (e.g. south Asian, African Caribbean and Middle Eastern) and to achieve optimal health benefits for bone and soft tissue
? once vitamin D deficiency or insufficiency has been corrected, patients will generally need lifelong preventative vitamin D supplementation
• all patients receiving pharmacological doses of vitamin D should have the plasma-calcium concentration checked at intervals (initially weekly) and whenever nausea or vomiting are present
o serum calcium concentrations should be checked regularly for a few weeks after starting treatment for vitamin D deficiency; then vitamin D, parathyroid hormone (PTH) and calcium concentrations should be checked after 3-4 months of treatment to assess efficacy and adherence to therapy
? after this check at 3-4 months then vitamin D and calcium concentrations should be checked every 6-12 months.”
GPNotebook does add though:
• “Breast milk from women taking pharmacological doses of vitamin D may cause hypercalcaemia if given to an infant.” [2]

 

Of interest also will be an article on rickets in which it states:

 

“Babies get vitamin D from their mothers while in the womb, and then from milk until they are weaned. If a pregnant or breastfeeding woman is lacking in vitamin D, the baby will also have low vitamin D levels. This is a common reason why babies get rickets, and the problem can occur both in the newborn period and later.

 

Who gets rickets?
…Vitamin D deficiency is more likely to occur in the following situations:
Breastfed babies whose mothers lack vitamin D, or breastfed babies where weaning is delayed - if they are not taking vitamin drops. (These babies do not need to stop breastfeeding, they can have breast milk plus vitamin D supplements.)
Children who get very little sun on their skin such as those who are stay indoors a lot, or who cover up when outside.
Children with medical conditions which affect the way the body handles vitamin D, as listed above under causes.
Children with dark skins or of South Asian origin.
Children with a family history of vitamin D deficiency.” [3]

 

Given the lack of guidance on this issue, we would recommend seeking advice from a local specialist or the specialist drugs in lactation medical information service. Should you wish us to refer your query to Medicines Information, please let us know via this link: http://www.clinicalanswers.nhs.uk/index.cfm?action=contact

 

NOTE: Since posting this article we have received correspondance recommending the following articles:

 

1) High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study.
http://www.ncbi.nlm.nih.gov/pubmed/17661565

 

Conclusion: With limited sun exposure, an intake of 400 IU/day vitamin D(3) did not sustain circulating maternal 25(OH)D levels, and thus, supplied only extremely limited amounts of vitamin D to the nursing infant via breast milk. Infant levels achieved exclusively through maternal supplementation were equivalent to levels in infants who received oral vitamin D supplementation. Thus, a maternal intake of 6400 IU/day vitamin D elevated circulating 25(OH)D in both mother and nursing infant.

 

2) Perspective: Vitamin D in pregnancy: an old problem still to be solved?
http://adc.bmj.com/cgi/content/full/92/9/740

 

3) Editorial: The urgent need to recommend an intake of vitamin D that is effective
http://www.ajcn.org/cgi/content/full/85/3/649

 

4) Clinical Review: Not enough vitamin D, Health consequences for Canadians
http://www.cfp.ca/cgi/content/full/53/5/841?searchid=1
 

 

References
1. PatientPlus. Vitamin D deficiency. November 2007.(http://www.patient.co.uk/showdoc/27001328/)
2. GPNotebook. Treatment of vitamin D deficiency. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=1872363567&linkID=35618&cook=yes)
3. PatientPlus.Rickets. November 2007. (http://www.patient.co.uk/showdoc/27001328/)

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