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Infants, Vitamin D & The Truth About Diet

ALL infants need vitamin D supplement in the UK, anyone in the Northern hemisphere is deficient! As rickets reappear, so do generalised guidelines - and parents are often told that diet can't provide much vitamin D, instead it's all about sunshine and supplements.

Official Guidance

The NHS say:
"Vitamin D only occurs naturally in a few foods, such as oily fish and eggs. It is also added to some foods, such as fat spreads and breakfast cereals. The best source of vitamin D is summer sunlight on our skin. 
It's important that young children still receive vitamin drops, even if they get out in the sun.  All babies and young children aged six months to five years should take a daily supplement containing vitamin D, in the form of vitamin drops. This helps them to meet the requirement set for this age group of 7-8.5 micrograms (mcg) of vitamin D per day.  Babies who are fed infant formula don't need vitamin drops if they are having 500ml (about a pint) of formula or more a day. This is because formula is already fortified with the vitamins they need.  If you are breastfeeding your baby and didn't take vitamin D supplements during your pregnancy, your health visitor may advise you to give your baby vitamin drops containing vitamin D from the age of one month."
So I thought it might be interesting to explore just how much D lurks in food and what contribution this could realistically make to intake.

First we need to talk briefly about the different types of vitamin D.  There are 6, but D2 and D3 are the types sold as supplements.  D3 is generally considered superior to D2 but again it gets more complicated because not all studies nor experts agree.

It's also not easy to tease things apart, as many studies use synthetic supplements, whilst in nature other compounds that work in synergy (if you want to get techy read more here) are also found. 

Some studies that make the case against D2, highlight more is needed to generate the same circulating levels and it has a much shorter life after a single ingestion when studied over the next 28 days, however when it comes to infants they concede:
"Despite early evidence of differences in potency between the 2 vitamin D forms on a per weight basis, it must be highlighted that the widely practiced addition of vitamin D2 to milk in the United States and Europe in the 1930s served to successfully eradicate rickets as a significant health problem.  Additionally, fortification of milk with either vitamin D2 or vitamin D3 to this day has proven effective in the elimination of infantile rickets in North America. 
To prevent infantile rickets, a minimal intake of 2.5 μg (100 IU) vitamin D/d in infants with little sun exposure was shown to be efficacious (10). Thus, despite potential differences in the dose equivalence of vitamin D2 and D3, it is likely that vitamin D2 is currently provided at a high enough dose per kg infant body weight to maintain adequate bone mineral metabolism." here
In short, in "real life" either appears to protect against rickets, in a lab D3 sometimes looks better on paper - particularly when discussing supplements..

They're often quotes as offering a little, but not much D.  But what if that depends on the egg?

An independent study showed that UK eggs today have 70% more vitamin D3 than in the 1980's.  Birds also need sunlight or food sources of D and the reduction in caged hens and increase in free range and organic who see daylight,  plus improvements to their diet mean things have changed.

How much?
Well one medium sized egg can now contain as much as two-thirds (66%) of the RDA for an adult according to EU labelling regs.

At the time several, including the director of the "British egg information service" (made me chuckle) called for this significant egg finding to drive industry use (Pinchen H., Roe M., Finglas P. M., Buttriss J., Grey J., Cryer A.2012)

So, the EU lists adult RDA of 5µg and the NHS states that 1-5 year olds have a requirement of 7-8.5µg.  If one egg provides 66% of adult RDA, each egg provides roughly 3.3µg.  I wouldn't call nearly 50% an insignificant contribution would you?  

Fish can be a good source of D3.  This study though found farmed salmon contained 75% less than vitamin D than wild did.  As farmed fish is now the supermarket standard, you can see why some conclude it's not always easy to obtain D from food.

Furthermore cooking method impacts; baking salmon retains almost all the vitamin D, whilst frying in vegetable oil reduced the content by half.

What this paper also highlighted was that type of fish, diet, environment all impacted on vitamin D levels. You can see a list of the vitamin D value of fish here - although researchers concluded that the lists were out of date and new tests were needed.

Mushrooms are a huge vitamin D secret mainly because they can be hacked (by exposing them to bright sunlight), to have a higher D level either during after picking, Maitake for example, when grown in the sun can boast as much as 28.1µg per 100g, with 1 cup serving providing 20µg of D.

