Acta Pdiatr 87: 73740.

1998

Vitamin D status of breastfed Pakistani infants

M Atiq 1, A Suria 2, SQ Nizami 1 and I Ahmed 1
Departments of Paediatrics 1 and Pharmacology 2, The Aga Khan University Hospital, Karachi, Pakistan

Atiq M, Suria A, Nizami S.Q, Ahmed I. Vitamin D status of breastfed Pakistani infants. Acta Pdiatr 1998;
87: 73740. Stockholm. ISSN 08035253
This study was conducted to evaluate the vitamin D status of healthy breastfed Pakistani infants and their
nursing mothers. Sixty-two breastfed healthy infants and their nursing mothers belonging to the upper and
lower socioeconomic classes were examined. Serum 25-hydroxy vitamin D [25(OH)D], serum calcium,
phosphorus and alkaline phosphatase were measured. The mean serum 25(OH)D in infants was 34.59 6
26.56 nmol/l. Fifty-five percent of infants and 45% of mothers had very low serum 25(OH)D levels
(,25 nmol/l). Significantly higher levels were found in infants of lower socioeconomic class ( p , 0:001)
and in those living in mud houses ( p 0:002) and infants .6 months ( p , 0:001). A high prevalence of
vitamin D deficiency was found in breastfed infants and nursing mothers, predominantly among those
belonging to the upper socioeconomic class. Infants of the lower socioeconomic class had comparatively
higher serum 25(OH)D levels, but even these levels were below the normal range for infants (90 6
27.5 nmol/l). ` Breastfed infants, nursing mothers, 25 hydroxy cholecalciferol, vitamin D deficiency
M Atiq, Department of Paediatrics, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500,
Karachi-74800, Pakistan

The occurrence of clinical rickets in Pakistani infants and

children probably represents only the tip of the iceberg,
whereas the real problem may be the extent of undiagnosed
vitamin D deficiency in infants and their mothers. In a
study from Saudi Arabia, Sedrani et al. found vitamin D
deficiency in 30% of mothers of infants with rickets (1). In
a previous study in Karachi, Ahmed et al. reported severe
vitamin D deficiency in all of the nursing mothers (15/15)
of infants with rickets and hypocalcaemic seizures,
in whom serum 25 hydroxy cholecalciferol [25(OH)D]
levels were measured (2). The National surveys from
Pakistan indicate that breastfeeding for the first 3 months
is prevalent to the extent of 8598% (3). In another study,
70% of Pakistani infants were reported to be breastfed until
4 months of age (4). The present study was therefore
undertaken to determine the vitamin D status of healthy
breastfed infants and their nursing mothers, and factors
contributing to any deficiency seen.

Material and methods

From June 1993 to May 1995, serum levels of 25(OH)D
were measured in 62 breastfed infants and their nursing
mothers. Of these, 22 and 15 infants and their mothers
belonged to the upper and middle social classes, respectively;
they were selected from the Well Baby Clinic at the Aga
Khan University Hospital (a private institution), Karachi,
where the infants were brought for routine follow-up and
immunization. Twenty-five infants and mothers belonged to
the lower socioeconomic group and were selected from
the paediatric outpatient clinic of a Government General
Hospital in Karachi. Of the 62 infants and mothers, 40/62
q Scandinavian University Press 1998. ISSN 0803-5253

were examined, and blood samples were collected in

summerautumn (AprilOctober), and from the rest in
winter and spring.
The detailed history included vitamin D intake and
amount of exposure to sunlight of the infants, maternal
socioeconomic status, their level of education, housing,
their diet and vitamin D intake. Clinical examination was
done by one of us (MA). Only those infants and mothers
who were healthy and had no clinical evidence of vitamin
D deficiency were included in the study. Blood samples
were collected after informed consent from mothers for
measurement of serum 25(OH)D levels, calcium, phosphate, alkaline phosphatase and alanine transaminase.
The serum samples were frozen and stored at 208C.
Serum levels of 25(OH)D were measured by radioimmunoassay (Incstar Corporation, Stillwater, MN, USA).
Serum calcium, phosphorus, alkaline phosphatase and
alanine transaminase were measured by the standard technique (Astra system, Beckman Instruments Inc. Galway,
Ireland) at the Clinical Laboratory of the Aga Khan University Hospital. The measurements of serum 25(OH)D
levels were carried out in the research laboratory of the
Department of Pharmacology, the Aga Khan University
Hospital. The results were analysed by using the computer
programme, EPI-Info-version 6.02 CDC/WHO October
1994 in which x 2 test was used to determine significance
values.

Results
Several social and demographic factors were studied.
Owing to social and demographic similarities, the upper

738

M Atiq et al.

