Breast milk alone may not provide all the vitamins a growing baby needs. Sometimes pediatricians will recommend additional Vitamin D and iron. Why are these vitamins being recommended and what kind of effect does it have on mother and baby?
The Boob Group
Vitamin Supplements For The Breastfed Baby
Episode 6, July 2nd, 2012
Please be advised, this transcription was performed from a company independent of New Mommy Media, LLC. As such, translation was required which may alter the accuracy of the transcription.
Dania Lindenberg: When a baby is exclusively breastfed, sometimes a concerned is raised that the baby may not be getting enough essential nutrients, specifically, Vitamin D and Iron. I’m Dr. Dania Lindenberg, a pediatrician with Scripps Coastal Medical Centre in Hillcrest. Today, we will be discussing important supplements to consider for your exclusively breastfed baby. This is The Boob Group, Episode 6.
Robin Kaplan: Welcome to The Boob Group broadcasting from the World Education Centre at San Diego. I’m your host, Robin Kaplan. I’m also a certified lactation consultant and owner of the San Diego Breastfeeding Centre, at The Boob Group where your online support group for all things related to breastfeeding. Wondering how you can become involved with our show? Visit our website at http://www.theboobgroup.com where you can send us comments or suggestions through our contact link. You can also join the conversation on our Facebook page. You can even call The Boob Group hotline at 619-866-4775. The Boob Group is also looking for listeners to join our blogging team. If you’d like to share your current or past experiences with breastfeeding, be sure to send us an email. Today, I’m joined by three fabulous panelists in the studio. Ladies, would you like to introduce yourself?
Sunny Gault: Hi everyone, I am Sunny Gault. I’m actually not breastfeeding at the moment. I am ten days away from giving birth. So, I will be breastfeeding very, very shortly. I am 34 years old, a web video host and producer. But, I’m also the host of our sister show which is called Preggie Pals for all the pregnant listeners out there, it’s a good opportunity to network with other moms to be. And, I have one other child at home, Sayer, a little boy and this one’s a little boy too.
Heidi Runge: Hi, my name is Heidi Runge. I’m 33 years. I’m a Paralegal. I have one son, Asher, who has just turned 4 months and then my man-child husband. [Laughs]
Cassidy Freitas: My name is Cassidy and I’m 26. I’m the urgent family therapist intern working at UCST and I have one daughter and she’s 7 months old.
[Featured Segment: Breastfeeding Tips for the Working Mom]
Robin Kaplan: Before we get started with today’s topic, here’s Wrendy Wright talking about breastfeeding tips for the working mom.
Wrendy Wright: Hi Boob Group listeners, I’m Wrendy Wright, an internationally board certified lactation consultant and the owner of Lactation Navigation in Colorado, California. I’m here to answer some of your most common questions about returning to work as a breastfeeding mother such as, why should I continue to breastfeed after I return to work? This is a great question and one that we get all the time. Now, the primary reason to continue to breastfeed after returning to work is to provide the best nutrition for your baby. Also, by continuing to breastfeed after you return to work and by that I mean pumping while you’re at work and then breastfeeding while you’re with your infant together, it does make it possible for you to continue to breastfeed on the weekends and evenings. It’s a great way to maintain a special closeness with your baby even when you must be a part for work or for travel. Another reason to continue breastfeeding after you return to work is to save money. Purchasing a can of formula every week to provide your infant can get very, very expensive and by pumping your own breast milk while at work, you know, definitely see the financial impact for your family. Another nice reason to continue breastfeeding when you return to work is it does help you avoid some of the health risks associated with formula feeding such as, higher instance of ear infections, higher incidence of respiratory infections and in general, just in overall, improves health for your infants with breast milk. And the last reason to continue that I’d just like to mention is that the American Academy of Pediatrics does recommend mothers and babies exclusively breastfeed for the first six months of life. In any state, the average woman returns to work about six weeks after delivery of a child and that definitely falls within the first six months of life. So, by continuing to breastfeed after you returning to work, you’re providing the best health for you and your baby. Please remember to visit http://www.lactationnav.com for more great information about my business, Lactation Navigation and be sure to listen to The Boob Group for fantastic conversations about breastfeeding and breastfeeding support.
