Vitamin D in infants

Short answer

According to the Turkish Ministry of Health, free vitamin D supplementation at 400 IU/day has been provided nationwide to children under one year of age since May 2005. ^[1] The scientific board guide of the same ministry calls for 400 units of vitamin D per day to be given to all newborns from the first day of life, regardless of feeding method; it does not consider higher doses or ampoule use necessary for prophylaxis. ^[2] This page reports the official statements with reference to their own sources; it does not recommend a personal dose.

What is the Ministry of Health’s infant vitamin D program?

According to the General Directorate of Public Health’s “Vitamin D Deficiency Prevention and Control Program” page, the aim is to prevent rickets, one of the health problems caused by unbalanced and inadequate nutrition. The page states that free vitamin D supplementation of 400 IU per day for children under one year of age was started nationwide in May 2005 and continues until 1 year of age, and that supplementation has been started in nearly 15 million infants to date. The same page also notes that vitamin D deficiency was detected in about 80% of mothers and about 40% of their infants. ^[1]

According to the Scientific Board guide (February 2018), vitamin D preparations (400 units/3 drops) are supplied by the Ministry of Health and distributed by family physicians. The guide states that family physicians are responsible for ensuring that all infants receive 400 units daily on a regular basis until the end of the first year, regardless of climate and socioeconomic differences, and that at every child health follow-up visit it should be asked whether the supplement is being given. ^[2] Current implementation details of the program (product, distribution) may change; up-to-date information is obtained from the family physician or the ministry’s announcements.

What do international recommendations say?

In its 2008 report, the American Academy of Pediatrics (AAP), citing limited natural food sources, the difficulty of individually determining sun-based synthesis, and the risk of skin cancer, recommended that all infants, children, and adolescents receive at least 400 IU of vitamin D per day starting shortly after birth. This recommendation replaced the earlier 200 IU/day recommendation. ^[3] The 2016 Global Consensus on rickets states that 400 IU/day is sufficient to prevent rickets and is recommended for all infants from birth to 12 months, independent of feeding method. ^[4]

The AAP recommendation as reported by the NIH is divided into two groups: 400 IU/day for fully or partially breastfed infants starting shortly after birth, until weaning and consumption of at least 1,000 mL per day of vitamin D–fortified formula or whole milk; and 400 IU/day also for infants who are not breastfed and consume less than 1,000 mL per day of fortified formula or milk. ^[6] The Türkiye guide does not make this distinction; it covers all newborns regardless of feeding method. ^[2] Because different frameworks word things differently, which one applies to a given infant is clarified with the pediatrician.

Which is at greater risk, the breastfed infant or the formula-fed infant?

The vitamin D level in breast milk is low; infants fed only breast milk are at risk of insufficiency. A Cochrane review (19 studies, 2,837 mother-infant pairs) reports that 400 IU per day can raise the infant’s 25(OH)D level and that supplementation given to mothers can also raise the infant’s level, but that the evidence is of low certainty. ^[5] The NIH states that prolonged exclusive breastfeeding without vitamin D supplementation can lead to rickets in infants. ^[6]

With formula, the amount depends on the product and the volume consumed. The NIH reports that in the United States infant formula is required to be fortified with 1–2.5 µg (40–100 IU) of vitamin D per 100 kcal. ^[6] EFSA’s 2018 assessment calculated that, where formulas can contain 3 µg/100 kcal, some infants up to 4 months of age could exceed the 25 µg/day UL from formula alone (without taking additional supplements into account). ^[7] For this reason, the need for supplementation and the total amount in a formula-fed infant are reviewed together with the physician.

What is rickets, and what does it look like?

