DOI: 10.1542/peds.2009-1195 2010;125;105-111; originally published online Nov 30, 2009; Pediatrics

James A. Taylor, Leah J. Geyer and Kenneth W. Feldman Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods

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Use of Supplemental Vitamin D Among InfantsBreastfed for Prolonged Periods

WHAT’S KNOWN ON THIS SUBJECT: Because of the risk ofnutritional rickets, vitamin D supplementation is recommendedfor all breastfed infants. There is emerging evidence of otherbenefits of vitamin D for children.

WHAT THIS STUDY ADDS: The results of this study provideinsight into the proportion of breastfed infants who receivevitamin D supplementation and the reasons parents choose toprovide the vitamin to their children.

abstractOBJECTIVES: To determine the rate of vitamin D supplementation inpredominantly breastfed children. To identify patient characteristics,parental beliefs, and practitioner policies associated with supplemen-tation.

METHODS: A prospective observational study was conducted in apractice-based research network. Network pediatricians completed asurvey regarding their policy on vitamin D supplementation for breast-fed infants. Parents of children 6 to 24 months old completed a surveyon the initial type of feeding given to the child, length of breastfeeding,formula supplementation, and use of multivitamins. Parents indicatedtheir level of agreement with statements regarding vitamin D supple-mentation.

RESULTS: Among 44 responding pediatricians, 36.4% indicated thatthey recommended vitamin D supplementation for all breastfed in-fants. A total of 2364 surveys were completed on age-eligible children;1140 infants were breastfed for at least 6 months with little or noformula supplementation. The rate of vitamin D use for these infantswas 15.9%. Use of vitamin D was significantly associated with parentalagreement that their child’s pediatrician recommended supplementa-tion (odds ratio [OR]: 7.8), and that vitamins are unnecessary becausebreast milk has all needed nutrition (OR: 0.12). Among parents of pre-dominantly breastfed infants who indicated that their child’s doctorrecommended vitamin D, 44.6% gave the supplementation to theirchild. Conversely, 67% of parents agreed that breast milk has allneeded nutrition, and only 3% of these parents gave vitamin D to theirchildren.

CONCLUSIONS: A minority of breastfed infants received vitamin D sup-plementation. Educational efforts directed at both physicians and par-ents are needed to increase compliance with vitamin D supplementa-tion guidelines. Pediatrics 2010;125:105–111

AUTHORS: James A. Taylor, MD,a Leah J. Geyer, AB,a andKenneth W. Feldman, MDa,b

aDepartment of Pediatrics, University of Washington, Seattle,Washington; and bDepartment of Pediatrics, Seattle Children’sHospital, Seattle, Washington

KEY WORDSbreastfeeding, vitamin D, infants, rickets

ABBREVIATIONSAAP—American Academy of PediatricsPSPRN—Puget Sound Pediatric Research NetworkOR—odds ratioCI—confidence interval

www.pediatrics.org/cgi/doi/10.1542/peds.2009-1195

doi:10.1542/peds.2009-1195

Accepted for publication Jul 30, 2009

Address correspondence to James A. Taylor, MD, University ofWashington, Child Health Institute, Box 354920, Seattle, WA98195. E-mail: uncjat@u.washington.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2009 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Because the vitamin D content in hu-manmilkmay be relatively low, breast-fed infants are at risk for rickets un-less they are exposed to adequateamounts of sunshine to produce en-dogenous vitamin D or receive it fromother sources.1–4 For more than a de-cade, supplemental vitamin D has beenrecommended for certain infants whoare breastfed to prevent rickets.5 In2003, the American Academy of Pediat-rics (AAP) recommended that allbreastfed infants receive at least 200IU/day of supplemental vitamin D;in 2008, the recommendation waschanged to at least 400 IU/day.2,6

Estimates of physician adherence tothe AAP recommendations regardingvitamin D supplementation vary. A1999 survey of North Carolina pediatri-cians found that 44.6% recommendedthe supplement for all breastfed in-fants, and 38.6% recommended it forsome infants.7 These results are simi-lar to a study of Las Vegas, Nevada,pediatricians in which 48% recom-mended vitamin D for breastfed in-fants.8 Recently, it was reported that89% of responding pediatricians in theUS military recommended supplemen-tation for all, or some, infants fed hu-man milk.9 More important, however,there have been few data on whetherthese recommendations influence pa-rental behavior and how many breast-fed infants actually receive supple-mental vitamin D. In a study on theprevalence of hypovitaminosis D inyoung children in the Boston, Massa-chusetts, area, Gordon et al10 reportedthat only 2% of breastfed infants re-ceived supplemental vitamin D.