Robin Kaplan: Today, on The Boob Group, we’re discussing nutritional supplements for the exclusively breastfed baby. Dr. Dania Lindenberg is a pediatrician with Scripps Coastal Medical Centre, Hillcrest and a mother of two with a third one on the way. Dr. Lindenberg, welcome to the show and thanks for joining us.
Dania Lindenberg: Thank you, sure.
Robin Kaplan: So, we’ll just get right into it. Dr. Lindenberg, according to the American Academy of Pediatrics, which Vitamin supplements ore nutritional supplements are recommended for exclusively breastfed babies and at which age?
Dania Lindenberg: So, according to recent AAP guidelines, Vitamin D and Iron as we mentioned are the two supplements that are recommended. An updated Vitamin D policy just came out in 2008 which recommended that all solely breastfed babies or babies who are receiving, who are not receiving one litre of formula a day, a supplement of Vitamin D should receive 400 international units of Vitamin D starting very soon after birth. This was the policy statement that came out in 2010. It actually recommends that all solely breastfed babies start receiving an Iron supplement of 1 milligram per kilogram per day starting at 4 months of age until the introduction of Iron containing supplementary foods.
Robin Kaplan: Ladies, did your pediatrician recommend that you supplement your baby with additional nutrients?
Sunny Gault: Yeah, I’m naturally low in Iron anyways and so I think it’s some point with my son, my first born, may have been about 6 months or so, he did suggest supplementation. But, you know, I don’t know, the drops that I got, my son just really wasn’t into. So, it didn’t work out very well. Even if, you know, I would have just kind of put it in some breast milk or whatever. He could still sense the Iron anyways. But, yeah, our pediatrician did recommend it.
Robin Kaplan: How about you Heidi?
Heidi Runge: Actually, I just had my four month appointment yesterday and he did recommend it. I partial breastfeed so he adjusted the amount that I should supplement. I believe he cut it in half and had 200…yes. So, it was based on the fact that he does get some formula, probably about 60-70% formula and 30-40% breast milk. So……
Cassidy Freitas: Yeah, at our four month, it was our 6th month check up that actually our pediatrician recommended maybe supplementing, adding, you know, oatmeal or rice cereal that had Iron in it. But, I was confused because I had heard from, you know, other moms or other sources that, you know, rice cereal wasn’t good. You know, it can be very constipating or may be try other ways to introduce Iron so, actually I’m interested in hearing more about that.
Dania Lindenberg: I guess we could talk about the Iron issue first. This new guideline, to be honest a lot of us aren’t putting 4 month olds on supplementary drops. I think that there are certain cases where most of us would, certain conditions would predispose the baby to iron deficiency, prematurity because a lot of the Iron actually, the vast majority of Iron is occurred during the third trimester. So, if the baby is born premature, I think most of us would probably put the baby on Iron and then if it’s a diabetic mothers and some other conditions, that being said I think that this new guideline is about because more and more research is coming out about subtle effects of Iron deficiency, not even Iron deficiency, anemia, per say, and so breast milk is poor, has less I should say Iron than formula. As a lot of people know, it’s more bio available Iron. So, babies absorb a greater percentage of it but, they have been seeing that there is a trend that babies who are solely breastfed, especially if it’s more than 6 months to become Iron deficient. So, where most of us don’t necessarily start an Iron drop at 4 months of age, then you’re gonna tell me pediatrics does recommend starting solids sometime between 4 or 6 months of age. Although, another guideline says to wait till 6 months to introduce solids in solely breastfed babies. So, there’s a little bit of a discrepancy. What I would tell you is if you decide to introduce supplementary foods before 6 months, I really try to emphasis sources of Iron that are more well-absorbed meats. The Iron in meats is heme Iron as supposed to non-heme iron which is in foods that are supplemented. So, your baby is really going to absorb the Iron better in foods that have it naturally like, meat. So, it used to be people wait it last in choosing meats. Now, really the emphasis is on in choosing them earlier.
Robin Kaplan: Around what age would you say for meats because some of the research I’ve read is around 8 months?
Dania Lindenberg: I’d say 6 months. Robin, you can do them right with other solids.
