160

REVIEW

Vitamins for babies and young children

A A Leaf, on behalf of the RCPCH Standing Committee on Nutrition
...................................................................................................................................

Arch Dis Child 2007;92:160–164. doi: 10.1136/adc.2006.109066

The Welfare Food Scheme has recently been reviewed, and, VITAMIN PHYSIOLOGY
The fetus can acquire most vitamins from its
although changes are being made, free vitamin supplements for mother. Water-soluble vitamins—B group and C—
children ,4 years old will remain an important part of the new are actively transported across the placenta
‘‘Healthy Start’’ scheme. Establishing precise daily requirements throughout pregnancy, whereas fat-soluble vita-
for vitamins is not easy, and there is considerable individual mins A, D and E are transferred towards the end of
pregnancy. There is negligible transfer of vitamin
variation; however, achieving the reference nutrient intake (RNI) K.6 Breast milk from mothers with adequate status
should be possible with a healthy balanced diet for all except supplies sufficient amounts of most vitamins apart
vitamins K and D, which require additional physiological or from vitamins K and D. Thus, unsupplemented
infants depend on synthesis of vitamin K by gut
metabolic processes. For vitamin K, there is a well-established bacteria, and on antenatally acquired hepatic
neonatal supplementation programme, and clinical deficiency is stores of vitamin D as well as cutaneous synthesis
extremely rare. For vitamin D, however, supplementation is in response to sunlight.6
inconsistent, and both clinical and subclinical deficiencies are
not uncommon in young children in the UK, particularly infants DEFINING RECOMMENDED INTAKES
Table 2 lists the reference nutrient intakes
of Asian and Afro-Caribbean ethnic origin, and those who (RNIs)7 8 for infants. The RNI is set at 2 standard
have prolonged exclusive breast feeding and delayed weaning. deviations (SD) above the estimated average
Most vitamin supplements contain vitamins A, C and D, with or requirement and represents the amount estimated
without some of the B group of vitamins. There is clinical and to prevent deficiency in 97.5% of a healthy
population. Although most infants receiving lower
dietary evidence to support vitamin D supplementation and amounts will avoid deficiency, the risk increases as
some evidence from dietary surveys that vitamin A intakes may the average daily intake falls. The lower RNI is set
be low; however, there is no evidence to support at 2 SD below the estimated average requirement
and is sufficient for only a few individuals who
supplementation of diets of UK children with water-soluble have low needs.
vitamins. Future strategy should aim at education of the public Setting reference values and determining the
and health professionals regarding dietary intake and risk of nutrient deficiency in children is diffi-
physiological aspects of vitamin sufficiency, as well as cult,7 9 10 and there is a lack of evidence from
randomised trials. For babies ,6 months old, the
increasing awareness and availability of supplements, estimated average requirement is generally based
particularly of vitamin D, for those at increased risk of on the average intake of healthy breast-fed infants.
deficiency. For older infants and children, daily amounts are
calculated from metabolic and deprivation studies
.............................................................................
on adult volunteers and extrapolated on the basis
of body weight. A new paradigm, combining