We conducted a study to determine therate of supplemental vitamin D usageamong a group of infants from the Se-attle, Washington, area who were pre-dominantly breastfed for at least thefirst 6 months of life. We were inter-ested in identifying the reasons par-ents choose to supplement, or to not

supplement, their breastfed infants.We were particularly interested in therole that their child’s pediatrician hadin influencing this choice. Before theproject, we postulated that approxi-mately one third of infants who werebreastfed for at least 6 months wouldreceive supplemental vitamin D andthat a parent’s decision regarding sup-plementation would be highly influ-enced by the recommendation of theirchild’s pediatrician.

METHODS

A prospective observational study wasconducted by the Puget Sound Pediat-ric Research Network (PSPRN), a re-gional practice-based network of pri-mary care pediatric practices in theSeattle, Washington, area. For thisproject, 44 PSPRN practitioners from 7private practice offices and 1 inner-city pediatric clinic participated. Thestudy consisted of 2 surveys, includinga practitioner vitamin D survey and aninfant-feeding survey completed byparents. Survey data were collectedbetween July 2006 and June 2008.

Before collecting data on infants, thepractitioner vitamin D survey was dis-tributed to 44 PSPRN pediatricians. Thepediatricians were asked about theircurrent recommendation regarding vi-tamin D supplementation for breastfedinfants. Possible responses includedrecommend vitamin D for all breastfedpatients; recommend for “high-risk” chil-dren; discuss pros and cons of supple-mentation with parents; and do not rou-tinely discuss vitamin D with parents.Pediatricians were asked to indicatetheir level of agreement with 4 state-ments regarding supplemental vitaminD by using a 6-point Likert scale, withpossible responses to each statementranging from “completely agree” to“completely disagree.” The statementson vitamin D usage are shown in Table 1.

For the analysis of data in the prac-titioner vitamin D surveys, the

responses to statements by pedia-tricians who indicated that they rec-ommended vitamin D for all breastfedinfants were compared with the re-sponses of those who had some otherpractice regarding supplementation.Likert-scale responses were trans-formed to an ordinal scale for the anal-ysis. Regression analysis was used toassess differences; generalized esti-mating equation techniqueswere usedto account for the clustering of pedia-tricians in different practices.11

The infant-feeding survey was distrib-uted to parents of children 6 to 24months old at the time of an office visitto a PSPRN practice. This survey wasanonymous; no identifying health in-formation was collected. Surveys wereavailable in both English and Spanishand were distributed by a research as-sistant who visited practices on a reg-ularly scheduled basis. Surveys were

TABLE 1 Statements Regarding Vitamin DSupplementation and Rickets on thePractitioner Vitamin D Survey andParental Survey of Infant Feeding

Practitioner vitamin D surveyIn order to practice high quality medicine it isimportant to follow AAP practice guidelines.A major limitation of the AAP recommendationthat all breastfed infants receivesupplemental vitamin D is that therecommendation is not evidence-based.Routinely recommending vitamin D forbreastfed babies may result in somemothers electing to formula feed instead.Some of my breastfed patients will likelydevelop rickets if they don’t receivesupplemental vitamin D.

Parental survey of infant feedingI think that giving vitamins to babies and youngchildren is important for their overallhealth.Vitamins may be needed to prevent rickets orother bone diseases in some babies.It is inconvenient to give vitamins to youngbabies.When my baby was less than 6 months old,he/she didn’t need any extra vitaminsbecause the breast milk or formula thathe/she took had everything my baby needed.If babies are out in the sunlight and fresh airthey don’t need extra vitamins.My child’s doctor recommended that I give mybaby vitamins.