This has been dismissed by some as it's D2, however along with what we learnt about about D2, a 2011 study specifically explored mushrooms.

They found "the bioavailability of vitamin D2 from vitamin D2-enhanced button mushrooms via UV-B irradiation was effective in improving vitamin D status and not different to a vitamin D(2) supplement"

And a 2013 study again exploring vitamin D and mushroom consumption/bioavailability noted several things. 

First that the D2 in mushrooms was as bioavailable as that in a supplement. Furthermore the D2 in mushrooms was as effective at raising and maintaining blood levels of D as a supplement of either D2 or D3.

Second that D4 had been found in mushrooms as early as 1937. Therefore they decided to test a range including oyster, portabella & shiitake and found all contained varying levels. Another study continued their research exploring the D4 and again found this linked to light exposure.

Further examination revealed some also provided D3 whilst "Shiitake mushrooms not only produce vitamin D2 but also produce vitamin D3 and vitamin D4"

Leading them to conclude:
"The observation that some mushrooms when exposed to UVB radiation also produce vitamin D3 and vitamin D4 can also provide the consumer with at least two additional vitamin Ds"

Hack my shrooms

Some mushrooms like button, grow in the dark and so naturally have lower levels of vitamin D. However this study found a short short exposure to sunlight increased the vitamin D levels from 5µg to 374µg per 100 grams.

And the more exposure, the more vitamin D.  Putting Shiitake mushrooms with 40 IU of vitamin D into the sunlight for eight hours with the gills upward (ie sun-drying) resulted in 46,000 IU of vitamin D2. Another six hours (14 hours in total) of sunlight exposure boosted levels to an astonishing 267,000 IU of vitamin D per 100 grams."

In addition, researchers found that one year later, the sun-dried mushrooms retained a large amount of vitamin D; therefore sun-dried mushrooms could be stored and used in winter months.

Some feel more data is needed about mushrooms however because of one particular study in which researchers gave "sun-treated" or untreated mushrooms to a group of adults.  They found vitamin D2 supplementation via mushrooms didn't help overall, as the participant's vitamin D3 levels reduced to compensate - thus giving no-overall effect.  The massive flaw in this study as I see it is that these were healthy adults who started with totally normal serum levels, and maintained totally normal levels.  Yet it appears well accepted when giving a D supplement that the blood level does not keep increasing even with ongoing supplementation. It rises into the ideal range and then it stabilises. Vitamin D is consumed by the body, it is utilised and then inactivated (Dr David Grimes, Consultant physician and gastroenterologist)

You can see a table here of the different values recorded in meats in different studies.  As you can see beef offal packs a huge punch.

Our shift in what meats we choose to eat has also likely reduced our vitamin D intake:

This review finds numerous studies linking fat and vitamin D and says it was:
"significantly associated with the fat content of whole cuts, and in the cuts 8 to 10 times more vitamin D-3 and 2 to 3 times more 25(OH)-D-3 was found in lard and intramuscular fat than in the lean parts."
Fatty whole joints slow cooked used to be pretty standard as they were cheap (now often called "traditional cuts").  Many locally recall their parents home rendering lard and "dripping" which was even eaten on bread for lunch.

Then came the fat phobic/convenience era and lean steaks with the fat removed that could be cooked in minutes increased in popularity.  Use a Griddle so you make sure you strain as much of the evil arterty clogger away.   Liver was left behind, the overcooked dried offerings presented as school dinners etched on our brains, mingled with a fear of overdosing on vitamin A.  Lard and tallow were replaced with vegetable and sunflower oils and without realising we also waved goodbye to fat soluble vitamin D.

The problem with the convenience era, is that animals don't grow 33 leg chops and chickens don't have 20 breasts.  We therefore need many more animals to meet demand than when "nose to tail eating", that is consuming as much of the animal as possible rather than selecting choice cuts.

The trouble is if nobody wants a huge chunk of the animal, the parts we do want become more in demand - this drives down price and producers need to find cheaper and more economical ways of raising animals. 

Hello factory farming; feeding animals low grade foods, keeping them in low grade conditions provides cheap meat and fish. But at what cost?

