Quality Improvement: Vitamin D Supplementation in Breastfeeding Infants in a Pediatric Resident Continuity Clinic

Monday, October 13, 2014
Marriott Hall 1 (San Diego Marriott Marquis )
Rashmi A Patel, DO and Shiva Zargham, MD, East Carolina University/Vidant Medical Center, Greenville, NC


Pediatric residents participating in a continuity clinic at the East Carolina University, Brody School of Medicine, Pediatric Clinic were concerned that breastfeeding mothers were not aware of the need to supplement Vitamin D in their infants. The objective was to educate breastfeeding mothers on the importance of Vitamin D supplementation in their infants. The aim was that post-intervention, 100% of mothers be aware that they should supplement with Vitamin D and 75% of mothers would provide Vitamin D supplementation.


Exclusively breastfed and partially breastfed infants were identified in a continuity clinic. A pre-intervention questionnaire (Figure1) was administered to their mothers at a well child check (WCC) of patients 2 weeks to 4 months of age to assess their baseline knowledge regarding Vitamin D supplementation. Residents reviewed the American Academy of Pediatrics recommendations regarding Vitamin D supplementation in breastfeeding infants and created a handout (Figure2) with key teaching points that was used as a tool for educating parents. This information was verbally shared with mothers at WCC as anticipatory guidance.  A post-intervention questionnaire (Figure3) was administered to mothers 6 to 8 weeks later at the following WCC.


5 breastfeeding mothers were included in the study. Pre-intervention, it was found that none of the mothers knew about Vitamin D supplementation in exclusively or partially breastfed infants. Post-intervention, 60% (3/5) were aware that Vitamin D supplementation was necessary, but 40% (2/5) were unable to find Vitamin D at their local pharmacy (Graph1).


Breastfed infants are at risk for Vitamin D deficiency because a very small amount of Vitamin D is transferred to human milk. This is coupled with the fact that sun exposure should be limited in infants, putting them at an even higher risk of hypovitaminosis D (which can lead to rickets).  All exclusively breastfed infants, as well as infants consuming less than 32 ounces of formula daily, should receive 400 IU of Vitamin D.

The goal of this quality improvement project was to improve education for breastfeeding mothers. It was found that this was not part of anticipatory guidance that mothers received in the newborn nursery.

As a result of this project, members were able to propose recommendations including adding Vitamin D supplementation in the newborn nursery discharge order set in the electronic medical record, collaborating with lactation specialists to provide education, and that a handout be given at the newborn follow-up visit as well as the 2 week WCC. Difficulties encountered included not having surveys and handouts available in Spanish, a very small population of mothers who were breastfeeding at 2 weeks to 4 months leading to limited recruitment in the study, difficulty obtaining follow-up surveys, non-compliance, and cost. Results indicated that much of what was discussed during the office visit was forgotten and should be reinforced.