Robin Kaplan: How do you recommend serving them to babies?
Dania Lindenberg: It depends. It’s a really good question because if you’re like me and you didn’t make your own baby food. The forms in meat are pretty non-palatable to eat sometimes. If you’re someone who makes your own food, you can boil, you can boil checking don’t add a lot of extra of anything. Salt, you can mix it with sweet potatoes. You can mix it with vegetables, just puree it. You can do, the darker the meat, the more rich in Iron it’s going to be. So, there’s really no contra indication to starting those foods early.The whole thing with the cereal, I think that cereal is a very important source of Iron because a lot of people don’t give meats early for a various number of reasons including just not making their own, for example. In terms of rice cereals, I think that it tends to be constipating. Often, I have all my patients go directly to oatmeal or to quickly move to mixed grain variety. Sometimes, I like the variety that have probiotics in them because I find that those are less constipating sometimes. So, I think that the whole thing about rice is that you want the food that your baby eats to be the foods that you want them to eat for life. So there’s one campaign I’ve seen from someone I trained with actually, you know, it’s a stand for called a White Out. He talks about avoiding White foods. You know what you’re baby is eating. There’s so much refined starches. So, rice cereals often are just very refined and white. So, if you’re gonna do rice, I would say do a whole grain brown rice. It’s not that rice is bad but it’s just it doesn’t have a whole lot of good things except for the iron really.
Cassidy Freitas: I really appreciate that because when I was deciding what I’m going to be feeding my daughter from the very beginning, you know, I wanted it to be things that I wanted her to be eating for life and things that I eat because it’s good for me and you know, with rice, it’s just sitting fill, the white rice, it’s not that I would eat on normal day-to-day basis and you know, I wanted her to get the Iron so, I appreciate that. Other forms besides meat so, I believe the lentils have a lot of Iron.
Dania Lindenberg: Yeah, beans are good. Leafy greens, that’s really hard to get enough leafy greens in a little baby but, beans if you compare them, lentils, egg yolks have Iron and those are safe for babies. Actually, new allergy guidelines really even limit much of anything which I’m sure we’ll talk about it in a different Boob Group Episode later. But, yeah I mean, those are good sources. The best are gonna be foods that have it naturally. So, yeah, absolutely.
Heidi Runge: Can we back track a little bit, may be, just talking about anemia a little like, I was anemic, I guess they found out in 28 weeks. How does that effect, would that have a negative impact like on my breast milk or on like, may be Asher, now him needing more Iron?
Dania Lindenberg: It depends how anemic all pregnant woman are. I mean, I was anemic too when I was pregnant. Now, I take Iron too. You get diluted, basically you need more blood volumes. So, all women are gonna drop their hemoglobin. So, it depends how anemic but, if you aren’t depleted or you don’t take any Iron, there’s a potential for him to have lower Iron storage when he is born which could set him up for possibly becoming iron deficient earlier. He basically depends on your iron stores until about 46 months of age. That’s where the salt comes into play. He receives your stores in his, if he was born with enough which a lot a babies are, some aren’t, I think that’s part of the concern, he starts running out at 46 months. If he’s already kind of, on the lower side ‘cause if your store, he could run out quicker or become deficient. That being said, I think it depends on how deficient you are.
Robin Kaplan: What type of symptoms which show? Are there any in a baby that would show that there are anemic or low in Iron?
Dania Lindenberg: I think you have to be pretty low to actually have severe symptoms. I think part of the concern is that more and more studies are or some studies at least have shown that there is subtle accommodative deficits that they may have later in adulthood, problems of nerve myelination, kids performing lower on certain development skills, cognition, concentration, just more subtle things that are very hard to quantify. But, in terms of actual symptoms, people compensate if it’s something gradual, like, it’s amazing how normal child can look with a very low hemoglobin just from being able to sort of compensate for it.
Robin Kaplan: So, would you recommend in your own practice to test babies at 4 months for their hemoglobin levels so that way if, I don’t know if that’s even possible but, if so, if a baby does need an Iron supplement, we can just supplement the babies that need it whereas supplementing them straight across the board?
Dania Lindenberg: I think in parents who you identify that there’s a potential for low iron, for anemia.