Turns out raising animals in substandard conditions leads to substandard meat.  What the animal is fed impacts on what nutrients it provides, to quite a large degree.  It also turns out that animals, like humans need sunlight themselves to produce adequate quantities of vitamin D, or they need their feed supplementing too.

PART 2: Shame on the British Media! What Really Happened?

After posting this blog, I was made aware that the devastating story of Landon's life, portrayed by the media - may not be entirely accurate.

These posts sent to me, were from a PUBLIC forum:

Some points that may be relevant:

1)  Baby had experienced a difficult delivery,  with concerns for oxygen levels and heart rate following compression of the umbilical cord - resulting in 14 medical staff and an emergency section.

2) Being " a bit dehydrated" after birth, typically occurs when there has been excessive blood loss such as placental abruption, which isn't noted above.  I suspect what actually happened is they tested baby's blood sugars, which due to the difficult delivery were low enough to warrant immediate IV intervention whilst still in recovery.  
"Treatment depends on how severe the low blood sugar is in your baby and on your baby’s feeding skills. In some cases, frequent feeding is enough to correct the problem. In other cases, the doctor or advanced practitioner caring for your baby may provide extra sugar in a mixture that is given through a tube placed in the baby’s nose or mouth. In severe cases, sugar (called glucose) is fed right into the baby’s bloodstream through a needle placed in the infant’s vein. This is called an intravenous line or IV. The baby may need an IV for several days, but he or she can usually still feed from the mother’s breast or bottle during this time."
3.  The next few days in hospital don't give detail as to what happened with regard to doctors monitoring baby following this.  Normal protocols following this type of delivery and early IV required, would be that blood sugars and hydration levels would be checked constantly during this period; ensuring baby had stabilised.   This means either baby was hydrated with good blood sugar levels during his stay (and he was feeding well and crying for another reason, perhaps linked to delivery), or that inadequate checks were made during this period.

4.  There is no mention of distress when they returned home - in fact far from the media reports of constant crying, or sleeping as one would expect in a dehydrated infant, parents report they enjoyed "playing" with their baby.

5.  Only a few hours later at 2.15am did mum discover the tragedy - there isn't enough time here for a baby to have become severely dehydrated since their discharge at tea-time.

6.  Doctors immediately discussed seizures and SIDS.  And with good reason.  If we look at
"What causes neonatal seizures", we can see the most common causes listed here, the first being:
  • lack of oxygen before or during birth because of problems such as placental abruption (premature detachment of the placenta from the uterus), a difficult or prolonged labour, or compression of the umbilical cord.
In fact as this paper from the Department of Clinical Neurophysiology, Great Ormond Street Hospital, London outlines, 30-53% of seizures are as a result of such labour complications - compared to 0.1-5% as a result of low blood sugars.  As low sugars are also linked to complicated deliveries like the above, this makes things more complex.

"Seizures in the neonatal period are also the most common neurological emergency and are associated with high mortality and morbidity 1,2."
6.  Baby Landon survived several weeks in hospital, following his re-admittance - where he received expressed breastmilk.

6.  There is no mention of any link associated with feeding and the initial episode until 2015, when Christie del Castillo-Hegyi, founder of the "fed is best" movement, and recipient of questionable healthcare pertaining to her own infant, contacted this family.

It appears a not entirely unbiased mother (an A&E doctor, not a pathologist), went through the autopsy results of another, and concluded it was lack of breastmilk that caused the seizure that resulted in Landon's death.


Do you think the media representation accurately depicted the mother's words?

    Shame on the British Media! The Starving Breastfed Baby - Fact V Fiction

    1. I've watched in horror as the British media including the Sun, Mirror and Metro have covered the tragic story of a newborn who died from dehydration, in the inaccurate, irresponsible, scare-mongering style only they can.

    Headlines have included:
    "If I Had Given Him Just 1 Bottle, He'd Still Be Alive"
    Which the cynic in me struggles to believe isn't a play on one of breastfeeding's most hard hitting papers "Just One Bottle Won’t Hurt” -- or Will It?".
    "Cluster Feeding Led to Newborn's Death"
    This one irks me as "cluster feeding" is a totally normal, typical part of feeding - yet parents everywhere will now be terrified, but perhaps that was the plan?  This baby wasn't "cluster feeding" - when a term, healthy baby feeding well and typically several weeks old, takes a number of feeds back to back over two or three hours, in order to fill up their tummy and support a longer sleep stretch of 5 or 6 hours.  

