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Behind the new recommendations:
Now we need to supplement with Vitamin D?!?

By Christine Climer

In April of 2003, the American Academy of Pediatrics issued new guidelines for preventing rickets and vitamin D deficiency in children. Because cases of rickets continue to be reported, the AAP recommends that all children receive a vitamin supplement containing 200 IU of vitamin D daily, unless they drink at least 17 ounces of either vitamin D-fortified milk or infant formula.

These new recommendations have caused quite a controversy, even among the medical community.

What are rickets and vitamin D, anyway?
When skin is exposed to ultraviolet light, it makes vitamin D from cholesterol. The active form of vitamin D is actually a hormone that controls the absorption and metabolism of calcium and phosphorus, so it affects how our bones are formed.

Children who do not have enough vitamin D can experience stunted growth and skeletal deformities such as bowed legs; this disorder is known as rickets.

But they say breast milk doesn’t have enough Vitamin D!
Everyone knows that breast milk is the most perfect food for babies. It contains small amounts of vitamin D because nature intended for babies to be exposed to sunshine. Vitamin D in breast milk is intended to supplement the vitamin D that infants make themselves from sunshine; it is not to provide 100% of their daily requirement. According to the Institute of Medicine, “with habitual small doses of sunshine, breast- or formula-fed infants do not require supplemental vitamin D.”

Babies are born with stored vitamin D that they get from their mothers during pregnancy. These stores are used during those first weeks of life when sunlight exposure is often limited. A full-term infant whose mother was not vitamin D-deficient during pregnancy should have enough stored vitamin D to last up to 8 weeks without supplementation.

How much sunshine is enough?
The answer to this question depends on many factors. Higher levels of ultraviolet light exist during the summer months, at lower latitudes and when air pollution levels are low. Clothing, sunscreen and windows block most ultraviolet light. And people with darker skin pigmentation require greater exposure for vitamin D production than do lighter-skinned individuals. All of these variables make it impossible to determine a precise measurement for how long any specific child should be exposed to sunshine in order to achieve the daily requirement of vitamin D.

In an effort to decrease the incidence of skin cancer, the AAP recommends that children under 6 months old stay out of direct sunlight and that older babies and children wear protective clothing and sunscreen when they are exposed to sunshine. The AAP claims that initiating sunlight exposure at an earlier age increases the risk of skin cancer. However, research demonstrates that only episodic, high exposure sufficient to cause sunburns increases the risk of developing skin cancer later in life, not routine exposure of minimal duration. Further research into sun exposure and vitamin D status in infants has been met by stiff resistance from many doctors who feel that it is unethical to expose children to sunshine without sunscreen.

Dr. Michael Holick, one of the most respected vitamin D researchers in the world (professor of Medicine, Physiology and Dermatology at Boston University School of Medicine, and chief of Endocrinology, Metabolism and Nutrition), believes that exposing the arms and face to sunlight for just 5 to 10 minutes two to three times a week during the summer, spring and fall is adequate for vitamin D production and will not significantly increase the risk of skin cancer or damage the skin. This correlates with the recommendations of the World Health Organization and the New Zealand Ministry of Health. A study of breast-fed infants at 39°N latitude in Cincinnati, Ohio, demonstrated that adequate vitamin D was made when infants wearing only a diaper were exposed to sunshine 30 minutes a week. Babies fully clothed without a hat required about 2 hours of sunshine each week.

How can we get vitamin D?
Latitude and season affect the amount of ultraviolet light that reaches the earth’s surface. During the period of “vitamin D winter,” when sunlight exposure results in no vitamin D production, dietary supplementation might be warranted. This is why Sweden’s Ministry of Social Welfare recommends supplementation for children over one year of age only from September through April. For people living at 52°N latitude, this period extends from October through March, and for those at 42°N latitude from November through February. People living at 34°N effectively make vitamin D throughout the winter.