ACTA PDIATR 87 (1998)

and middle classes were combined as upper socioeconomic

(USE) class. Thirty-seven (60%) infants belonged to USE
class and 25 (40%) belonged to lower socioeconomic
(LSE) class.

Table 2. Serum 25(OH)D levels of infants and mothers in relation to their

socioeconomic class.

Total no.

Mothers data
The mothers were of average build, did not receive vitamin
D supplementation during or after pregnancy and had no
symptoms suggestive of osteomalacia. Thirty-seven of the
62 mothers lived in villas and flats and were considered to
belong to USE class and 25/62 mothers belonged to the
LSE class and lived in mud houses (kachi abadis) with one
or two rooms opening on the street or into small courtyards.
Thirty-five of the 62 mothers were educated above the
primary level and only 6 of them belonged to LSE
class (Table 1). The women wore the local loose dresses
(shalwar kameez), which covered most of the skin surface,
but the face and the hands were exposed. Women of USE
class were mostly housewives, preferred to stay indoors
and kept their infants inside. Mothers of the LSE class spent
more time outdoors with their infants because of the poor
housing conditions and walked to their place of work, to the
shops and clinics.
The mean serum 25(OH)D concentration in all mothers
was 32 6 22.46 nmol/l. The levels were significantly
higher in women of LSE class ( p , 0:001). In 28/62
the serum level was in osteomalacic range (,25 nmol/l),
predominantly in mothers of the USE class (20/28)
(Table 2).
Infants data
The age of infants ranged from 6 weeks to 11 months
Table 1. Serum 25(OH)D levels in infants in relation to social and
demographic factors.

All infants

25-OHD levels nmol/l

(mean 6 SD)

62

34:59 26:56

p value

Age
,6 months
.6 months
Infants social class
Upper
Lower

38
24

24:74 18:17
49:97 30:38

,0.001

37
25

22:46 16:4
52:34 28:78

,0.001

Residence
Flats/Villas
Kachi Abadis

37
25

27:57 24:65
48:99 24:93

0.002

Season
Summer
Winter

40
22

40:68 29:45
24:46 16:97

0.01

Maternal education
Educated
Uneducated

35
27

23:03 17:55
49:47 28:96

,0.001

Mothers social class

Upper social class
Lower social class

37
25

26:5 24:1
39:76 15:7

0.01

USE a
Infants
Mothers

37

LSE b
Infants
Mothers

25

Serum 25(OH)D
levels nmol/l
(mean 6 SD)

No. (%) with Serum

25(OH)D
# 25 nmol/l

22.46 6 16.4
26.5 6 24.1

28 (75)
20 (55)

52.34 6 28.78
39.76 6 15.7

4 (16)
8 (32)

Upper socioeconomic class.

Lower socioeconomic class.

(mean 6 SD 5.1 6 2.7 months) with an equal sex distribution. Thirty-eight of the 62 infants were aged ,6 months.
From the age of 4 months, 35/62 infants were started on a
weaning diet, which consisted of khichri (a lentil and rice
cereal preparation), porridge and yoghurt, mostly cooked at
home and unfortified with vitamin D. None of the infants
received vitamin D supplementation.
The mean serum 25(OH)D concentration in all infants
was 34.59 6 26.56 nmol/l. The social and demographic
factors influencing the serum 25(OH)D concentrations
are listed in Table 1. Significant differences in the serum
levels of 25(OH)D were observed in infants of USE and
LSE classes. The serum levels were higher in infants of
LSE group ( p , 0:001), in infants of uneducated mothers
( p , 0:001), and in those living in mud houses
( p 0:002). Higher levels were also found in infants .6
months of age ( p , 0:001), in the summer months (April
October) ( p 0:01). There was a significant correlation
between the serum 25(OH)D levels of breastfed infants
under 3 months (21/62) and their mothers (r 0:53,
95%CI = 0.150.77, p , 0:01) (Fig. 1).
Thirty-two of the 62 infants had serum 25(OH)D concentrations in the rachitic range (,25 nmol/l), of these 28
infants were from USE class (Table 2). There was a

Fig. 1. Correlation between serum 25(OH)D levels (nmol/l) of infants

below 3 months and their mothers (r 0:53, 95% CI 0.150.77,
p , 0:01).