    This baby wasn't "clustering", he was starving.  He was trying constantly to get food - he didn't die from cluster feeding, no "feeding" was taking place, he died from insufficient milk intake.

    The level of ignorance from doctors who have been quoted on the subject goes beyond cringe-worthy, to downright shocking - although it's no surprise the press have jumped to support the "fed is best" campaign, when it's all about readership not facts.

    Until I started reading studies and facts from other sources, I don't think I would have believed how much manipulation goes on to sell the desired angle to the audience - click bait headlines and half the facts, deliver a very different picture to the truth.

    So let's talk about the story this week.

    Indeed tragically a breastfed baby died due to insufficient milk intake.  This much is true.

    However a number of key details that parents should be aware of:

    1) This was the USA FIVE years ago!

    Practices and protocols surrounding infant feeding and hydration in the UK are completely different. The risk of hypertraenemic dehydration in some US hospitals is recorded as relatively high, particularly in comparison to the UK.

    A 2013 study analysing almost 1,000,000 births in the UK and Ireland found just 62 cases of severe neonatal hypernatraemia, equivalent to just seven in every 100,000 births and an individual risk of 0.007%. No baby died, had seizures or coma or was treated with dialysis or a central line. At discharge, babies had regained 11% of initial birth weight after a median admission of 5 (range 2-14) days and none had long-term damage. (3)

    2) This was medical ignorance; numerous warning signs were ignored by healthcare providers:

    In startling parallels with the story of  Dr Christie del Castillo, founder of the "Fed is Best movement", whose son also developed hypertranemic dehydration (and was inappropriately re-hydrated leading to life-long consequences) - numerous flags were raised here too.

    According to newspaper reports, the baby cried for abnormally long spells:
    "Mother whose baby cried all day didn’t realise he was starving to death"  (Mirror)
    And had lost a concerning amount of weight even prior to discharge:
    "Landon was discharged from hospital on the third day of his life, having lost 9.7 per cent of his body weight - considered 'routine' and 'unremarkable'."
    Considered "routine" and "unremarkable" by whom?

    The American Academy of Pediatrics states:
    “Weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.” 
    The International Lactation Consultant Association and the Registered Nurses' Association of Ontario specify that:
    A loss of more than 7% of birth weight, continued loss after day 3, or failure to regain birth weight within a minimum number of days (i.e., 10 days or 2–3 weeks, respectively) are signs of ineffective breastfeeding.
     The Academy of Breastfeeding Medicine advises:
    "Possible indications for supplementation in term, healthy infants [include] weight loss of 8% to 10% accompanied by delayed lactogenesis (day 5 or later).” (1)
    So we have a concerning situation - a baby with a bigger than typical weight loss, who is crying excessively, being discharged without any feeding plan to ensure adequate intake.  This was a huge gamble.

    If my child was in hospital showing every sign of kidney failure and a team of kidney specialists all failed to recognise this -you can bet I'd be looking for answers as to how on earth they were so incompetent they missed the blooming obvious.  I'd be campaigning not that we should all be given artificial kidneys, but that those paid and employed to care for those with kidney conditions, could a) identify when they were failing, b) know the safest course of action to take should this arise.

    The debate surrounding the number of women with "failed lactation" is thrown about - but in terms of saving lives, knowing a figure isn't key to outcome; even one baby suffering a preventable condition as a result of poor practice is too many.  As long as we have trained healthcare professionals who can then educate caregivers, we can save lives - it's not an invisible situation where baby goes from fine to desperately ill without warning.

    3) Neither the British media, nor fed is best have made parents aware that far more babies die as a direct result of infant formula e.g bacterial contamination and as a result of not being breastfed.

    Bacterial Contamination

    In April 2016, the CDC released a new report, warning of a bacteria called Cronobacter Sakazakii, one of the most lethal contaminants found in paediatric food and/or milk formula, with an estimated mortality rate as high as 80%.  This bacteria has been isolated from items in the home such as vacuum cleaner bags - and thus often contamination of the powder can also occur once the tin has been opened.  Using recommended protocols to reconstitute the powder significantly reduces risks - trace levels of bacteria are unlikely to cause harm, but multiplying in warm milk can significantly increase the load.

