LLL dogma: still a barrier to properly informing women.

As you know, I’m not a huge vitamin pusher. However, I do realize the importance of supplementing babies’ diets – especially those of exclusively breastfed babies – with 400IU of vitamin D daily until the age of a year. I also pointed out, almost a year ago, that lactofanatic dogma – that breastmilk is perfect for all babies, always – has caused some AP/NPers to resist vitamin D supplementation for their babies, despite the research that shows that exclusively breastfed babies are prone to vitamin D deficiency and even rickets.

But science is finding that vitamin D has far greater importance than mere maintenance of bone health. Vitamin D receptors have been found in many tissues of the body, and low vitamin D levels have been associated with an increase in the incidence or as a possible cofactor in the pathogenesis of many diseases, including various cancers, high blood pressure, autoimmune disease, heart disease ,both types of diabetes, and possibly dementia. While most of the research has not proven causation and vitamin D is starting to sound a lot like the vitamin du jour, there is a strong case to be made that raising the vitamin D levels of the population to the levels now considered normal (30-100 IU/liter) will reduce the incidence of various illnesses.

Which is why I find La Leche League’s epiphany on the subject of breastfeeding and vitamin D more than a bit underwhelming:

(October 16, 2008) Schaumburg, IL – La Leche League International encourages all mothers to recognize the importance of vitamin D to the health of their children. Recent research shows that due to current lifestyles, breastfeeding mothers may not have enough vitamin D in their own bodies to pass to their infants through breastmilk.

In October 2008, the American Academy of Pediatrics recommended that infants receive 400 IU a day of vitamin D, beginning in the first few days of life. Children who do not receive enough vitamin D are at risk for rickets and increased risk for infections, autoimmune diseases, cancer, diabetes, and osteoporosis.

Vitamin D is mainly acquired through exposure to sunlight and secondarily through food. Research shows that the adoption of indoor lifestyles and the use of sunscreen have seriously depleted vitamin D in most women. The ability to acquire adequate amounts of vitamin D through sunlight depends on skin color and geographic location. Dark-skinned people can require up to six times the amount of sunlight as light-skinned people. People living near the equator can obtain vitamin D for 12 months of the year while those living in northern and southern climates may only absorb vitamin D for six or fewer months of the year.

For many years, La Leche League International has offered the research-based recommendation that exclusively breastfed babies received all the vitamin D necessary through mother’s milk. Health care professionals now have a better understanding of the function of vitamin D and the amounts required, and the newest research shows this is only true when mothers themselves have enough vitamin D. Statistics indicate that a large percentage of women do not have adequate amounts of vitamin D in their bodies.

La Leche League International acknowledges that breastfeeding mothers who have adequate amounts of vitamin D in their bodies can successfully provide enough vitamin D to their children through breastmilk. It is recommended that pregnant and nursing mothers obtain adequate vitamin D or supplement as necessary. Health care providers may recommend that women who are unsure of their vitamin D status undergo a simple blood test before choosing not to supplement.

Health care providers may recommend that women check their vitamin D level before choosing not to supplement? How about what LLL recommends? Not much of substance, apparently. I can just see an AP/NPer thinking, “Well, I’m white, live in California, and spend a lot of time out in the sun. So my breastmilk must be all-natural and perfectly calibrated as Nature intended. That advice surely doesn’t apply to me!”.

I have to say that in my practice, many women have requested, and in some cases I’ve initiated, vitamin D level checks among my patients. I think I may have seen one normal vitamin D level among them. While many of the women walk around covered up but for their faces and hands, not all the vitamin D-deficient ones do, and Israel is a very sunny country. Quite a few of my fellow family physicians who practice in more liberal areas of town have also found a high percentage of vitamin D deficiency among the women they’ve checked, modest dress code or not. Even among the lily white in a hot, sunny country, vitamin D deficiency is very common. We all stay indoors more, use sunscreen, and don’t get enough vitamin D from dietary sources. You can’t just assume that a healthy lifestyle will assure your milk is ‘perfect’. A strong recommendation that any woman considering not supplementing check her vitamin D levels ahead of time would be more to the point. So would letting go of the ‘breastmilk is perfect’ ideology and reiterating the AAP’s position that breastfed babies need direct vitamin D supplementation. But that is, apparently, too bitter a pill for LLL to swallow.