A
lthough vitamin (A, C and D) supplementa- studies of nutrient intake alongside measures of
tion has been regarded as an important part specific metabolic function, would allow a more
of the Welfare Food Scheme since it was accurate estimation of requirements.11 For reasons
introduced in the 1940s, the uptake of vitamin arising both from the accuracy of observations and
supplements in the UK is patchy, and vitamin from the confidence in the reference values,
deficiency still occurs in early childhood.1–3 The comparisons of observed intakes with reference
Welfare Food Scheme has recently had its first values are not always reliable. Nonetheless, low
major appraisal starting with a scientific review by intakes should alert us to an increased risk of
the Panel on Child and Maternal Nutrition of the deficiency.
Committee on the Medical Aspects of Food and Some of the factors underlying the variability in
Nutrition Policy in 1999.4 This was followed by requirement are evident. For example, dark-
discussion and public consultation, resulting in a skinned children and those whose cultural practice
........................ revised scheme, ‘‘Healthy Start’’ (table 14 5), which results in little exposure of mother or baby to the
Correspondence to: was launched nationwide in November 2006. sun are at increased risk of vitamin D deficiency.
Dr A A Leaf, Southmead Healthy Start retains the use of vitamin supple- Increased use of sunscreen in response to concern
Hospital, Bristol BS10 5NB, ments, but the criteria for their use and entitle- about the damaging effects of sunlight may also
UK ment have changed and apply now only to compromise dermal synthesis of vitamin D. Other
children ,4 years old. Thus, it is opportune to factors such as maternal status and genetically
Accepted
11 September 2006 review the justification for continuing to recom-
........................ mend vitamin supplements. Abbreviation: RNI, reference nutrient intake

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Vitamins for babies and young children 161

Table 1 Summary of entitlements in the Welfare Food Scheme and Healthy Start*
Benefit Welfare Food Scheme4 Healthy Start5

Milk—7 pints of cows’ milk Pregnant and lactating women; pregnant teenagers Children ,5 years in daycare (200 ml/day)
only if family already have entitlement; children
,5 years; disabled children between 5 and 16 years
not attending school; children in daycare (200 ml/day)

Infant formula Children aged ,1 year (includes some children in low-

income families not on IS/IBJSA)

Vitamins (A, D, C) Pregnant women; breastfeeding women (up to 1 year Pregnant and lactating women (C, D, folic acid);
postpartum); children ,5 years old children ,4 years old (A, D, C)

Food vouchers—for cows’ milk, Pregnant and lactating women; all pregnant women
infant formula, fresh fruit and ,18 years; children ,4 years
vegetables—value £2.80 (double
for family with child aged 0–
12 months)

*For families in receipt of income support (IS), income-based jobseeker’s allowance (IBJSA) or child tax credit on an income below £14 155.

determined variation are less apparent. This intrinsic variability D and C) in certain groups. The basic advice in Present day
in requirement of populations underpins the need to set a practice in infant feeding: third report13 is still mainly applicable,
population reference intake at a higher level than most healthy and in the case of vitamin D has recently been reaffirmed by the
individuals need. In that sense the recommendation to use chief medical officer, because biochemical and clinical rickets
supplements constitutes a ‘‘safety net’’. remain major public health issues. However, as is evidenced in
table 4,13–16 although key messages are similar, the details in
DIETARY SOURCES available advice on vitamin supplementation vary. This may
Table 312 lists the vitamin content of breast milk and of infant have led to confusion contributing to the relatively low use of
formulas available in the UK. Infant formulas are constituted so vitamin supplements. The Committee on the Medical Aspects of
that babies receiving 150 ml/kg/day should receive adequate Food and Nutrition Policy reports and the Department of
intakes of all vitamins. However, for some formulas the RNI of Health report on nutrition and bone health17 provide guidance
some vitamins will only be achieved with an intake of 700– on intake of vitamin D and calcium at all ages and highlight
800 ml/day. It is recognised that the milieu of infant formula pregnancy and lactation as high-risk periods. An RNI of 10 mg/
and its effect on intestinal function may alter the efficiency day (400 IU/day) is set for these groups. This is very unlikely to
with which nutrients are absorbed and used compared with be met by diet, as the average daily intake of women of
those in breast milk.6 Simple compositional comparisons are reproductive age approximates 3 mg/day. Uncertainty has
not necessarily reliable as a basis for assessment of nutritional therefore arisen from recent guidance from the National
adequacy. Institute for Clinical Excellence18 stating that there is insuffi-
cient evidence to support routine provision of vitamin D to
pregnant mothers.
CURRENT ADVICE FOR HEALTH PROFESSIONALS
REGARDING VITAMIN SUPPLEMENTATION
Perhaps there is potential for confusion about vitamin CURRENT PRACTICE
supplementation in young children, and also in pregnant and The Infant Feeding Survey in 200019 found a steady decline in
lactating women. The Department of Health reports re- the use of vitamin supplements in the preceding decade; only
emphasise the need for vitamin supplements, particularly (A, 4% of babies at 4–10 weeks received supplements, 5% at 4–