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also distributed to parents by officestaff in participating practices duringmultiple data-collection periods thatranged from 1 to 3 months.

For the infant-feeding survey, parentsof age-eligible children provided thecurrent age of their child and wereasked the initial type of feeding for himor her (breast milk or infant formula).Parents of those infants who were ini-tially breastfed were asked how longtheir child received human milk, howmuch formula their child received on aroutine basis, and how often the childreceived�16 oz of formula in a singleday (possible responses included“never or almost never,” “a few dayseach week,” “almost every day,” or“every day,”). Parents were askedwhether their child routinely receiveda multivitamin (all containing vitaminD) during the first 6 months of life. Theparent was also asked to provide thename of his or her child’s pediatricianduring the child’s first 6 months of lifeand to indicate how important thisphysician’s recommendation was re-garding the decision of whether to givehis or her infant vitamins; responseswere categorized with a 5-point Likertscale that ranged from “very impor-tant” to “very unimportant.” Parentswere also asked to provide the raceand ethnicity of their child.

Six statements regarding vitamin Dsupplementation were listed on thesurvey. As with the practitioner survey,parents indicated their level of agree-ment with each statement by using a6-point Likert scale. The statements onthe infant-feeding survey are listed inFig 1.

Much of the analysis of data in theinfant-feeding surveys was focused onthose children who were predomi-nantly breastfed for at least the first 6months of life. Children were consid-ered to be predominantly breastfed ifthey routinely received �8 oz of for-

mula daily during the first 6 months oflife and “never” or “almost never” re-ceived�16 oz of formula in 1 day. Be-cause commercial formula contains400 IU/L,12 the infants who were de-fined as being predominantly breast-fed received�100 IU of vitamin D fromformula on a routine basis and neveror almost never received 200 IU daily.On the basis of the recommendationfor 200 IU of supplemental vitamin Ddaily that was in place when the studydata were collected,2 none of thesepredominantly breastfed, unsupple-mented study children received�50%of the recommended vitamin D dosefrom infant formula on a daily basisand virtually never received all of therecommended dose from this source.The rate of supplemental vitamin D usein the children who were predomi-nantly breastfed for at least 6 monthswas calculated. The rate of breast-feeding, prolonged breastfeeding,and vitamin D use was also com-puted for children from different ra-cial and ethnic groups; 95% confi-dence intervals (CIs) around pointestimates were calculated.

Characteristics and parental beliefsassociated with supplemental vitaminD use in children who were predomi-nantly breastfed for at least 6 monthswere assessed with the use of logisticregression. Generalized estimatingequation techniques were used inthese analyses to account for the clus-tering of patients in different prac-tices.11 Characteristics assessed in-cluded race, ethnicity, and age. Data onthe infant-feeding surveys regardingthe child’s pediatrician during the first6 months of life were linked to re-sponses on the practitioner vitamin Dsurveys. On the basis of this linkage,the association between having a pedi-atrician who recommended vitamin Dfor all breastfed infants versus havinga provider who had another policy re-

garding supplementation and use ofvitamin D in study patients was as-sessed. Parental agreement withstatements regarding vitamin D usewas dichotomized; responses of “com-pletely agree” or “agree” were com-pared with all other responses foreach item. Similarly, the response tothe item in the infant-feeding survey inwhich parents were asked how im-portant their child’s pediatrician’srecommendation was regarding sup-plemental vitamin D was dichotomizedby comparing responses of “very im-portant” or “important” to otherresponses.

Each individual characteristic or beliefwas compared with the use of vitaminD in predominantly breastfed study pa-tients. Those characteristics and be-liefs statistically associated with vita-min D use in univariate analyses,defined as an odds ratio (OR) with a95% CI that did not include 1.0, wereincluded in a multivariate model toidentify factors independently associ-ated with vitamin D use in breastfedchildren.

Finally, during the study period, therewas increasing publicity regarding vi-tamin D deficiency in children andadults.13,14 To protect the anonymity ofstudy children and their parents, wedid not collect data on the date thatinfant surveys were completed (thesedates corresponded to dates of physi-cian visits, which is considered to beidentifiable health information).15 How-ever, information on the surveys wasentered into databases as they werecollected. To assess the effects of sec-ular trends in vitamin D use during thestudy period (2006–2008), we catego-rized study patients into tertiles on thebasis of the chronological order ofwhen their data were entered into thestudy databases.