    This information isn't new. 

    In 2008 the CDC Morbidity and Mortality Weekly Report covers two cases and states:
    "Previous investigations have found Cronobacter spp. cultured from prepared formula, unopened Powdered infant formula (PIF) containers, and the environment where PIF was reconstituted, clearly implicating PIF as the source of outbreaks. "
    Infants throughout the world consume PIF, some exclusively. PIF preparers should be aware that PIF is not sterile and can contain pathogenic organisms (e.g., Cronobacter spp.). Preparers also should be aware that PIF can be contaminated extrinsically (although mechanisms for such contamination are not well defined) and that bacteria can multiply rapidly in reconstituted PIF. Consequently, WHO has developed guidelines for preparation of PIF, including reconstitution with water hot enough to inactivate Cronobacter organisms (3). Universal adoption of these guidelines can aid in implementation of safer PIF preparation, storage, and handling.
    Yet we don't know is what prompted the 2016 safety update...

    In June 2016, just two months later, 27 day old Axel Burnett tragically succumbed to the meningitis & sepsis caused by Cronobacter bacteria.

    On her Facebook page his mum Jamie says:
    "We are so mad and so upset that Enfamil Gentlease would not put a warning label on the label knowing this could happen! Our baby boy got tooken from contaminated formula, did we know this would happen? No, why? Because NO ONE WARNED US!"
    His mum tried to raise awareness of the issue online, founding a "Justice for Baby Axel" page, which has received over 11,000 likes.  Despite this still no major news station or parenting site has covered the story.
    "This bacterium is an emerging opportunistic pathogen that is associated with rare but life-threatening cases of meningitis, necrotizing enterocolitis, and sepsis in premature and full-term infants. Infants aged <28 days are considered to be most at risk. Feeding with powdered infant formula (PIF) has been epidemiologically implicated in several clinical cases."
    One study found:
    "The presence of Enterobacter sakazakii and other Enterobacteriaceae was surveyed in 82 powdered infant formula milk (IFM)

    Although Enterobacteriaceae were enumerated from one powdered IFM sample (Klebsiella ozaenae, 200 cfu/g), 7/82 had detectable Enterobacteriaceae after enrichment in EE broth."

    Do you know how many babies die per year of Cronobacter from infant formula?  No?  Neither does anyone else.  As the CDC explained in 2008in the United States; formal surveillance and reporting systems exist only in Minnesota. 

    Yet parents are still not aware how important safe formula preparation is, we only have to look at how popular products like the "Perfect Prep" machine are.  Despite concerns the small amount of water released in the "hot shot",  may rapidly fall below 70 when it hits the powder, not sustaining the temp for 2 minutes to effectively eradicate all bacteria present - nobody appears to have examined this further.

    Lack of breastmilk & formula use

    A review published in the journal Archives of Disease In Childhood titled, “Marketing breast milk substitutes: problems and perils throughout the world,” suggests:
    "Currently, suboptimal breastfeeding is associated with over a million deaths each year and 10% of the global disease burden in children"
    In her article with over 100 references - Dr Folden Palmer estimates over 9000 US infant lives are lost each year due to lack of breastfeeding.  She says:
    "The final relative risk for formula feeding comes out to 2—that’s double the risk of death for American infants who are fed with formula, compared with babies who are fed naturally.
    A multitude of studies demonstrate that when breastfeeding is accompanied by formula supplementation, illness and death rates are much closer to those of babies who are fully formula-fed. Studies also reveal conclusively that the longer breastfeeding lasts, the greater the measurable difference in illness and death rates."
    A 2010 a study published in Pediatrics quoted 1000 lives:
    "The United States incurs $13 billion in excess costs annually and suffers 911 preventable deaths per year because our breastfeeding rates fall far below medical recommendations," the report said.
     There's also a whole heap of interesting studies and reading on risks of not breastfeeding here.

    We need to realise this one sided approach from our media, is purely to appease their readership. The "Fed is Best" campaign is anti-feminist, paternalistic propaganda, to try and convince parents how they feed their baby doesn't really matter.  It does.

  • Enterobacter sakazakii: An Emerging Pathogen in Powdered Infant Formula 2006
  • Marketing breast milk substitutes: problems and perils throughout the world 2011


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