Table 2 Summary of reference nutrient intakes for vitamins (units/day)

RNI 0–3 months and RNI 7–9 months
7 7 7 8
Vitamin 4–6 months or 10–12 months RNI 1–3 years Tolerable upper intakes

A (mg) 350 350 400 800 mg/day (1–3 years)

D (mg) 8.5 7 7 25 mg/day (0–24 months)
E (mg) 0.4 mg/g PUFA 0.4 mg/g PUFA 0.4 mg/g PUFA 10 mg/100 kcal of formula
K (mg) 10 10 10 Not given
B1 (thiamine) (mg) 0.2 0.2/0.3 0.5 Not given
B2 (riboflavin) (mg) 0.4 0.4 0.6 Not given
Niacin (equivalents mg) 3 4/5 8 2 mg/day (1–3 years)
B6 (pyridoxine) (mg) 0.2 0.3/0.4 0.7 5 mg/day (1–3 years)
B12 (mg) 0.3 0.4 0.5 Not given
Biotin (mg) Not given Not given Not given 7.5/100 kcal
Pantothenate (mg) 1.7 1.7 1.7 1.2/100 kcal
Folic acid (mg) 50 50 70 200 mg/day (1–3 years)
C (mg) 25 25 30 30 mg/100 kcal

PUFA, polyunsaturated fatty acids; RE, retinol equivalents; RNI, reference nutrient intake.
Vitamin A expressed as retinol equivalent: 1 mg RE = 3.33 IU.
Vitamin D (calciferol): 1 mg = 40 IU.
Vitamin E, a-tocopherol equivalent: 1 mg = 1 IU.
Vitamin C expressed as ascorbic acid.
Biotin—no daily reference value given; however, an intake between 10 and 200 mg/day considered safe and sufficient.

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162 Leaf

Table 3 Vitamin content of breast milk and infant formula (U/100 ml)
Vitamin Mature human milk12 Infant formula—UK term formula*

A (mg) (retinol equivalents) 60 63–82

D (mg) 0.01 1–1.4
E (mg) 0.35 0.48–1.4
K (mg) 0.21 2.7–6.7
B1 (mg) 0.016 0.04–0.1
B2 (mg) 0.031 0.06–0.150
Niacin equivalents (mg) 0.23 0.7–0.9
B6 (mg) 0.006 0.03–0.06
B12 (mg) 0.01 0.14–0.3
Biotin (mg) 0.76 1–2
Pantothenate (mg) 260 200–300
Folate (mg) 5.2 3.4–16
C (mg) 3.8 6.9–9.0

*Formulas included: Farleys (Heinz), Milupa, Cow & Gate (Nutricia), SMA (Wyeth) whey-based and casein-based
formulas.

