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21/04/23 Ted Greiner
Nutrients of concern in exclusively breastfed infants
7th Neonatal Conference, Jeddah
Saudi Arabia, 20-22 Feb 2012Ted Greiner, Hanyang University
21/04/23 Ted Greiner
• Vitamin D and iron are the main nutrients of public health concern for all infants, and special considerations come into play with exclusively breastfed infants
• Vitamin D is actually not a vitamin but a steroid hormone.
• It is made in our skin when exposed to ultra-violet radiation from the sun.
21/04/23 Ted Greiner
• It is needed for the absorption of calcium, and maintenance of normal calcium and phosphorus levels, which in turn are needed to make bone and teeth.
• There are receptors for it in most of the cells in our body so it probably has other functions as well.
• It must undergo hydroxylation first in the liver and again in the kidney to be biologically active in the body as 1,25-dihydroxyvitamin D [1,25(OH)2D]
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• Deficiency of vitamin D and/or calcium leads to rickets, a disease in children in which the bones grow soft and deform in shape.
2-year old boy with rickets from
Eastern Cape, RSA
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• In adults this disease is called osteomalacia. Adequate vitamin D throughout life may also help prevent osteoporosis.
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• Vitamin D deficiency (VDD) also seems to lead to increased susceptibility to infection.
• It seems to have a role in modulation of cell growth, neuromuscular and immune function, and reduction of inflammation.
• VDD may be associated with an increased risk of developing diabetes and colon cancer.
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• Vitamin D is not present in many foods. It is in small amounts in eggs and butter but NOT in milk unless commercially fortified.
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• It is present in fatty salt-water fish that feed near the surface and thus cod-liver oil was used to provide supplemental vitamin D before it was available in synthetic form.
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• Recommended daily allowances (RDAs) are 400 IU (10 g) per day for infants <12 mo and 600 IU for others <70 yr.
• Mild adverse effects can in few cases be seen at the tolerable upper intake levels (ULs) at doses of about 1000 IU for infants < 6mo and 4000 IU a day for people >9yr. Sun exposure cannot lead to excess levels.
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• Vitamin D transferred placentally meets the needs of newborns until about 8 weeks of age if the mother was not deficient.
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• Breast milk usually provides 25-80 IU of bio-active vitamin D per day
• This can be increased by maternal supplementation of 2000-4000 IU per day
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• The required amount can be obtained from sunlight but how much is needed depends on:
– Skin colour – Amount of clothing worn– Cloudiness, smog or air pollution– Use of sun screen (when used
effectively, it prevents formation of vitamin D in skin)
– How high in the sky the sun is, in turn determined by: •Latitude•Time of day•Season
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Sun exposure may be inadequate among:
•Women who veil •Women or children who are sequestered in the home
•People who are too sick or old to spend enough time outdoors
•People who are institutionalised.
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• Sun exposure is NOT recommended < six months old:– increased risk of skin
cancer later in life.• Sun exposure should
be for short, regular periods.
• Avoid long exposures and mid-day exposures.
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• For breast-fed infants and others consuming <1L/d of fortified milk, 400 IU per day is recommended, given as drops.
• Indeed, all children should take a supplement if they do not consume adequate fortified milk
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• Commercial milk products and some commercial infant foods are the main foods fortified with vitamin D.
• This varies by country so you have to read labels.
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• Rickets is increasing in dark-skinned people where exclusive breastfeeding is increasing (USA and UK).
• Breast milk has 1/5 the calcium of cow milk.
• Supplements commonly given to babies (sugar water; teas) displace breast milk and calcium deficiency may result.
• This has received little attention
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Ted GreinerProfessor of NutritionHanyang UniversitySeoul, South Korea
Ted’s Email:[email protected]
Ted’s Website:www.tedgreiner.info