The study was approved by the SeattleChildren’s Hospital’s institutional re-view board.

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RESULTS

A total of 44 PSPRN pediatricians com-pleted the practitioner vitamin D sur-vey. At the time that the survey wascompleted, 16 pediatricians (36.4%) in-dicated that they routinely recom-mended supplemental vitamin D for allof their breastfed patients. Fourteenrespondents (31.8%) recommendedsupplemental vitamin D for breastfedinfants who were at high risk for de-veloping rickets. Six pediatricians(13.6%) responded that they discussedthe pros and cons of supplementationwith parents of breastfed infants, and8 (18.2%) indicated that they did notroutinely discuss vitamin D supple-mentation with parents.

Physicians who did not recommend vi-tamin D for all breastfed infants hadsignificantly higher levels of agree-ment with the statement, “A major lim-itation of the AAP recommendationthat all breastfed infants receive sup-plemental vitamin D is that the recom-mendation is not evidence based,”than pediatricians who recommendedvitamin D for all breastfed infants (39total responses; P� .011). Those prac-titioners who were not universally rec-ommending vitamin D also had higherlevels of agreement than those whouniversally recommended supplemen-tation for breastfed children with thestatement indicating that recommend-ing supplementation might lead somemothers to choose to not breastfeedtheir infants (P� .042). There were nosignificant differences in levels ofagreement for the statement regard-ing the importance of following AAPguidelines and the statement regard-ing the possibility of rickets in breast-fed children who were not supple-mented between those pediatricianswho routinely recommended vitamin Dand those who had another policy re-garding supplementation.

Data on completion of the infant-feeding survey by parents and on

breastfeeding practices of their chil-dren are summarized in Fig 1. Amongthe 2364 eligible children whose par-ents completed surveys, 1945 (82.6%[95% CI: 81.0%–84.1%]) were mainlyfed with human milk during their firstmonth of life. The race and ethnicity ofeligible children are shown in Table 2along with the rates of initial breast-feeding and the proportion who werepredominantly fed human milk for atleast 6 months. The mean age of theinfants and toddlers at the time theirparents completed the survey was 12.1months (SD: 4.8 months); 25% wereaged 8 months or younger, and 25%were aged 16 months or older.

As shown in Fig 1, surveys were com-pleted by parents of 1140 children whowere predominantly breastfed for atleast the first 6 months of life. The restof the analysis was focused on these1140 study infants and toddlers. Over-all, 181 of 1139 of these children(15.9% [95% CI: 13.8%–18.1%]) wereroutinely given supplemental vitamin Dduring the first 6 months of life. Infor-mation on vitamin D use for 1 child wasmissing. Use of supplemental vitaminD in predominantly breastfed infantsvaried according to race, with val-ues ranging from 14.2% (95% CI:11.9%–16.6%) amongwhite children to27.1% (95% CI: 20.9%–34.0%) among

2433 completed surveys-69 surveys on children <6 mo or >25 mo old2364 surveys on eligible children (97.2%)

1945 initially breastfed (82.6%) 411 formula fed (17.4%) 8 missing

- 287 infants who took ≥8 oz/d formula on routine basis and/or 16 oz formula a few

d/wk or more (20.1%)-29 with missing data

1140 infants predominately breastfed for ≥6 mo

(58.6% of those initially breastfed)

1456 infants breastfed for ≥6 mo (75%)4 missing

FIGURE 1Survey completion and breastfeeding practices in study children.

TABLE 2 Rate of Initial Breastfeeding Among Study Infants of Different Racial and/or Ethnic Groupsand Rates of Being Predominately Breastfed for at Least 6 Months

Race/Ethnicity No.a % InitiallyBreastfed

% PredominantlyBreastfed for�6 mo

Black 120 62.5 24.2American Indian/Alaskan Native 42 88.1 52.4Asian/Pacific Islander 427 81.5 44.8White 1695 85.1 52.4Hispanic ethnicityb 232 73.7 41.0a Data on children whose parents indicated that they were of multiple races are included in more than 1 race category.b Includes children from all racial groups.