5 months and 10% at 8–9 months. Black and Asian babies were intake record and blood samples. A survey carried out on
more likely to receive supplements: 11% and 17%, respectively, behalf of the Ministry of Agriculture, Fisheries and Food in
at 4 and 10 weeks, compared with 3% for white babies, and 1986 assessed dietary intakes of 488 infants aged between 6
23% and 17% compared with 4% at 4–5 months. At 8– and 12 months by means of a 7-day quantitative diary.21 Both
9 months, supplementation was more common in breast-fed surveys showed average dietary intakes of vitamin D consis-
babies (18%) and those fed on cows’ milk (17%) than those fed tently below those recommended for age. Plasma levels of 25-
on formula (8%). Although the survey does not identify specific hydroxyvitamin D showed seasonal variation, being highest in
risk factors within each age group, the low proportion of black July to September and lowest in January to March. Levels
and Asian babies, and breast-fed infants at 8–9 months, correlated significantly with intake. In all, 21% of children were
receiving supplements clearly indicate that guidelines are not receiving nutritional supplements, most including vitamins.20
being followed and it is reasonable to suspect that these low Although the median intake of vitamin A for children aged 1.5–
uptakes are partly responsible for the apparent increased 2.5 years in the National Diet and Nutrition Survey was just
prevalence of rickets. above the RNI, it became progressively lower in the older age
groups. Overall, nearly 50% of children had vitamin A intake
EVIDENCE FOR VITAMIN DEFICIENCY IN UK below the RNI of 400 mg, and 7–8% had intakes below the lower
CHILDREN reference nutrient intake.20 The higher vitamin intake in
Table 520 21 summarises data for UK children aged 6 months to younger age groups reflects higher consumption of infant
2.5 years from two dietary surveys. The National Diet and formula, commercial baby foods and fruit drinks.21 The intake
Nutrition Survey20 studied a representative cohort aged 1.5– of B vitamins and vitamin C was well above the RNI.
4.5 years between July 1992 and June 1993. In all, 2101 Vitamin D deficiency is not uncommon in the UK, resulting
children were identified, and between 54% and 88% of the in rickets and symptomatic hypocalcaemia.1–3 22 23 Risk factors
sample contributed data to various components of the study include Asian or Afro-Caribbean ethnic origin, prematurity and
which included parental interview, 4-day weighed dietary prolonged, exclusive breast feeding with delayed weaning.24 A

Table 4 Guidance on vitamin supplementation

Source of advice Population What to give When to start Duration of supplementation Additional notes

Present day practice in All infants and young Vitamin A 200 mg 6 months routinely, To at least 2 years, and Emphasises importance
infant feeding: third children Vitamin C 20 mg but start supplements preferably 5 years of vitamin D supplement
report, 198813 Vitamin D 7 mg at 1 month if any to pregnant and lactating
doubt about vitamin mothers
intake at that time

Community paediatrics, All infants and children Multivitamin 6 months At least 2 years, preferably
2nd edn, 199314 supplement 5 years (endorses DH
guidelines)

Health for all children, All children Multivitamin 1 year Not stated Identifies vegetarian and
15
4th edn, 2003 Breast-fed and high-risk supplement 6 months Not stated vegan infants as high-
Asian and Caribbean risk groups
children on exclusion diets
Pregnant and lactating Multivitamin
women supplement
Vitamin D

Weaning and the Breast-fed infants Vitamins A and D 6 months 5 years Emphasises importance
16
weaning diet, 1994 Formula-fed infants on Vitamins A and D 6 months 5 years of varied diet, moderate
,500 ml/day exposure to sunlight and
All children (unless intake Vitamin A and D 1 year 5 years foods and drinks rich in
ensured from diet and vitamin C
sunlight)

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Vitamins for babies and young children 163

Table 5 Daily dietary vitamin intake of UK children

Vitamin Intake 6–9 months21 Intake 9–12 months21 Intake 1.5–2.5 years20

A (RE) (mg/day) 783 (733) 745 (593) 589 (441)

D (mg/day) 4.7 (2.14) 2.2 (0.95) 1.8 (1.0)
E (mg/day) 4.5 (3.7) 3.5 (2.9) 3.9 (3.6)
B1 thiamine (mg/day) 1.16 (1.12) 1.03 (0.93) 0.7 (0.7)
B2 riboflavin (mg/day) 1.57 (1.53) 1.53 (1.45) 1.2 (1.2)
Niacin equivalents (mg/day) 12.48 12.47 14.7 (14.1)
Pyridoxine (mg/day) 0.82 (0.83) 0.84 (0.79) 1.1 (1.0)
B12 (mg/day) 3.0 (2.9) 3.4 (3.2) 2.9 (2.5)
Biotin (mg/day) 26.5 (22.0) 23.8 (21.3) 17.1 (16.0)
Pantothenic acid (mg/day) 3.9 (3.7) 3.5 (3.2) 2.7 (2.6)
Folic acid (mg/day) 104 107 120 (114)
C (mg/day) 117 (99) 81 (57) 50.7 (38.4)

RE, retinal equivalent.