Robin Kaplan: Who would those potentials be?
Dania Lindenberg: Definitely moms who may have been quite anemic during pregnancy. Any baby whose less than 37 weeks of age, although lot of times, we just supplement those babies, but, in parent’s we’d rather know absolutely, we can test. I think it’s always a balance ‘cause we try to avoid unnecessary testing as well ‘cause parents don’t , you know, the cost and also parents don’t want their babies to be poked a whole lot. And that brings up the whole sheet of how to test. You can do a hemoglobin stick but if you’re iron deficient without anemia, your hemoglobin may still be normal. So then, you would need to go for further iron studies which is a lab job. A lot of parents don’t love the idea of a lab job for a 4 month old.
Sunny Gault: But, I think in some cases, yeah, if the risk benefit to you as a mom is totally, if you say to me, I’d rather get tested before supplementing. I think I’m fine with that. I think that’s great ‘cause you actually know what you’re doing, you know what you’re giving as opposed to just following your guideline. And there are other sources of anemia. This particular guideline, it actually says that in toddlers only 40% of anemia is due to the iron deficiency which, in my practice I would think it’s more. But, that’s what in the US, that’s what they came up with.
Robin Kaplan: Okay terrific, when we come back, we’ll be discussing Vitamin D supplementation for the exclusively breastfed baby. Is it really necessary? We’ll be right back.
Robin Kaplan: Okay, we’re back. Dr. Lindenberg, what is the protocol for Vitamin D supplementation? You had mentioned that it was 400 IUs. Why is it recommended for exclusively breastfed babies?
Dania Lindenberg: So literally, when we’re talking about iron, breast milk does not have a lot of Vitamin D in it and as more and more research comes up, I mean, these are really hot topic right now for research. Vitamin D deficiency has been linked to many things. Obviously, to bone health and subtle bone, bone weakening even at slightly deficient levels but, not also now to immune defects and cancers and obesity and seems like Vitamin D is always in the news. So, more and more it’s been shown that a lot of kids and later, even adults are Vitamin D deficient and babies who are exclusively breastfed are at higher risk of being Vitamin D deficient. So, because there’re so many variables in your Vitamin D levels, everything from your, the maternal levels of Vitamin D which can pass across the placenta to the darkness of your skin. Less than 10% of Vitamin D is actually dietary. Over 90% is what you making your own skin. So, skin color is huge, what latitude you live in, how much sun exposure you have, how direct the sunlight is because those variables are so hard to quantify, the AAP has come out with a guideline that babies who receive at least half maternal breast milk or solely breastfed should receive 400 international units starting soon after birth ‘cause that just has been shown to prevent both Osteomalacia, a Vitamin D deficiency and Rickets.
Robin Kaplan: What exactly is Rickets?
Dania Lindenberg: Rickets is a condition that results from Vitamin D deficiency which causes, basically, demineralization of bone. It causes sort of thickening at the ends of bones, widening, splaying and basically, demineralization and weakness of bones. They can cause bowing of your legs. It can be pretty serious.
Robin Kaplan: Women who are breastfeeding says that the recent research states that if a mother actually takes 4000 IUs of a day of vitamin D, that her milk can contain enough so that the baby won’t need supplementation. Have you found that to be true?
Dania Lindenberg: Well, I mean, I looked into this a bit and there’s been may be a couple studies, the one that you’re referring to is the study from 2004. There is, these studies do show that if a mother takes, these are basically mega doses of vitamin D that, yes, it can raise the level in breast milk similarly, there are enough, an equivalent amounts to a baby taking 400 International Units. The safety of that approach is not proven. I mean, those are very, very large levels of Vitamin D. But, it is something that should be looked at. I don’t know if that’s really safer though like, for a mother to take that much of supplement of vitamin compared to a baby taking 10% of that. But, yeah, it’s something that has been looked at a couple times.
Robin Kaplan: Are there negatives to having too much vitamin D in your body?
DaniaLindenberg: There can be, it’s fat soluble vitamins. So you definitely can get too much of it. There are conditions associated with excess of vitamin D and it doesn’t excrete in your urine like lot of other vitamins ‘cause it’s fat soluble so, potentially yes. In this particular study, any other I’ve looked at, there was no adverse effects seen but, there is a potential.