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Asian/Pacific Islander children. A totalof 29 black patients were predomi-nantly breastfed for at least 6 months;6 of these children (20.7%) receivedsupplemental vitamin D. The rate of vi-tamin D usage among Hispanic chil-dren who were breastfed for at least 6months without significant formulasupplementation was 15.8% (95% CI:9.1%–24.7%).

The univariate association between vi-tamin D use in predominantly breast-fed children and several variables, in-cluding race, ethnicity, age, parentalbeliefs, and the policy of the child’s pe-diatrician regarding supplementation,are summarized in Table 3. In theunadjusted analyses, most of the vari-ables assessed were statistically asso-ciated with supplementation. To iden-tify characteristics and beliefs thatwere independently associated with vi-tamin D use in breastfed infants, ananalysis including those variables sig-nificantly associated with supplemen-tation in univariate comparisons wasconducted. Because of both the over-lap between several racial and ethnicgroups and evidence that �90% ofchildren in the United States with nu-

tritional rickets are nonwhite and/orHispanic,16 only 1 race variable (non-white race and/or Hispanic ethnicity,or non-Hispanic white race) was in-cluded in the model. In addition, be-cause 213 predominantly breastfedstudy children had an initial primarycare provider who was not a memberof PSPRN and did not complete thepractitioner survey, data on the child’spediatrician’s vitamin D recommenda-tion policy were not included in thelarger model. The results of the multi-variate analysis are shown in Table 4.

Of the variables assessed in the fullmodel, parental agreement that thechild’s pediatrician recommended vi-

tamin D supplementation and that vita-mins are important for a child’s over-all health were the only variables thatwere positively and significantly asso-ciated with the use of vitamin D. Con-versely, parental agreement that sup-plementation is unnecessary becausebreast milk has all needed nutritionand that giving vitamins is inconve-nient were both significantly associ-ated with not using vitamin D. Addi-tional models that included all racialvariable terms and/or data on thechild’s pediatrician’s recommendationregarding supplementation were ana-lyzed. The results of every analysiswere similar. Parental agreement thatvitamin D was recommended by thechild’s physician (adjusted ORs rang-ing from 7.76 to 8.93 in different analy-ses) and agreement that vitamins aregood for overall infant health (ad-justed ORs: 1.98–2.23) were signifi-cantly associated with providing sup-plementation; agreement that breastmilk had all needed nutrition (adjustedORs: 0.10–0.12) and agreement thatgiving vitamins is inconvenient (ad-justed ORs: 0.45–0 .46) were statisti-cally associated with not giving vita-min D.

When asked to identify their child’smain doctor during the first 6 monthsof life, parents of 927 patients listed aPSPRN pediatrician who had com-pleted the practitioner vitamin D sur-vey (81.3% of those infants who were

TABLE 3 Univariate Association Between Vitamin D Use and Patient Characteristics, ParentalBeliefs, and Policy of the Child’s Pediatrician Among Study Children Who WerePredominantly Breastfed for at Least the First 6 Months of Life

Variable ORa 95% CI No.b

White 0.63 0.44–0.90 1089Nonwhite race and/or Hispanic ethnicityc 1.67 1.22–2.27 1089Black 1.12 0.49–2.62 1089Asian/Pacific Islander 2.02 1.43–2.87 1089Hispanic ethnicity 0.93 0.56–1.54 1084Child’s age 1.00 0.97–1.03 1139Parent agrees: vitamins important for overall health 5.22 3.45–7.90 1101Parent agrees: vitamins needed to prevent rickets/other diseases 2.77 1.93–3.98 1020Practitioner survey: child’s doctor recommends vitamin D for allbreastfed infants

3.88 2.23–6.73 926

Parent agrees: child’s doctor recommended vitamin D 19.52 10.61–35.93 1083Parent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.07 0.04–0.13 1109Parent agrees: giving vitamins inconvenient 0.59 0.42–0.84 1087Parent agrees: vitamins not needed if infant is out in sunlight 0.29 0.17–0.49 1074Child’s doctor’s recommendation regarding vitamin D important inparent’s decision about vitamin D supplementation

2.88 1.65–5.03 1037

a OR was calculated by using logistic regression after accounting for clustering of children into different practices.b No. indicates number of valid responses to each item.c Of the study children, 335 of 1090 (30.7%) were nonwhite race and/or Hispanic ethnicity; information on vitamin Dsupplementation was collected for 1089 of these children.