Values are given as mean (median).

survey of Asian children aged 2 years living in England showed PROPRIETARY VITAMIN SUPPLEMENTS AVAILABLE
a high incidence of subclinical hypovitaminosis D.25 Those FOR BABIES
receiving Department of Health Children’s Vitamin Drops (A, D Table 635 36 lists the contents of some commonly used multi-
and C)—about 25% of sample—had higher circulating levels of vitamin supplements currently (or recently) available for
vitamin D. Many Asian adults have low levels of vitamin D, and prescription in the UK. The Department of Health Children’s
if pregnant Asian women do not receive supplements their Vitamin Drops are currently unavailable but previous contents
babies are at significantly increased risk of clinical deficiency.22 of these drops35 and those being provided for Healthy Start are
The recent guidance from the National Institute for Clinical included in table 5. Vitamin A in ‘‘Abidec’’ is carried in highly
Excellence18 raised concern among paediatricians who empha- refined peanut oil, necessary, according to the manufacturers,
sised the need for greater public awareness about vitamin D.26 to enable it to be incorporated into a water-based solution. The
The Department of Health has recently restated the recom- oil is protein free, and not considered to be allergenic. The
mendation that pregnant and nursing mothers should take vitamin A content of ‘‘Dalivit’’ is three times that of Abidec and
10 mg/day supplement of vitamin D.27 close to the tolerable upper intake limit of 800 mg8 for term
Clinical vitamin A deficiency is widespread in children in infants when given at the recommended dose of 0.3 ml/day.
developing countries and is associated with blindness and with
increased mortality and morbidity from infectious diseases. In RECOMMENDATIONS
countries with a high prevalence of mild or severe vitamin A Risk factors for vitamin deficiency may be identified in the
deficiency (defined as serum retinol ,0.7 and ,0.35 mmol/l, child or in the diet, and both must be assessed. The only
respectively), there is good evidence that giving high doses of vitamin for which there is strong evidence of clinical deficiency
vitamin A improves infant survival.28–30 There is no such in the UK is vitamin D, and dietary intake is generally low in all
evidence for vitamin A deficiency causing morbidity in the UK. age groups. Vitamin A intake may be suboptimal in up to 50%
Vitamin K deficiency bleeding is rare but still occurs, of children, but clinical deficiency is not seen. Intake of water-
particularly in breast-fed babies who have not received vitamin soluble vitamins is satisfactory in the great majority, and there
K at birth. Neonatal vitamin K supplementation has been is no evidence for vitamin C deficiency. Diet has only a partial
extensively reviewed after concern in 1992 that babies given role for vitamins D and K, but is important for all other
intramuscular vitamin K had an increased incidence of child- vitamins. The key steps to ensuring adequate vitamin status of
hood cancer.31 Subsequent epidemiological studies did not children are thus to give vitamin K at birth, to optimise dietary
confirm the association.32 33 In 1998, the Department of Health intake throughout early life, and to maintain a low threshold
issued a statement supporting the use of either a single for providing supplementary vitamin D. The American
intramuscular dose of 1 mg of vitamin K to newborn babies Academy of Pediatrics recommends that all infants should
(0.4 mg/kg for preterm infants) or an alternative oral regimen have a vitamin D intake of at least 5 mg/day (200 IU).37 This
of three 2-mg doses during the first 6–8 weeks.34 Infant formula should be started within the first 2 months of life as a
is fortified with vitamin K, providing about 4–10 mg/kg/day. supplement for breast-fed infants and those fed on ,500 ml/