Robin Kaplan: Panelists, did you end up supplementing your baby with vitamin D?
Heidi Runge: I haven’t yet but, I just got recommendation yesterday. So, I do plan on looking into it and supplementing him at least half of what I think a full breastfed baby would be.
Cassidy Freitas: We haven’t yet and so I think it’s only the information is really out there. I’m actually really appreciating hearing all these ‘cause we haven’t yet. But, absolutely from this point forward I think we’re going to be so….
DaniaLindenberg: I’m surprised that we just brought up to now, your baby is 5 months, is that correct?
Heidi Runge: 4 months.
DaniaLindenberg: So, the recommendation is to start soon after birth. So, usually I’ll bring it up at least by the 1 month visit.
Heidi Runge: Okay. I know the doctor had it on the hand out but, I know when I asked her about it at his two month visit, I was told, you know, it will be addressed at the next visit.
Robin Kaplan: What do you think the concern would be waiting until the baby is 6 months old? For example, not supplementing with Vitamin D and waiting until they’re starting to get solids and things like that. Do you think that is possible to make up for, I know you described that you get about 10% from what you ingest so, do you think you could make up for that if they decided that they didn’t want to supplement before that?
DaniaLindenberg: Actually, I don’t think so. In a vitamin D deficiency, I think that a lot of the groups who look at it, find that toddlers are also deficient. It’s not that rich in foods and to really get enough, you’ll have to take a liter of Vitamin D milk or a liter of Formula. So, I don’t think like, Iron, like we were saying about Iron that it’s like, suddenly at 6 months you’re getting enough Vitamin D. That being said, in this latitude, in this climate we don’t see a whole lot of, I mean, I’ve never seen Rickets but, in terms of deficiency, may be it will be something which has more often which, actually this guideline talks about testing pregnant women which I know my OB/GYN hasn’t tested me but, that’s interesting to me. But, probably in this area we see lots of it because you do get sunlight. That brings us to a whole lot of other topics about the taboo of sun which we can get into at any time.
Robin Kaplan: No, I’d love to actually because, you know, especially being here in sunny California, southern California, is it necessary for our babies if we were out in the sun? I think the recommended dose of sun was like, two hours a week or something like that.
DaniaLindenberg: There’s just various different amounts that, you know, they’ve said can create enough Vitamin D to be sufficient. But, it varies a lot again with latitude, how directly the sun is coming down. It’s really UVB rays that create, that are most important in creating Vitamin D and the mid-day sun is really not important because it comes in obliquely. It doesn’t have the same effect as direct sunlight. But, I mean, there’s all kinds of estimate to meet. Some studies have looked at, you know, as two hours of sun exposure for per week. A lot of estimates were sort of based on old levels of Vitamin D, Vitamin D sufficiency. Now, they’ve kind of raised those. But, until 6 months of age, AAP recommends not exposing your baby to direct sunlight. One article I read is by endocrine society who brings into question this taboo against sunlight, if you look at the public health cost of Vitamin D related disorders, if you include things that are thought to may be, be vitamin D related, like the cancers, the prostrate breast cancers, the Rickets and Osteomalacia compared to the public health cost of skin cancers, it could be much, much higher. So, it’s possible to may be a turn-around in that. It’s recommended to just go in the sun. [Laughs]
Robin Kaplan: I’m just out without sunscreen now.
DaniaLindenberg: May be for 15 or 20 minutes.
Heidi Runge: Instead of UVB, instead of UVI….
DaniaLindenberg: Right, and the sunscreen block, in this article they were saying that if you couldn’t put on sunscreen correctly it blocks over 95% of the sun’s rays so you really aren’t making Vitamin D then. But, one of the things they mentioned, got to let you and your baby for 15 minutes before they have a chance to bring that, they may make enough in that time of Vitamin D. The problem is that it’s not quantified and 400 International units is not dangerous and so, because they can’t quantify that at all they just say everybody get this amount. But, really the ones at risk are gonna be the dark skinned babies in northern climates in winter months especially.
