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Vitamin supplements: ensuring a healthy start in life

Sarah Jean-Marie
BSc(Hons) PGDip
Senior Children's Centre Dietitian
Stamford Hill Children's Centre

A wide range of supplements containing either single nutrients, such as vitamin C or calcium, or a range of nutrients are available on the market. A healthy, balanced diet will provide most of the body's essential nutrients, but for babies, children, pregnant and breastfeeding women supplements may be of benefit.

Pregnant women
Good nutrition before, during and after a woman's pregnancy is vital for the healthy development of the baby. Research shows that a woman's nutritional status can have an impact on the size of the baby which in turn can have an impact on the baby's short- and long-term health.(1)
A varied balanced diet is important to ensure that a wide range of nutrients is consumed. A pregnant woman's nutritional requirements are similar to before pregnancy except for an increase in protein, riboflavin, folic acid and vitamins A and D.(2) In the last trimester the requirement for vitamin C, thiamine and energy also increases.(2) It is vital that adequate supplies of all nutrients are taken including protein, energy, calcium, iron, folic acid, and vitamins C and D.
Alongside a healthy varied diet there is also a role for vitamin supplements during pregnancy. The importance of folic acid has long been recognised in the prevention of spina bifida and other neural tube defects. Women are advised to take 600mg of folic acid a day through a combination of diet and a supplement containing 400mg of folic acid, when planning a pregnancy, or if there is any chance that they may become pregnant, up until 12 weeks of pregnancy.(3)
Women who have had a baby with spina bifida are recommended to take a supplement containing 5mg of folic acid, available on prescription from their GP.
Despite a number of campaigns to increase the uptake of folic acid before pregnancy, the uptake has been limited.(3) Educated women or those in higher socioeconomic groups are more likely to take folic acid before pregnancy. Women who have unplanned pregnancies are less likely to have taken folic acid during the recommended period.(4,5) The Food Standards Agency (FSA) is considering fortifying foods with folic acid, as is the case in the USA and Canada, to reduce the number of babies born with neural tube defects, and has launched a public consultation.(6)
Government guidelines recommend that pregnant women take a supplement containing 10mg of vitamin D.(7) Some vitamin D is available from the diet - from oily fish, butter, eggs, fortified margarine and breakfast cereals - but this is not sufficient to meet the requirements of pregnant women, women who breastfeed and young children.
For most people the main source of vitamin D is from sunlight. How ever, the ability of the skin to synthesise adequate supplies of vitamin D is limited between October and March. Women with dark skin, eg, Asian, African and Caribbean women, and women who cover up for cultural reasons, may be unable to synthesise adequate supplies of vitamin D, and studies show that these communities are more likely to have vitamin D deficiency.(8-10)
Vitamin D deficiency during pregnancy can have an impact on the baby's nutritional status in the short and long term. One study reported that maternal vitamin D status during pregnancy can have an impact on the bone mass density of a child at the age of nine years old.(11)
It is also important for women to have an adequate supply of vitamin A for tissue growth and for the development of eyes, heart, skin, ears and mucous membranes. However, excess vitamin A (retinol) can lead to deformities of the heart and brain. Vegetable sources of vitamin A (beta-carotene) contained in carrots, pumpkin, red pepper, and so on, do not lead to these problems.
Multivitamins and multiminerals are not essential if a woman is eating a balanced and varied diet; however, it is recommended that all women take folic acid during the first trimester and vitamin D throughout the pregnancy. 
Some women may benefit from multivitamins and multiminerals; however, supplements should be specifically tailored for pregnant women and not contain vitamin A. Examples of supplements for pregnant women include ProNatal (from Sanatogen) and Pregnacare (from Vitabiotics). From March 2007, vitamins for women will be available through the Healthy Start government initiative, containing vitamins C and D as well as Folic acid (see Table 1).

[[nip33_table1_44]]

Women who may be at nutritional risk and could benefit from supplements include:

  • Women who live on a low income with limited amount of money to spend on food.
  • Women who have a poor appetite or a limited diet due to nausea and vomiting.
  • Teenagers who tend to have a diet low in nutrients.
  • Women who have closely spaced pregnancies.
  • Women who have a low body mass index before pregnancy.
  • Women who are expecting twins.
  • Women who smoke.
  • Women who consume a vegetarian or vegan diet.

Breastfeeding mothers
Breastfeeding is encouraged for the numerous benefits it offers both mother and baby. However, it is essential that mothers have a healthy balanced diet supplemented with vitamin D. Breast milk is low in vitamin D especially if the mother has not taken vitamin D supplements during pregnancy. The government recommendations are that women take vitamin D during the first six months of breastfeeding. However, if there is any doubt about the baby's nutrition status vitamin A, C and D should be given to the baby from one month.(7)

Babies
The government recommends that babies are weaned at six months. Introducing a variety of food is important to ensure that the baby receives adequate nutrients. Alongside the introduction of food it is recommended that babies who are still breastfeeding are given vitamins drops.(7)
Unfortunately there has been a decrease in the uptake of vitamins among women who are breastfeeding. In 1990, 30% of women who were breastfeeding offered vitamin drops to their baby, which dropped to 18% in 1995 and 10% in 2000.(12)
There are various types of vitamin supplements that may be given, eg, Healthy Start vitamins, Abidec (from Chefaro) and Dalivit (from LPC Medical), which all contain vitamins A, C and D (see Table 2).

