1992;326:137-138. 5. Mahaffey KR, Annest JL. Association of

erythrocyte protoporphyrin with blood lead level and iron status: National Health and Nutrition Examination Survey, 1976-1980. Environ Res. 1986;41:327-338.

1. Bolognia JL, Berwick M, Fine JA, Simpson P, Jasmin M. Sun protection in newborns: a comparison of educational methods. AJDC. 1991;

145:1125-1129. 2. Specker BL, Valanis B, Hertzberg V, Edwards N, Tsang RC. Sunshine exposure and serum 25-hydroxyvitamin D concentrations in

Sun Protection and Vitamin D Status in Infants

exclusively

Sir.\p=m-\Iread with interest the article by Bolognia et al1 in the October 1991 issue of AJDC. They recommended that parents "decrease unprotected time in the sun." The authors do not appear to have serious concerns about possible

1988;67:373-378. 4. Matsuoka LY, Wortsman J, Haddad JG, Hollis BW. In vivo threshold for cutaneous synthesis of vitamin D3. J Lab Clin Med. 1989;114:

vitamin D deficiency, as "spending 30 minutes per week outdoors wearing only a diaper or 2 hours fully clothed without a hat is sufficient [in exclusively breast-fed infants] to maintain serum calcifediol levels above the lower limit of normal.2 The recommendation by Bolognia et al does not take into account issues related to race, latitude, and season. In a challenging 1988 study, Webb et al3 demonstrated that exposure to winter sunlight in Boston, Mass, and Edmonton, Alberta, does not promote vitamin D3 synthesis in human skin. Moreover, Matsuoka et al4 confirmed that in the northern United States, winter UV-B irradiance does not reach the threshold required for cutaneous synthesis of vitamin D3

(regardless

of the exposure time). Therefore, newborn infants who live at northern latitudes remain highly de¬ pendent on body stores and dietary supplies to meet vitamin D require¬ ments during winter. Human milk contains significantly less vitamin D and calcifediol (12 to 60IU equivalents of vitamin D per liter) than fortified formulae (400 IU/L),5 and vitamin Ddeficiency rickets is almost exclusively reported in breast-fed (mostly black) infants.6 I would like to emphasize that, if I concur with the recommenda¬ tion by Bolognia et al to decrease new¬ born infants' unprotected time in the sun, this recommendation must be combined with careful administration of daily vitamin D in breast-fed infants, since their amount of endogenous syn¬ thesis with the use of sunblocks is unknown. FRANCIS MIMOUNI, MD

Magee-Womens Hospital Department of Pediatrics

300 Halket St Pittsburgh, PA 15213-3180

breast fed infants. J Pediatr. 1985;

107:372-376. 3. Webb AR, Kline L, Holick MF. 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.

301-305. 5. Makin HLJ, Seamark DA, Trafford DJH. Vitamin D and its metabolites in human breast milk. Arch Dis Child. 1983;58:750-753. 6. Mimouni F. Vitamin D functions and requirements in the first year of life: calcium nutriture for mothers and children. In: Tsang RC, Mimouni F, eds. Carnation Nutrition Education Series. New York, NY: Carnation Co, Glendale/ Raven Press Ltd; 1992;3:39-51.

In

Reply. \p=m-\Ourstudy protocol

plied that on sun

im-

focusing primarily exposure during the summer we were

The summer season was chosen because an estimated 80% of sun exposure in the northern latitudes occurs during the spring and season.

summer.1 We

appreciate the attention drawn

to the need to combine our recommen-

dation for a decrease in unprotected sun exposure with the administration of supplemental vitamin D to breast\x=req-\ fed infants living in northern latitudes during the winter season. JEAN L. BOLOGNIA, MD Department of Dermatology JUDITH A. FINE MARJORIE JASMIN, RN Cancer Prevention Research Unit Yale University School of Medicine 500 LCI PO Box 3333 New Haven, CT 06510-8059 MARIANNE BERWICK, PHD Cancer Prevention Research Institute 36 E 22nd St New York, NY 10010 PAMELA SIMPSON, MPH Charles R. Drew Medical School 12021 S Wilmington Ave Los Angeles, CA 90059 1. Scotto J, Fears TR, Gori GB. Measurements of Ultraviolet Radiation in the United States and Comparisons With Skin Cancer Data. Washington, DC: US Dept of Health, Education, and Welfare; 1976. Publication 76-1029.

Downloaded From: http://archpedi.jamanetwork.com/ by a University of Michigan User on 06/14/2015

Another Look at Pediatrician Promotion of Breast-feeding Sir.\p=m-\Furman1 raises some interesting points in her letter published in the May 1992 issue of AJDC. Although we have far to go with regard to support for parenting in this country, we will not improve the duration or quality of the mother-infant nursing rela-

tionship by simply extending maternity leaves and providing job security to working mothers. I believe that we as pediatricians (as well as obstetricians and family physicians) do a very poor job of promoting breast-feeding

patients. Yes, we say "breast is are we really providing mothers with enough resources to re-

to

our

best," but

alize these goals? There are several

companies promoting products (electric pumps that allow both breasts to be pumped simultaneously, specially designed pillows that make positioning much easier) that can make a tremendous difference

in the

success a

mother has with

breast-feeding, yet few pediatricians know of these products. Despite the promotion of "family-centered care" in many maternity units throughout the country, we still see glucose water appearing

in the bassinets of

borns, and mothers

new¬

sent home with

discharge gift packs of infant formula.

How many of us still recommend that young infants get a supplemental bot¬ tle of proprietary formula each day so we know that they are getting enough" ! I could footnote study after study "

showing

that all these maneuvers detrimental to the nursing rela¬ tionship. There are neonatal inten¬ sive care units in this country in which breast milk, lovingly ex¬ pressed by mothers, is being dis¬ carded down the drain. Surely, if there were a substance that could make such a difference in the health of an adult, its promotion would be legislated and advertising detrimen¬ tal to it (proprietary formula adver¬ tisements) would be prohibited. Yes, there are women who should not breast-feed their infants, but I think in the interest of not inducing guilt in mothers, we permit mothers who have no contraindications to breast-feeding to give up too easily are

Sun protection and vitamin D status in infants.

1992;326:137-138. 5. Mahaffey KR, Annest JL. Association of erythrocyte protoporphyrin with blood lead level and iron status: National Health and Nut...
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