Chief Medical Officer Scotland: Vitamin D supplementation

From letter from Dr Catherine Calderwood Chief Medical Officer Scotland 
24 November 2017

New Recommendations on Vitamin D Supplementation

Vitamin D plays an important role in maintaining bone health throughout life. Vitamin D deficiency impairs the absorption of dietary calcium and phosphorous. This can lead to:
 Infants having muscle weakness and bone softening leading to rickets;
 Adults having muscle weakness and osteomalacia, which leads to bone pain and tenderness.
The most recent National Diet and Nutrition Survey shows that a proportion of the UK population has low vitamin D levels, which may put them at risk of the clinical consequences of vitamin D deficiency.
Last year, the Scientific Advisory Committee on Nutrition (SACN) made new recommendations on vitamin D and health.  The full report is available at:

Click to access SACNVitamin_D_and_Health_report.pdf

SACN considered all relevant evidence suggesting links between vitamin D and various health conditions and concluded that the risk of poor musculoskeletal health (e.g. rickets, osteomalacia) is increased with low vitamin D levels. SACN found insufficient evidence to draw firm conclusions on the impact of low vitamin D levels for non-musculoskeletal health outcomes.
The Scottish Government has now updated its advice on vitamin D in line with the new SACN recommendations as follows:

Everyone age 5 years and above should consider taking a daily supplement of 10μg of vitamin D, particularly during the winter months (October – March). Between late March/early April and September, the majority of people aged 5 years and above will probably obtain sufficient vitamin D from sunlight when they are outdoors, alongside foods that naturally contain or are fortified with vitamin D.
From October to March, everyone aged 5 and over will need to rely on dietary sources of vitamin D. Since vitamin D is found only in a small number of foods, it might be difficult to get enough from foods that naturally contain vitamin D and/or fortified foods alone.

Children aged 1 to 4 years of age should be given a daily supplement containing 10μg vitamin D. We recommend Healthy Start vitamin drops for all children in health.

A new-born baby’s vitamin D level depends on their mother’s levels near the birth and will be higher if the mother took a vitamin D supplement during pregnancy. Some mothers and babies have a higher risk of vitamin D deficiency, including those born to mothers who habitually wear clothes that cover most of their skin while outdooors and those from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin.
However, as a precaution, we are now recommending that all babies from birth up to one year of age should be given a daily supplement of 8.5 to 10μg vitamin D. Babies who are formula fed do not require a vitamin D supplement if they are having at least 500ml per day, as infant formula already has added vitamin D.
We recommend Healthy Start vitamin drops for infants. Neonatologists and paediatricians may recommend alternatives for premature infants, children with clinical conditions or clinical presentations of vitamin D deficiency.
Advice for parents on vitamin D supplementation for breastfed babies must be carefully considered as there is a risk that infant formula could be viewed as superior to breastmilk. Breastfeeding is the normal way to feed infants. It has an important and lasting impact on the public health of the population and it is vital that we protect and support breastfeeding. It is recommended that you emphasise that the potential problem is related to a lack of sunlight in the UK, and that it affects the whole 
population, not just breastfed babies.
It is recommended that those at greatest risk of vitamin D deficiency take a daily supplement all year round. These groups include:
 pregnant and breastfeeding mothers
 children under 5 years of age
 people who are not exposed to much sunlight, such as frail or housebound individuals, or those that cover their skin for cultural reasons; and
 people from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin, because they require more sun exposure to make as much vitamin D.
General information leaflets on vitamin D for both the public and healthcare professionals have been updated to reflect these new recommendations and are available online at: http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
New guidance has been developed for parents and healthcare professionals to support parents to follow this new recommendation. This includes advice on how to administer vitamin D drops to young babies. It is available at:
http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
From April 2017, Healthy Start vitamins for women (which provide Vitamin D, folic acid and Vitamin C) are provided free of charge to all pregnant women in Scotland for the duration of their pregnancy, regardless of their entitlement to the Healthy Start scheme.
Breastfeeding women and children up to age 4 who are eligible for Healthy Start can also get free supplements containing vitamin D. Further information on the Healthy Start scheme can be found at http://www.healthystart.nhs.uk
Healthy Start vitamin drops for babies and children currently contain 7.5μg per 5 drops of vitamin D, as well as vitamin A and vitamin C. The new recommended dose for vitamin D is 8.5-10μg and vitamins containing the new recommended dose will be available from October 2018. In the meantime, parents should be advised to continue to give the current dosage of 5 drops per day.
In Scotland, NHS Boards are responsible for supplying Healthy Start vitamin supplements universally to pregnant women and to breastfeeding women and children who are eligible for the Healthy Start scheme. NHS Boards are also able to sell Healthy Start vitamins to families who are not eligible for Healthy Start. Some Health Boards have chosen to provide additional free vitamins for infants.
We are not currently in a position to extend universal provision of vitamin supplements to the whole of the Scottish population or to additional at risk groups including the elderly, women in the pre-conception period, infants or young children.
Vitamin D supplements for adults and children are also available to buy from most major supermarkets, high street pharmacies and health food stores.

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