维他命D补充品:提供给妈妈还是婴儿?


  【24drs.com】妈妈每天补充6400 IU的维他命D会使乳汁内有足够量的维他命D,而可满足哺乳婴儿的需求,因此,母亲的维他命D补充或许可作为婴儿直接补充的替代策略。
  
  南卡罗来纳医学大学儿童医院Bruce W. Hollis博士等人的随机控制研究结果,9月28日发表于在线版的10月小儿科期刊,这篇双盲试验探讨妈妈的维他命D补充是否可以替代给婴儿的补充。
  
  这篇研究是以三种剂量(每天400、2400或6400 IU的维他命D3)给予哺乳妇女,然后在全母乳哺餵的婴儿测量维他命D值;持续给予补充品6个月,这篇研究的两个地点是在不同纬度地区进行,包括了广泛的种族/族裔多样性。
  
  相较于每日400 IU,每日剂量6400 IU可安全且明显地增加母亲的维他命D和25(OH)D值(P < .001)。对于那些母亲没有使用这类补充品的婴儿,每天接受400 IU的维他命D也可以增加他们的25(OH)D值。
  
  研究者指出,在研究开始时,医学研究院设定维他命D的每日上限为2000 IU,这个剂量远低于本研究发现的有效剂量,医学研究院也报告指出,维他命D毒性与高尿钙症和高血钙症、以及肾结石风险有关。
  
  虽然维他命D毒性已记录在案,医师们同意,纯母乳哺餵之婴儿的维他命D大部份是缺乏的,除非他们有接受口服维他命D补充品。因此,一般认为人类母乳的维他命D含量不足以帮助纯母乳哺餵之婴儿达到营养需求,且让这些婴儿的佝偻病风险增加。
  
  因此,医界建议,母乳哺餵之婴儿应给予维他命D补充品,且在出生后几天内就开始,特别一提的是,美国小儿科学院建议婴儿每天口服400 IU维他命D。
  
  不过,母乳中缺乏维他命D的文献纪录也提出另一个可能性 ,也就是母亲本身的维他命D不足,所以造成子代也不足。如果这论述为真,那么,问题就是:该由哪里个医师处方维他命D给妈妈?举例来说,妈妈的维他命D补充品建议并不属于美国小儿科学院指引的范围。
  
  无论从哪里个角度看来,这篇研究提出了许多需要回答和解决的问题。
  
  俄亥俄州克里夫兰凯斯西储大学医学院大学附属彩虹婴幼童医院Lydia Furman医师在编辑评论中写道,这些策略有一些财务上的障碍要克服:医疗补助计划(Medicaid)健康维持组织有关婴儿保险卡的未发行时间长达数周,或者,该计画可能需要事先授权,而综合维他命滴剂的花费对于中低收入家庭来说可能会有困难。
  
  Furman医师写道,不过,单靠免费药物也非万能,蒙特娄的免费处方计画未能改善婴儿获得维他命D的机会,在四年的研究期间,处方摄取量降低且佝偻病风险增加。
  
  Furman医师结论指出,其它可能的策略包括公卫讯息,将婴幼儿维他命D纳入门诊电子病历医嘱,且加强实习生教育。最后,我们需要有一种方法来追踪维生素D缺乏性佝偻病的比率,而非仅依赖案例报告,全国性的资料登记将有助于此。像Hollis博士等人的杰出研究,提出诸多问题与答案,最终可帮助我们处理棘手的临床问题。
  
  资料来源:http://www.24drs.com/
  
  Native link:Vitamin D Supplementation: Give to Mother or to Infant?

Vitamin D Supplementation: Give to Mother or to Infant?

By Lara C. Pullen, PhD
Medscape Medical News

Supplementing mothers with 6400 IU vitamin D per day results in breast milk with adequate vitamin D to satisfy a nursing infant's requirement. Thus, maternal vitamin D supplementation may represent an alternative strategy to direct supplementation of an infant.

Bruce W. Hollis, PhD, from the Medical University of South Carolina Children's Hospital in Charleston, and colleagues published the results of their randomized controlled trial online September 28 and in the October issue of Pediatrics. The double-blind trial explored whether supplementation of maternal vitamin D can substitute for infant supplementation.

The study included three dosing schedules (400, 2400, or 6400 vitamin D3/day) in lactating women, and vitamin D levels were measured in their exclusively/fully breast-feeding infants. Supplementation was continued for 6 months. The two-site study was conducted at distinct latitudes and included a wide range of racial/ethnic diversity.

The dose of 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline relative to 400 IU/day (P < .001). It also raised infant 25(OH)D levels to those seen in infants who breast-fed from mothers who were not supplemented with vitamin D but who themselves received 400 IU vitamin D per day.

The investigators note that at the time the study was initiated, the Institute of Medicine had set an upper limit of 2000 IU per day for vitamin D, a dose that was much lower than the dose found in this study to be effective. The IOM also reported that vitamin D toxicity is associated with hypercalciuria and hypercalcemia, as well as risk for kidney stones.

Breast Milk Insufficient

Although vitamin D toxicity has been documented, physicians agree that solely breast-fed infants are almost universally deficient in vitamin D unless they receive oral vitamin D supplementation. As a consequence, it has long been recognized that human milk supplies an inadequate amount of vitamin D to meet the nutritional needs of a solely breast-fed infant and leaves the infant at increased risk for rickets.

The medical community therefore recommends that a vitamin D supplement be given to breast-feeding infants, starting within the first few days after birth. Specifically, the American Academy of Pediatrics recommends that infants be given 400 IU oral vitamin D daily.

However, the documented lack of vitamin D in breast milk raises the possibility that it is the mothers who are deficient, and that the mothers are passing their deficiency on to their offspring. If this is true, then the question becomes: Which physicians should be prescribing the vitamin D to the mothers? A recommendation for vitamin D supplementation of mothers, for example, would no longer fall under the American Academy of Pediatrics guidelines.

Whichever way you look at it, the research raises many questions that demand answers and solutions.

"Strategies to overcome ?nancial barriers are needed: Medicaid health maintenance organizations do not issue infant insurance cards for several weeks or the plan may request 'prior authorization,' and the cost of multivitamin drops may tip the budget for low- or middle-income families," Lydia Furman, MD, from the University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine in Cleveland, Ohio, writes in an accompanying editorial.

"Free medication alone, however, is not a panacea: a free prescription program in Montreal failed to improve odds of obtaining vitamin D for the infant, with reduced prescription uptake and an increased prevalence of rickets cases over the 4-year study period," Dr Furman writes.

"Other possible stratagems include public health messaging, addition of infant vitamin D to ambulatory electronic medical record order sets, and augmented trainee education. Finally, we need a way to track rates of vitamin D deficiency rickets, rather than just relying on case reports, and a National Registry could facilitate this," Dr Furman concludes. "Excellent studies, like the work of Hollis et al, generate as many questions as answers, and ultimately energize us to tackle tough clinical questions."

The investigators and Dr Furman have disclosed no relevant financial relationships.

Pediatrics. 2015;136:625-634.

    
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