Vitamin D status of breastfed Pakistani infants

ACTA PDIATR 87 (1998)

739

Table 3. Risk factors for low plasma levels of 25(OH)D (nmol/l) in infants.
Risk factors

na

x2b

p value

OR (95% CI)

Age ,6 months
Upper social class
Resident of bunglow/villa
Educated mother
Low level of maternal vitamin D
Winter season

38
37
37
35
28
22

9.45
18.72
10.2
10.73
5.14
5.4

0.002
,0.001
0.001
0.001
0.02
0.02

6.33 (1.7823.61)
0.06 (0.010.27)
7.93 (1.9734.78)
6.82 (1.9624.77)
3.74 (1.1612.38)
0.25 (0.70.84)

Infant numbers.
x with Yates correction.

b 2

significant difference in the mean serum 25(OH)D levels

among infants below ( p 0:03) or above 6 months of
age ( p 0:005), of both social classes. The mean serum
calcium was 2.35 6 0.25 mmol/l, serum phosphorus was
1.76 6 0.72 mmol/l and serum alkaline phosphatase was
207 6 98 U/l. Serum alanine transaminase was normal in
all infants (,55 IU/l in males, 333 IU/l in females).
Serum biochemical changes suggestive of subclinical vitamin D deficiency rickets were present only in 5/35
(14%) vitamin D deficient infants. In them the mean
serum calcium was 1.85 6 0.24 mmol/l, serum phosphorus
was 0.77 6 0.3 mmol/l and the mean serum alkaline
phosphatase was 458 6 52 U/l.
Infants of USE class had a higher risk of having low
levels of vitamin D with an OR of 0.06, 95% CI = 0.010.27, p , 0:001 (Table 3). Similarly, the risk of having a
low level was also higher in infants of educated mothers
(OR = 6.82 95% CI = 1.9624.77) and in those living in
villas and flats (OR = 7.93 95% CI = 1.9734.78).

greater exposure to sunlight, because their weaning food

was mainly unfortified cereals. Infants of the mothers of
USE class lived in flats and villas, mothers were mostly
housewives, and confined their infants indoors. They had
reduced exposure to sunlight, and this could explain the
high prevalence of vitamin D deficiency among them. It
seems from our findings that the infants of USE class, of
educated mothers and those living in flats and villas are at
high risk of hypovitaminosis D and rickets. A majority of
the infants with hypocalcaemic seizures and rickets
reported from Karachi belonged to upper and middle
social class families (2). Eighty percent of Saudi infants
with rickets lived in flats and villas and none of the rachitic
infants lived in tents (1).
The higher levels of 25(OH)D observed in infants of
LSE class were, however, below the normal level of 90 6
27.5 nmol/l for infants (11, 13). Therefore the potential to
develop rickets remains high during the winter months,
unless infants are supplemented with vitamin D. Seventy
percent of infants with hypocalcaemic seizures and rickets
reported previously presented during the winter months (2).

Discussion
The breast milk content of vitamin D is low (5, 6) and
contributes little to the infants vitamin D status. In early
infancy the vitamin D status depends mainly upon the
stored vitamin D obtained across the placenta before
birth (7, 8). Infants born to vitamin D deficient mothers
are known to have low levels of 25(OH)D at birth (9, 10)
and exclusively breastfed infants become vitamin D deficient unless supplemented or adequately exposed to direct
sunlight (7, 11, 12). In the present study 45% of the mothers
had serum 25(OH)D concentrations in the osteomalacia
range (,25 nmol/l) with low normal levels in the others.
Our finding of a direct correlation between the vitamin D
levels of mothers and their infants under 3 months of age
indicates that maternal deficiency existed during pregnancy and the infants had low levels at birth. Other factors
contributing to subclinical hypovitaminosis D in infants
were low dietary content, non-supplementation with vitamin
D or reduced exposure to sunlight.
The higher levels observed in LSE infants could only be
explained by more exposure to sunlight, which is related to
increased time spent outdoors with their mothers. Similarly
higher levels in older infants could only be explained by

Conclusions
We have demonstrated that subclinical nutritional vitamin
D deficiency is common in exclusively breastfed infants
and nursing mothers, but surprisingly more so in infants
and mothers of the upper socioeconomic class. This is a
serious health problem. Paediatricians, obstetricians and
general practitioners in Pakistan should be aware of this
condition. Vitamin D supplementation to high-risk women
during pregnancy and after, as well as to their infants
should be considered. Exposure of women and infants to
sunlight should be encouraged.
Acknowledgment.We are grateful to Prof. B.S. Lindblad and Prof.
R.A.L. Sutton for reviewing this manuscript and providing valuable
suggestions. We acknowledge the technical assistance of Ms Fouzia
Rasheed in performing the radioimmune assay of serum 25(OH)D. We
also thank Amin Mansoor Ali and Asif Amir Ali for their efficient
secretarial help.

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Received Aug. 5, 1997. Accepted in revised form Mar. 10, 1998