Table 6 Multivitamin supplements in UK: vitamin content of recommended daily dose for infants aged ,1 year
Children’s Vitamin Drops Children’s Vitamin Drops–
Vitamins Abidec (0.3 ml) Dalivit (0.3 ml) (5 drops)* Healthy Start

A (mg) 200 (667 IU)` 757 (2500 IU) 214 (700) 233 (770 IU)
D (mg) 5 (200 IU) 5 (200 IU) 7 (280 IU) 7.5 (300 IU)
B1 (thiamine) (mg) 0.2 0.5 — —
B2 (riboflavin) (mg) 0.4 0.2 — —
Nicotinamide (mg) 4 2.5 — —
B6 (pyridoxine) (mg) 0.4 0.25 — —
C (mg) 20 25 21 20

Abidec 0.6 ml/day recommended for preterm infants.

*Children’s Vitamin Drops formulation until approximately 2000 in A neonatal vade mecum.35
Children’s Vitamin Drops formulation for Healthy Start; personal communication, Department of Health, 2006.
`In peanut oil.

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164 Leaf

day of formula, until a dietary intake of at least 5 mg can be 10 Aggett PR, Bresson J, Haschke F. Recommended dietary allowances (RDAs),
recommended dietary intakes (RDIs), recommended nutrient intakes (RNIs), and
ensured from fortified foods. It is not yet clear whether this population reference intakes (PRIs) are not ‘‘recommended intakes’’. J Pediatr
dose will be sufficient for all children.38 Gastroenterol Nutr 1997;25:236–41.
If vitamin supplements are given, it is important that they do 11 King J. The need to consider functional endpoints in defining nutrient
requirements. Am J Clin Nutr 1996;63:983S–4S.
no harm. For those supplements described in table 6, the daily 12 Department of Health. The composition of mature human milk, DHSS report on
amount of water-soluble vitamins or of vitamin D would Health and Social Subjects, number 12. London: DH, 1977.
probably not exceed recommended upper limits (tables 2 and 13 Department of Health. Present day practice in infant feeding: third report, DOH
3). Vitamin A could quite easily exceed the recommended Report on Health and Social Subjects, number 32. London: DH, 1988.
14 Polnay L, Hull D. Community paediatrics, 2nd edn. Longman, UK: Churchill
intake (800 mg/day) if a high-dose supplement is given. It Livingstone, 1993.
would therefore seem prudent to have a limited number of 15 Hall D, Elliman D, eds. Health for all children, 4th edn. Oxford: Oxford University
vitamin preparations available for those children in whom Press, 2003.
16 Department of Health. Weaning and the weaning diet. DOH Report on Health
nutritional intake is unlikely to be sufficient. These should err and Social Subjects, number 45. COMA Report 45. London: DH, 1994.
on the lower side for vitamin A, while ensuring a satisfactory 17 Department of Health nutrition and bone health. Report on Health and Social
dose of vitamin D. Water-soluble vitamin content, if included, Subjects, number 49. Norwich: HMSO, 1988.
should be modest. Vitamin C aids in the absorbtion of iron. 18 National Collaborating Centre for Women’s and Children’s Health. Antenatal
care: routine care for the healthy pregnant woman. London: RCOG, 2003,
Some risk factors for vitamin deficiency in infancy will http://www.rcog.org.uk.
continue through early childhood and it will be wise to 19 Hamlyn B, Brooker S, Oleinikova K, et al. Infant Feeding Survey 2000. London:
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20 Gregory JR, Collins DL, Davies P, et al. National Diet and Nutrition Survey.
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requirements of UK children. The mainstay of prevention of 22 Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new
concern. Arch Dis Child 2002;86:147–9.
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vitamin for which supplementation is most important is Arch Dis Child 2004;89:781–4.
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