Vitamin D Supplementation for

Infants
Biological, behavioural and contextual rationale

Vitamin D is a fat-soluble vitamin that exists in two forms, vitamin D3

or cholecalciferol which is the mammalian form and vitamin D2 or
ergocalciferol which is the fungal form (1, 2). From a nutritional
perspective both forms are metabolized similarly (3). At birth, human
infants have a limited amount of vitamin D stores that primarily
reflect transfer from the mother during pregnancy (1, 2). After birth,
vitamin D can be obtained by the infant through mother’s milk (0.5-
1.8 micrograms per liter), and through supplements (1). Vitamin D
can also be made in the infant’s skin when exposed to ultraviolet
beta solar radiation (4). However, at latitudes greater than 37
degrees north or south the beta radiation is too low to enable vitamin
D production during the late fall to early spring months. In addition,
melanin pigmentation of the skin absorbs beta radiation and thus it
limits the ability to make vitamin D for those with darker skin (5).
Parents are advised to limit their infant’s exposure to ultraviolet solar
radiation by use of hats, swaddling in blankets and avoidance of
direct exposure to sunlight (6-8). This means that even though
vitamin D can be made in the skin in some regions and seasons, the
limited exposure of infants to sunshine renders this source to be
minimal. Therefore, the main sources of vitamin D for the infant
include vitamin D obtained from the mother during pregnancy and
after birth from diet and supplements.

The best biological indicator of body stores of vitamin D from all

sources is blood serum concentration of 25-hydroxyvitamin D
(25(OH)D) (1). Values of 25(OH)D below a concentration of 30
nanomoles per liter (nmol/L) of serum indicate high risk of vitamin D
:
 deficiency, whereas healthy concentrations for infants are believed
to be at or above 50 nmol/L (1). Body stores can decline by 50% over
less than a month in infants (9), and thus without a source of vitamin
D, vitamin D deficiency can rapidly develop.

Vitamin D deficiency in infants (10-18) is evident throughout the

world, covering a wide range of geographic regions and cultures.
This is in part because not all health care practitioners recommend
vitamin D supplementation even after considering exclusive
breastfeeding and dark skin pigmentation (19-23). Furthermore,
parent noncompliance to supplementation is a widespread concern
(24-26), in some cases due to parental perception that their infant
does not like the supplement (27-30). Immigration and refugee
status is also a risk factor for low vitamin D status in infants (31-33),
including countries with high beta radiation exposure (34).

Vitamin D is required to maintain blood calcium and bone health. The

consequences of vitamin D deficiency in infancy classically manifest
as soft malformed bones (rickets), seizures due to low blood calcium
and difficulty breathing (35-40). At the time of diagnosis, infants
with vitamin D deficiency rickets have very low serum 25(OH)D
concentration, below 25 nmol/L (41, 42) and most have not received
vitamin D supplementation (6, 43). Vitamin D deficiency is also
thought to increase risk of other diseases including type 1 diabetes
later in childhood (44-48).

The most widely accepted approach to building healthy vitamin D

stores in infants is through vitamin D supplementation. Based on
randomized controlled trials, 5 (49, 50) to 10 micrograms daily (49,
51-56) is enough to support a serum 25(OH)D concentration of 50
nmol/L in infants from birth to one year. Educational strategies aimed
at parents are effective in increasing infant vitamin D status (57).
High dose bolus supplementation to rapidly build stores in infants
:
 (58) is not yet recommended as a public health strategy.

Recommendations for vitamin D intakes in infancy are available from

various organizations throughout the world and are typically 5 (2) to
10 micrograms daily (1, 6, 59-62). Some organizations suggest
greater amounts (25 to 30 micrograms daily) as a supplement to
exclusive breastfeeding (63). Supplements are usually
recommended to begin within the first month of birth and continue
until that amount can be attained from other foods (1, 6, 59). For
some cultures and countries, the introduction of alternative milks,
such as fortified cow’s milk or infant formula, and cereals may
provide an additional source. Strategies to increase the amount of
vitamin D in newborns using high dosage maternal supplementation
show potential in preventing vitamin D deficiency in newborn infants
(64-66), but are not part of public health policy recommendations at
this time. If an infant is diagnosed with rickets, global consensus
recommendations for the treatment of vitamin D deficiency have
recently been published (41).

There appears to be consistency across the world that newborn

infants are at an elevated risk of vitamin D deficiency and that a
vitamin D supplement to exclusive breastfeeding is highly
recommended in the primary prevention of vitamin D deficiency and
rickets (1, 2, 6, 59-63). Public health actions including information
dissemination to parents and health care providers need to be
strengthened to reduce the incidence of vitamin D deficiency.

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Disclaimer

The named authors alone are responsible for the views expressed in
this document.

Declarations of interests

Conflict of interest statements were collected from all named

authors and no conflicts were identified.
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