Heidi Runge: …who don’t ever have a chance to go outside because it’s too cold and all covered up completely.
DaniaLindenberg: Right, they’re covered. So, the more body surface area exposed, the more Vitamin D you’re gonna make.
Sunny Gault: So, how are these supplements, is it in a drop or is it liquid form of consuming or how are these given and how often?
DaniaLindenberg: It’s a really good question. I think that’s one of your questions too. They now sell a lot of just purely Vitamin D drops because understandably people don’t want to give things they don’t need to give. You can get a multivitamin drop which will always have the right amount of Vitamin D, the 400 international units. But, they now sell some forms of, there’s one form called Dvisock which is easy to find in pharmacies and that’s in a, basically comes in a dropper form. But, as some people may have expressed this other additives that may be not desirable to certain parents but, now there’s a few forms that actually come very, very concentrated, just one drop has enough Vitamin D. The risk of that is you could easily overdose. You just want to be careful to use just a drop.
But, there is a couple forms that I saw, one is called Just-T. It’s sunlight Vitamins and it has no additives. It’s just and you have to have it in like a oil based but, that’s it. Biodimotion, it’s another one that’s just Vitamin D and then Carlson, the company Carlson makes some that are also just Vitamin D without anything added.
Robin Kaplan: Where can we get these at?
DaniaLindenberg : I’ve seen, the D-Visol, the one that I was saying that’s, that may have some more additives, that’s in a slightly larger vine, you can get that a target in any drug store. These other ones, I’ve seen more online, like on their websites or Amazon has a lot of them. So, I send parents there. It’s great for breastfeeding moms if you do it ‘cause a lot of moms will just put one drop on their breast and then the baby just takes it ‘cause it’s pretty much taste free.
Robin Kaplan: That was going to be my question like, what does that taste like ‘cause when I had to give my son those Iron drops, I mean, he just totally was not going for it and we did like a multivitamin thing at first and that was fine. But, when the pediatrician said we need more Iron, I just got the iron drops and he was like, no, no, no, no. That’s good to know if there is like kind of odorless, tasteless kind of thing?
DaniaLindenberg: In terms of those, the drop forms, the D-Visol has a bit of a taste but from my experience the baby seem to like it a lot. Have you ever tasted the Iron supplement?
Robin Kaplan: I’ve smelled it. [Laughs]
DaniaLindenberg: My son was on Iron too. There are some forms that are little sweeter I can tell you about but, Iron just does not taste good. It’s a metal. Once there can be chewable later, it’s a little better. [Laughs]
Robin Kaplan: Well, terrific, well thank you so much, Dr. Lindenberg for all your insight into these supplements for the breastfed baby.
DaniaLindenberg: Anytime, thanks for having me.
[Featured Segment: From Our Listeners]
Anne: Hi Boob Group, my name is Anne and I’m from Michigan. I just listened to your episode about partial breastfeeding and I was so inspired by your panelists. I have been supplementing my daughter formula since she was 5 days old just as low milk supply and she’s now 2 months old listening to the moms on your show share their experience with low milk supply and how they’re still breastfeeding their baby even at 4 months and older just [Inaudible 00:27:23]. I knew every drop of breast milk counts. I just felt better once lactation [Inaudible 00:27:28]. Thanks you. Thank you so much, I totally appreciate your help.
Robin Kaplan: Thank you to all of our listeners. I hope you’ll visit our website, http://www.theboobgroup.com and our Facebook page to share your questions and comments about supplements for your breastfed babies. If you have any questions about today’s show and the topics we discussed, call our Boob Group Hotline at 619-866-4775 and we’ll answer your questions at the upcoming episode. If you have a breastfeeding topic you’d like to discuss, we would love to hear it. Please just visit our website, http://www.theboobgroup.com and send us an email through our contact link. Coming up next week, we’ll be discussing tips to entertain your toddler while breastfeeding your newborn. Thanks for listening to The Boob Group because Mothers Know Breast.
This has been a New Mommy Media Production. The information material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though such information materials are believed to be accurate, it is not intended to replace or substitute for professional medical advice or care and should not be used for diagnosing or treating health care problems or disease or prescribing any medication. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified healthcare provider.
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