Another issue not mentioned in the LLL press release is that in order to pass enough vitamin D into their breastmilk, women need high doses of vitamin D supplements – some 5-15 times higher than the doses normally given to infants (2000-6400IU vs. 400IU daily). While even these high doses do not pose, as far as is known, any health concern to the mother, it’s far simpler to just give the baby 2 drops of liquid – and thus more likely to be performed consistently- than have Mom swallow multiple pills every day, if the primary goal is to ensure that Baby is getting enough vitamin D in their diet. Sad to say, that doesn’t necessarily seem to be LLL’s primary goal.

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31 Responses

  1. I remember posting an article in the NYTimes about vitamin D deficiency and rickets on the rise to my BBC birth club and the first response was hoping that this wouldn’t end up as a way to take down breastfeeding. Talk about siege mentality. What the heck, is antibreastfeeding about keep doing it, but give a few drops in addition. The eyes, they roll. Luckily, a poster down the line, her husband was an orthopedic surgeon and said their professional organization was taking it very seriously and trying to get the word out.

    I like how the complicated route is what people want to take (practically overdosing on the stuff so it comes out the milk) instead of the easiest straightforward way. It goes back to the parenting thing being so process oriented.

    It’s funny this discussion came up on a political blog I follow, not the breastfeeding part, just that many people are deficient. Major kudos to the blogger’s doctor for bringing it up. It’s like pulling teeth to get him to give me recommendation from mine.

  2. Yah– diet sources of vitamin D are pretty laughable, so what with lifestyle issues (wearing clothing, staying indoors) and the “sun causes skin cancer” meme, vitamin D sources are pretty minimal.
    Hollis and Hollick push the idea that 200 IU or even 400 IU is not sufficient for normal adults, let alone breast-feeding ones. I lean towards the idea of supplementing the mother, since I worry just as much about my deficiency of vitamin D as well as my kid’s… of course, I also believe that the best “supplement” is sun exposure IN MODERATION.
    As far as adding vitamin D to the Tri-vi-flor, I think that the costs of the vitamin D assay (which one? What is “normal”) probably are more than just empirically giving the drops… but again, I don’t like paying for something I don’t need, and I always worry about unintended consequences…

  3. FYI, a few days ago Eastern United State LLL hosted a conference on the latest research on Vitamin D: http://www.llleus.org/events/hps/program.htm . Be sure you know what “dogma” you are actually referring to.

    • So – what were the practical recommendations made at this conference? And do they represent the official position of LLLI?

      • I was at a different session. I’m not aware that LLLI I has an “official” policy on Vitamin D. I believe the “official policy” is to assist in locating the latest evidence-based research. Can’t really expect more than that, can you?

        • Yes, I can expect more than that. LLL presents itself (and is often considered) the ‘go to’ source for breastfeeding issues, and at times bloviates on issues not directly its concern (e.g., the AAP’s stance on cosleeping). In the case of vitamin D, I would have expected a statement far more clear and concise to the LLLeaders going something like: “Many women, even white women exposed to sunlight, have vitamin D deficiency and can’t transmit enough vitamin D via breastmilk for adequate infant nutrition. The most straightforward way to get enough vitamin D into the baby is by giving them the drops, but if you choose not to, check your own vitamin D stores. If insufficient, take a large amount (2000-6400IU) of vitamin D for several weeks, recheck the level* and nurse while supplementing.” Not this wishy-washy “Your HCP may recommend blah blah”.

          I am reminded of the various statements made by LLLI regarding HIV-positive women breastfeeding:”LLLI is not making a recommendation about breastfeeding for HIV positive mothers at this time due to the inconclusive nature of the research and its various interpretations”. God forbid the LLL should admit that in the western world – which is from where most women who are capable of reading the statement online come from – formula is the safer and most practical choice for such women (as did the WHO, hardly a pro-formula organization).

          Which is why I say that LLL dogma – that any admission that breastmilk isn’t perfect and/or superior in all cases should be rarely and only reluctantly admitted – is impeding them from properly informing women.

          *I emphasize the need to recheck the level because I’ve encountered a case where a vit D-deficient pregnant woman in my care took vitamin supplements she’d gotten from the US which supposedly contained 5000IU, for several weeks. When she retested, her levels had barely budged. I implored her to take no more than 800IU due to the potential teratogenic effects of vitamin D, and of a local brand, which raised her levels far more efficiently. Not all supplements contain what they claim to.

          • Again, Esther, I wish I could ‘like’ a comment like facebook, because that last paragraph should give everyone pause.