Latitudes of selected major cities

Los Angeles, California 34°N
Dallas, Texas 33°N
Boston, Massachusetts 42°N
Edmonton, Canada 52°N
Santiago, Chile 33°S
London, England 51°N
Rome, Italy 42°N
Moscow, Russia 55°N
Tokyo, Japan 36°N
Beijing, China 40°N
Cairo, Egypt 30°N
Cape Town, South Africa 34°S
Sydney, Australia 34°S

Vitamin D can be obtained from foods many of us eat every day. Some dairy products, margarines, orange juice and grain products are fortified with vitamin D, but it is important to read the label to be sure. Other good food sources include halibut, herring and cod. The daily percentage value for vitamin D that is listed on food labels is based on a dosage of 400 IU, so children need only 50% of that in order to obtain the recommended amount daily.

Foods high in Vitamin D

• Cod liver oil contains about 450 IU/teaspoon. Pharmaceutical-grade oils have been highly purified and are more concentrated than food grade oils, so check labels for exact content.
• 3 ½ oz. salmon provides 360 IU
• 3 ½ oz. mackerel contains 345 IU
• 1 cup fortified milk or orange juice contains 100 IU
• 1 egg yolk contains 25 IU

Vitamin D supplements are available for children. In the United States, these are available only in multivitamins. The most common are those produced by manufacturers of infant formulas.

Vitamins should be stored securely out of children’s reach, to reduce the chance of accidental overdose. Due to a built-in protection mechanism, it is impossible to overdose on vitamin D that is made in our bodies from sunshine.


American Academy of Pediatrics, “Ultraviolet Light: A Hazard to Children,” Pediatrics 1999;104(2): 328-33.

Australian Broadcasting Corporation, “Vitamin D,” The Health Report with Norman Swan (1 November 1999).

Autier P, Dore J, “Influence of sun exposures during childhood and during adulthood on melanoma risk. EPIMEL and EORTC Melanoma Cooperative Group. European Organisation for Research and Treatment of Cancer,” Int J Cancer 1998;77(4): 533-7.

Children’s Nutrition Research Center at Baylor College of Medicine, “CNRC experts ‘D’-mystifies nutritional rickets,” Consumer News Vol 2 (2001).

Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride (Washington, DC: Institute of Medicine, 1999): 250-287.

Gartner L, Greer F, “Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake,” Pediatrics 2003; 111: 908-10.

Good Mojab C, “Sunlight Deficiency: A Review of the Literature,” Mothering 2003;(117):52-55, 57-63.

Gritz E, “Back to School Cancer Prevention Tips” CancerWise (Sept 2001). _2001/

Holick M, “Environmental factors that influence the cutaneous production of vitamin D,” Am J Clin Nutr 1995;61(3 Suppl.): 638S-645S.

Kaskel P, et al., “Outdoor activities in childhood: a protective factor for cutaneous melanoma? Results of a case-control study in 271 matched pairs,” Br J Dermatol 2001;145(4): 602-9.

National Institutes of Health Clinical Center, “Vitamin D,” Facts About Dietary Supplements.

Norman A, “Vitamin D and Milk,” University of California, Riverside, Dept of Biochemistry & Biomedical Sciences (2000).

Nozza J, Rodda C, “Vitamin D deficiency in mothers of infants with rickets,” Med J Aust 2001;175(5): 253-5.

Scanlon K, Ed., “Vitamin D Expert Panel Meeting October 11-12, 2001, Atlanta, Georgia, Final Report,” Centers for Disease Control (2001).

Specker B, et al., “Sunshine Exposure and Serum 25-hydroxyvitamin D Concentration in Exclusively Breastfed Infants,” J Pediatr. 1985; 107(3):372-6.

Webb A, DeCosta B, Holick M, “Sunlight regulates the cutaneous production of vitamin D3 by causing its photodegradation,” J Clin Endocrinol Metab. 1989;68(5):882-7.

Webb A, Kline L, Holick M, “Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin,” J Clin Endocrinol Metab. 1988;67(2):373-8.

World Health Organization, “The Known Health Effects of UV.”

Christine Climer is a registered nurse with experience in pulmonary disease, pediatrics, home health and hospice services. Also trained in early childhood education, she is currently executive director and child care nurse for an early childhood health promotion organization. She lives with her husband and three children (including a set of twins) in Texas and enjoys researching health issues and gardening.


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