The Ministry of Health guide defines rickets as a mineralization disorder in developing bone tissue; its most common cause is vitamin D insufficiency. The program page states that rickets is seen most often between 3 and 24 months of age and can present with findings such as convulsions, delays in walking and teething, softness and deformity of the skull bones, widening of the wrists, frequent infections, and head sweating. ^[1] These symptoms alone do not establish a diagnosis: the guide states that in cases where rickets is clinically suspected, the diagnosis is confirmed with radiological and biochemical findings. ^[2]

An infant walking late or having bowed legs does not mean “vitamin D deficient.” The guide explicitly states that a single high dose (stoss) of vitamin D is not to be used without laboratory findings for reasons such as delayed teething, bowed legs, and late walking. ^[2] Suspicious findings should be shown to the pediatrician; high doses are not tried on one’s own initiative.

Is a routine blood test needed?

According to the guide, serum 25(OH)D does not need to be checked routinely in the follow-up of healthy infants and children; it may be checked only in those at risk of deficiency (such as a dietary history predisposing to rickets, bone findings, certain chronic diseases and medications, dark skin or clothing that fully covers the body, and elevated ALP and/or PTH). ^[2] In the guide’s interpretation table, below 12 ng/mL is classified as deficiency, 12–20 ng/mL as insufficiency, 20–100 ng/mL as normal, and above 100 ng/mL together with hypercalcemia as intoxication; it states that above 20 ng/mL is sufficient in infants and children and that there is no need to reach the 30 ng/mL target mentioned for adults. ^[2]

How does overdose risk arise with drops and ampoules?

The Ministry of Health guide writes that doses higher than 400 units do not need to be given for prophylaxis in the first 12 months, that giving high-dose vitamin D by having the infant drink an ampoule is definitely not needed for prophylaxis, and that these practices create a risk of vitamin D intoxication. The same guide also states that dispensing vitamin D ampoules to children from pharmacies without a prescription must be strictly prevented and that the posology of ampoules on the market must be changed so that one ampoule contains 100,000 units. ^[2]

EFSA’s infant ULs are 25 µg/day up to 6 months and 35 µg/day for 6–12 months (1 µg = 40 IU; that is, 1,000 and 1,400 IU). ^[7] The US values reported by the NIH are 25 µg and 38 µg. ^[6] These are upper limits, not target doses.

With drop products, the risk is mostly one of measurement: for the Ministry’s preparation the guide uses the wording “400 units/3 drops”; one drop of another product may not contain the same amount. For this reason, when switching products the number of drops should not be carried over from the old product; the amount on the label, the drop/mL definition, and, for products with a pipette, the pipette mark should be read, and no more than what the pediatrician specified should be given. If overdosing is suspected, a pediatrician or emergency department is contacted with the product name and amount. Detailed product forms are on the vitamin D drugs and supplements page, and signs of excess are on the vitamin D excess page.

Sun and infants: are the official messages different?

The key messages of the Ministry of Health guide include encouraging all pregnant women and infants to be out in the sun for 10–15 minutes a day, outside midday hours; it adds that light passing through glass is of no benefit for vitamin D synthesis. ^[2] The AAP, as reported by the NIH, recommends keeping infants younger than 6 months out of direct sun, dressing them in protective clothing and hats, and, where this cannot be avoided, applying sunscreen to small exposed areas. ^[6] The messages of the two bodies are not the same; this page only reports the two official texts and does not give its own sun-exposure recommendation.

What happens after one year of age?

The ministry guide states that for the period after one year of age the requirement is set at 600 units per day and that this can be met through foods and/or oral vitamin D supplementation. Encouraging calcium-rich dairy products with the transition to complementary foods is also among the key messages. ^[2] This is an official reference; for administration in an individual child, the pediatrician’s recommendation is what applies. Dietary sources of vitamin D are covered on the foods containing vitamin D page.

Detailed guideExcess and toxicity: symptoms, upper limit, and warning signs→ Detailed guideVitamin D forms: drops, ampoules, and reading labels→ Detailed guideDeficiency symptoms and understanding test results→

Main guide: What is vitamin D? This page is not medical advice or a personal dose recommendation.