TABLE 4 Multivariate Analysis to Identify Patient Characteristics, Parent Beliefs, and ProviderPolicies Associated With Vitamin D Supplementation in Predominantly Breastfed Infants

Variable ORa 95% CI

Nonwhite race and/or Hispanic ethnicity 1.29 0.81–2.06Parent agrees: vitamins important for overall health 1.98 1.17–3.34Parent agrees: vitamins needed to prevent rickets/other diseases 1.37 0.81–2.31Parent agrees: child’s doctor recommended vitamin D 7.76 4.11–14.64Parent agrees: vitamins unnecessary, breast milk has all needed nutrition 0.12 0.07–0.23Parent agrees: giving vitamins inconvenient 0.45 0.26–0.76Parent agrees: vitamins not needed if infant is out in sunlight 0.94 0.42–2.10Child’s doctor’s recommendation regarding vitamin D important indecision about vitamin D supplementation

1.83 0.77–4.39

a OR calculated using logistic regression after accounting for clustering of children into different practices.

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predominantly breastfed). Amongthese 927 study children, 218 (23.5%)were seen by a health care providerwho indicated that he or she routinelyrecommended supplemental vitamin Dfor all breastfed infants. Parents ofchildren whose provider universallyrecommended vitamin D for breastfedinfants were significantly more likelyto agree that the provider recom-mended this supplement than those ofchildren whose pediatrician had an-other policy (64.7% and 22.7%, respec-tively; OR: 3.10 [95% CI: 1.95–4.91]).Parents of nonwhite and/or Hispanicchildrenwere alsomore likely to agreethat their child’s provider recom-mended vitamin D than those of whitenon-Hispanic children (44.6% and27.8%, respectively; OR: 1.75 [95% CI:1.37–2.27]). Overall, 33.3% of respond-ing parents indicated that their child’sprovider recommended vitamin Dsupplementation. Among these par-ents, 44.6% gave the supplement totheir child versus 2.8% of thosewhose child’s provider did not rec-ommend vitamin D (OR: 19.52 [95% CI10.61–35.93]).

Among the responding parents of chil-dren who were predominantly breast-fed for at least 6 months, 743 of 1110(67.0%) agreed with the statementthat vitamin D supplementation is notrequired because breast milk has allneeded nutrition. Only 3.0% of childrenof these parents received supplemen-tal vitamin D.

There was an increase in the use ofvitamin D in predominantly breastfedinfants during the 2-year study period.During the first third of the period,10.8% of these children received sup-plemental vitamin D; 12.7% receivedthe supplement during the middlethird and 24.0% during the last third ofthe study period (OR: 1.60 [95% CI:1.10–2.32] for comparison betweenthe final and first third of the study pe-riod). However, after controlling for

this secular trend, there were no sig-nificant changes in the results; 4 vari-ables (agreeing that the child’s doc-tor recommended supplementation,agreeing that vitamins are importantfor overall infant health, agreeing thatbreast milk has all needed nutrition,and agreeing that giving vitamins is in-convenient) remained significantly as-sociated with vitamin D use.

DISCUSSION

Our results indicate that only a minor-ity of study childrenwhowere predom-inantly breastfed for �6 months re-ceived supplemental vitamin D. Thisrate of usage is explained, to a largedegree, by 2 conflicting influences.Parents who reported that their child’spediatrician recommended vitamin Dwere �8 times more likely to providethe supplementation than parentswhose child’s pediatrician did notmake this recommendation. However,only one third of the parents of breast-fed infants indicated that the pediatri-cian recommended vitamin D. In addi-tion, and perhaps the most strikingfinding of this study, fewer than half(44.6%) of the parents who respondedthat vitamin D was recommended bytheir child’s pediatrician actually ad-ministered the supplementation. Thiscounterintuitive result is partially ex-plained by our finding that 67% of theparents believed that supplementationis unnecessary because breast milkhas all needed nutrition. Parents whohad this belief were �9 times lesslikely to give supplemental vitamin Dthan those who did not agree with thisstatement.