          • LLLI can not give medical advice as a legal matter – it can refer to the work of professionals with, among other things, malpractice insurance. But frankly it appears your feelings about LLLI would prevent you from being satisfied with any thing it did.

            As for your statement concerning HIV+ women and breastfeeding, thankfully LLLI has not taken the position you wish (that formula is always safer than breast milk for HIV+ mothers in the developed world) because your view is not supported by the research. See http://www.anotherlook.org/index.php – and, yes, Another Look is a non-profit founded by one of LLLI co-founders.

            • I’m not talking about the legal issues involved, but the practical and moral ones. And when a major breastfeeding organization sends a message that HIV transmission through breastfeeding is no big deal and we don’t know if it really happens unless mixed feeding is present, it’s clear LLL has a serious agenda problem.

              My views about LLL (other than having been a member for a short while) stem from their very selective misquoting of science and their tendency to push an entire lifestyle on mothers, despite their protests that they’re merely a BF advocacy organization. I judge them by what they say and do, and what they don’t say and do as well.

              As for that website you referred us to: You might want to tell Marain Tompson that when you stuff your advisory board with AIDS denialists (David Crowe, Rudolph Ballentine) and other quacks (Mayer Eisenstein), your org’s opinions on HIV are going to be questionable, at best. Especially when you also cast aspersions on giving antiretrovirals to prevent HIV transmission. But thanks for providing another look at how LLL (or at least founder Marian Tompson) is looking out for her own dogma and not necessarily the welfare of children.

              Either way, the folks at anotherlook.org profess not to know whether HIV can be transmitted via breastmilk while exclusive breastfeeding is maintained. They cite a single study, as far as I can tell (Coutsoudis 2001), which found that “Infants exclusively breastfed for 3 months or more had no excess risk of HIV infection over 6 months than those never breastfed”. However, there is ample evidence that even during EBF, transmission does happen. Either way, if you don’t know, recommending BF without recognizing that possible risk doesn’t make sense.

              In the developing world, there is a strong case to be made that the risks of formula feeding outweigh the risks of the infant acquiring HIV via breastmilk, especially if ther mother EBFs; however, most HIV-positive women perusing the internet or otherwise seeking advice from the LLL and coming upon their website (as opposed to the majority of HIV(+) women in the world) are not in that category, and the LLL needs to address their concerns and not confuse them further in denying the sense in the WHO guidelines or that of their doctor. In developed countries, the risk of death from formula is far lower than even the lowest estimate of HIV acquisition through breastmilk. The equation is entirely different, and nobody seriously contends otherwise. Not even Anna Coutsoudis, BTW:

              Efforts to reduce mother to child transmission (MTCT) of HIV by the use of antiretroviral drugs, caesarean section and formula milks have been extremely successful in industrialized countries and some middle-income countries.

              Although formula feeding is certainly the correct choice for some HIV-positive women who meet all the criteria of the WHO guidelines, exclusive breastfeeding for the first 6 months for the majority of HIV-infected mothers who are poor reflects the optimum balance between advantages and disadvantages (Note: I don’t think she’s talking about the large majority of the developed world’s poor here)

              .

  4. With my last baby (now 8 months old!), the thing that annoyed me was when the doctor told me I had to use the D-Vi-Sol drops, where to get the recommended 400 IUs (or whatever it is) you had to give the baby something like half a teaspoon of liquid, mostly corn syrup and colouring and who knows what else.

    Instead I was using D-drops, which contain the recommended dosage in a single drop of I think palm oil. I know quite a few breastfeeding mothers who were unhappy about the d supplementation because they didn’t like the idea of giving their baby such a large quantity of something other than breastmilk, especially considering the tininess of a newborn baby stomach, and once I showed them the D-drops they were MUCH more open to the idea of d supplementation.

    • 2.5cc a day, even for a newborn, isn’t that large an amount, but I see your point. It’s always been 2 drops in oil here (don’t remember which oil or any other additions, but I don’t remember the drops being sweet when I tasted them). It’s nice to know that not all the opposition to vitamin D supplementation is knee-jerk a la Mothering, but due to practical issues relatively easily solved.

      • Sorry, I think it’s profoundly weird that people would prefer rickets over a non-EBF child — however that’s measured out. That’s just wrong.

  5. Tell it to Eliza Jane Scovill. Oh wait, you can’t because she’s dead. She’s dead because her HIV+ mother breastfed her against medical advice.