[[nip33_table2_46]]

Vitamin D deficiency is more common in babies that have been exclusively breastfed, with delayed weaning and no vitamin supplementation.(13) A deficiency during infancy and childhood can result in rickets, poor growth, dental problems and hypocalcaemic convulsions.(14,15)
Babies that are given formula milk may not need to take vitamin supplements provided that they are having over 500ml a day (or 130ml/kg).(7)

Children
It is important that all children aged between one and five years take vitamin supplements containing vitamins A, C and D unless it is certain that they are receiving a diet with adequate nutrients.(7)
The uptake of vitamin drops has dropped recently and there has been a resurgence of rickets.16 This may be due to lack of awareness of the government guidelines on vitamins among health workers and among families.(17,18)

The Healthy Start scheme
The Healthy Start scheme, launched by the government in November 2006, aims to improve the diet of people on a low income and to promote the uptake of vitamins. It provides weekly vouchers worth £2.80 to families who receive income support, income-based job seekers allowance or child tax credits to buy fresh milk, formula milk or fresh fruit and vegetables. The vouchers are for pregnant women or children under four years. They will also be available for all pregnant women under the age of 18 regardless of whether they are in receipt of benefits.
Healthy Start vitamins for children under four are also available free for families receiving the above benefits or at a subsidised cost for other families. Healthy Start vitamins for pregnant women will be available from March 2007. Healthy Start provides a good opportunity to promote these messages, not just to families on a low income, but to all families.

References

  1. Barker DJP, Gluckman PD, Godfrey KM, et al. Fetal nutrition and cardiovascular disease in later life review article. Lancet 1993;341:938-41.
  2. Department of Health. Dietary reference values for food and energy and nutrients for the United Kingdom.  Report on health and social subjects 41. London: HMSO; 1991.
  3. Department of Health. Folic acid and the prevention of neural tube defects. Report of an expert advisory committee. London: DH; 1992.
  4. Mathews F, Yudkin P, Neil A. Folates in the periconceptional period: are women getting enough? Br J Obstet Gynaecol 1998;105:954-9.
  5. Brooke ZM, Doyle W. Primiparous women's reported preconception and first trimester folic acid use. Proc Nutr Soc 2001;60:224A.
  6. Food Standards Agency. Options to increase folate intakes of young women. London: FSA; 2006. Available from: http://www.food.gov.uk/consultations/ukwideconsults/2006/folate
  7. Department of Health. Weaning and the weaning diet: report of the working group on the weaning diet of the committee on medical aspects of food policy. London: HMSO; 1994.
  8. Zipitis CS, Markides GA, Swann IL. Vitamin D deficiency: prevention or treatment? Arch Dis Child 2006;91:1011-4.
  9. Callaghan AL, Moy RJD, Booth IW, et al  Incidence of symptomatic vitamin D deficiency. Arch Dis Child 2006;91: 606-7.
  10. Ladhani S, Srinivasan L, Buchanan C, et al. Presentation of vitamin D deficiency. Arch Dis Child 2004;89:781-4.
  11. Javaid MK, Crozier SR, Harvey NC, et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet 2006;367:36-43.
  12. Hamlyn B, Brooker S, Oleinikova K, et al. Infant feeding survey 2000. London: TSO; 2002.
  13. Mughal MZ, Salama H, Greenaway T et al. Florid rickets associated with prolonged breast-feeding without vitamin D supplementation. BMJ 1999: 318:39-40.
  14. Hochberg Z, Bereket A, Davenport M, et al. Consensus development for the supplementation of vitamin D in childhood and adolescence. Recent Prog Horm Res 2002;58:39-51.
  15. Muhe L, Lulseged S, Mason KE, et al. Case-control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children. Lancet 1997;349:1801-4.
  16. Allgrove J. Is nutritional rickets returning? Arch Dis Child 2004; 89:699-701.
  17. Cleghorn S. Do health visitors advise mothers about vitamin supplementation for their infants in line with government recommendations to help prevent rickets? J Hum Nutr Diet 2006;19:203-7.
  18. Leaf AA. Vitamins for babies and young children. Arch Dis Child 2007;92:160-4.

Resources

Department of Health
www.healthystart.nhs.uk

Food Standards Agency
www.food.gov.uk

British Dietetic Association
www.bda.uk.com

Sure Start
www.surestart.gov.uk

British Nutrition Foundation
www.nutrition.org.uk

Scientific Advisory Committee on Nutrition
www.sacn.gov.uk