Initially, vitamin D supplementationwas recommended for breastfed in-fants as a method to prevent rickets.2

However, there is emerging evidencethat vitamin D may play an importantrole in mitigating other disease pro-cesses in children.1,17 Informationabout this evidence, both in the scien-

tific and lay press, has likely increasedinterest in providing vitamin D tobreastfed infants. In our study, wefound that vitamin D use increased sig-nificantly during the final third of ourstudy period (roughly covering the pe-riod of late 2007 to mid-2008) whenthere was publicity about vitamin D.13,14

However, even during this most recentperiod, fewer than one quarter of theresponding parents of predominantlybreastfed infants reported giving vita-min D to their children. The same fac-tors (their child’s doctor’s recommen-dation and a belief that breastmilk hasall needed nutrition) remained signifi-cantly associated with a parent’s deci-sion regarding supplementation.

As expected, we found a high rate ofbreastfeeding in this population of in-fants seen in primary care pediatricpractices in the Seattle area. In 2002, itwas estimated that 71% of US childrenhad ever been breastfed and that63.2% were breastfed at 1 month ofage. The Pacific region of the countryhad the highest reported rates ofbreastfeeding, with 76.4% of infantsfrom this region reportedly beingbreastfed at 1month of age.18 We foundthat 82.6% of the children in our studywere mainly breastfed during the firstmonth of life. We also found thatbreastfeeding among black infantswas more common in our populationthan nationally. However, breastfeed-ing rates in Hispanic infants in ourstudy were comparable to US rates forHispanic infants.18 Perhaps more sur-prising was the finding that 1140 of the2364 infants in the study (48.2%) werebreastfed with little or no formula sup-plementation for at least 6 months.This is substantially higher than the35.1% of infants nationally who arebreastfed for at least 6 months.18

It is possible that the high rate ofbreastfeeding in study children waslinked to the reticence of the respond-

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ing pediatricians to recommend vita-min D in at least 2 ways. Pediatricianswho did not universally recommendsupplementation had a belief that rec-ommending vitamin D might causesome parents to not breastfeed theirinfant. Perhaps these practitionerswere wary of any intervention thatwould alter the high prevalence ofbreastfeeding. Conversely, pediatri-cians may have been hesitant to bringup supplementation to parents whohave strong beliefs about the nutri-tional advantages of human milk. Wefound that 68.2% of responding pedi-atricians recommended vitamin Dsupplementation for some or allbreastfed infants. Although this ishigher than rates found in surveys ofproviders conducted before the AAPrecommendation in 2003,7,8 it islower than the 89% rate of recom-mending supplementation that Sher-

man and Svec reported among 128military pediatricians.9

A potential limitation of this study isthat parents of children up to 2 yearsold were asked to report whether vita-mins were given during the first 6months of life and the reasons for thischoice. It is possible that some parentsdid not recollect correctly. To some ex-tent, our finding that significantlymore parents of study children whosepediatricians universally recommendvitamin D indicated that the practitio-ner recommended supplementationthan those whose child’s pediatriciandid not tend to validate the accuracy ofparental reporting on the surveys.

CONCLUSIONS

At the time that we began this study in2006, there was significant resistanceto the AAP recommendation for sup-plemental vitamin D for breastfed in-

fants among participating pediatri-cians. Our results suggest that vitaminD use is strongly linked to physicianrecommendations. Efforts to increasephysician acceptance of vitamin D rec-ommendations should lead to moreuse in infants and increase compli-ance with AAP guidelines.6 However,the results of our study also suggestthat there is a strong belief by parentsthat breast milk has all needed nu-trition. To a large degree, this beliefsupersedes physician recommenda-tion. Thus, to substantially increase vi-tamin D use in predominantly breast-fed infants, public health educationalcampaigns should also directly targetparents.

ACKNOWLEDGMENTThis study was funded by a grant fromthe Agency for Healthcare Researchand Quality.

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