    • Well, to be entirely fair, we don’t exactly know when EJ acquired HIV – in utero, at birth or during breastfeeding. No thanks to her mother or her buddy Peggy O’Mara, who cheerleaded her choice not to take antiretrovirals during pregnancy.

  6. It seems that LLLI has now accepted the AAP’s recommendation.
    In the most recent edition of Leaven, LLLI’s magazine for Leaders, an article appears entitled, “Vitamin D Requirements during Infancy” by Heather Will, MD, Sarah N. Taylor, MD, and Carol L. Wagner, MD. The final lines of the article: “Although supplementation of a lactating mother should be recommended for her health benefits, the dose at which supplementation of the mother would also benefit the breastfeeding infant has yet to be clearly defined. Therefore, at this time, supplementation of the breastfeeding infant with 400 IU of vitamin D per day should continue to be recommended.” The article doesn’t yet appear online.
    An article by Melissa Clark Vickers, MEd, IBCLC, How Do We Help Mother with Vitamin D Questions? states: “a mother should feel confident in continuing to breastfeed her child–while supplementing with Vitamin D.”

    • Hi, Hannah (long time no see! 🙂 ) and thank you! Please let me know when the articles come online, and I will update the posts and link to it. This is good news. Now if only they would put out a clearer statement regarding HIV-positive women…

  7. Hi, Hannah (long time no see! 🙂 )
    Please refresh my memory!

    • I used to be the CL for the Jewish chat at the parenting board we both frequented at the time (about 9-10 years ago). My username included my eldest son’s first name (I prefer to avoid using my kids’ names online these days). I once visited you briefly when I was pregnant with son #2.

      Ring a bell?

  8. Is the vitamin D supplements for infants a new thing? Our doctor never mentioned her needing a supplement and he knew my daughter was exclusively breastfed. I live in the Seattle area – not a lot of sun around here usually. My daughter is almost two years old.

    • It’s been recommended here in Israel (400IU starting at 1 month of age) for at least as long as I’ve been a parent (11.5 years). The AAP has also been recommending 200IU starting at 2 months for breastfed babies for years, but in October 2008 upped the recommended dose to 400IU and starting at birth. See here.

  9. vitamin d comes from the sun not breast milk sit int eh sun no need for suppliments

    • Not everyone can sit in the sun for very long or expose a lot of skin, and sitting in the sun has its downside as well.

      Hence the importance of getting adequate vitamin D in one’s diet.

  10. Esther, do you by any chance know of any useful guidelines, available on-line, concerning supplementation of breastfeeding women with Vitamin D deficiency? Just had a low result back on one of my patients, and the British National Formulary is warning me about the risk of hypercalcaemia in the baby with administration of Vitamin D to the mother. Presumably that’s considerably less than risks associated with *not* correcting the deficiency, but it would be nice to have more in the way of guidance at this point! I’m going to write off to a couple of specialists to get further advice, but would welcome anything you can point me in the direction of, as I don’t know how long it’ll take me to hear back from the people I write to.

  11. I don’t think there are hard-and-fast guidelines as yet for treating vitamin D deficiency – it’s too new a subject. I attended a lecture last year which suggested (for the general population) to treat with 800-2000IU daily for 6-8 weeks and retest, then keep on with similar doses as needed and diet/sunshine sources of Vit D are not available. Lactating women need more than that to transfer enough vit D to nourish the baby, however.

    There are two studies listed in the body of the blogpost which studied outcomes in mothers and infants with high-dose supplementation of vitamin D ( here and here). There do not seem to have been events of infantile hypercalcemia as a result. this newer study is also relevant. There are also Canadian guidelines here which discuss the need for higher dose supplementation, w/o actually recommending it (from 2007).

    BTW – this month’s Pediatrics has NHANES data on the prevalence of vitamin D deficiency/insufficiency in the US pediatric population. Not at all rare, to say the least.

  12. LLL’s purpose has never been to make recommendations, but rather to provide information which mothers can take and use themselves, do their own research on, and think about themselves. LLL provides information rather than giving advice – it is something their leaders are trained to do. Also, LLL will not make medical recommendations because they are not a medical association. That is why they tell mothers to ask their HCP about this sort of thing.

    There was also an article in the latest leader publication about vit D supplements for babies.

  13. Erin, these issues have both been mentioned – and addressed – upthread.

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