New guidelines from ACOG

On December 14, 2009, in Pregnancy after WLS, by Andrea

ACOG Issues Guidelines on Managing Obesity in Pregnancy

Laurie Barclay, MD

June 9, 2009 — The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin to summarize the risks for obesity in pregnancy and outcomes of pregnancy after bariatric surgery as well as to provide recommendations for management during pregnancy and delivery after bariatric surgery. The new guidelines are published in the June issue of Obstetrics & Gynecology.

“Obesity is associated with reduced fertility primarily as a result of oligo-ovulation and anovulation,” write Michelle A. Kominiarek, MD, and colleagues from the ACOG. “The increased risks for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity associated with obesity are well established….Obese patients are more likely to be admitted earlier in labor, need labor induction, require more oxytocin, and have longer labor.”

To identify pertinent articles published in the English language between January 1975 and November 2008, the guidelines authors searched the MEDLINE database, the Cochrane Library, and ACOG’s own internal resources and documents. The reviewers gave priority to articles reporting findings from original research and also consulted review articles and commentaries, but they did not consider abstracts of research presented at symposia and scientific conferences. Using the method outlined by the US Preventive Services Task Force, the reviewers evaluated the identified studies for methodologic quality.

Recommendations from professional societies including ACOG and the National Institutes of Health were also reviewed. Reference lists from identified articles were used to help identify additional studies. When reliable research findings were not available, the reviewers used expert opinions from obstetrician-gynecologists as a basis for their recommendations.

Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:

• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.

• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.

• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.

Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:

• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.

• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.

• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.

• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.

• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.

• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.

• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.

As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.

Additional points made by the authors of the practice bulletin include the following:

• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.

• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.

• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.

• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.

• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.

“As the rate of obesity increases, it is becoming more common for providers of women’s health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery,” the guidelines authors write. “The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes.”

Obstet Gynecol. 2009;113:1405-1413.

Authors and Disclosures

Journalist

Laurie Barclay, MD

Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.

Pregnancy and the band..

On December 12, 2009, in Pregnancy after WLS, by Andrea

A bit of “duh!” ahead, but none-the-less..

Severe Obesity And The Use Of Gastric Bands During Pregnancy

Bariatric surgery is used to treat morbid obesity. A common treatment is gastric banding where a constricting device is tied around the stomach to regulate food intake and appetite. According to a doctor presenting a case study at the 8th RCOG International Scientific Meeting, if a patient is pregnant, the gastric band may need releasing to prevent pregnancy complications.

Dr Neena Garg, a specialist trainee in obstetrics and gynaecology from Dewsbury District Hospital, dealt with a case of 33-year old patient who sought help at Rotherham Hospital for severe morning sickness and significant weight loss when she was 17 weeks pregnant. Prior to falling pregnant, she underwent a laparoscopic adjustable gastric banding because of obesity.

Doctors found she was severely malnourished. To correct this, parenteral nutrition was given and she received multivitamin supplements. The gastric band was released and this led to some improvement. Due to further deterioration, the gastric band was removed laparoscopically at 21 weeks. The patient was followed-up with serial growth scans and had a normal full-term vaginal delivery.

Dr Garg said, “Our case study shows that women who have had bariatric surgery may require release of the band when they become pregnant to avoid pregnancy complications.

“When a woman is pregnant, she needs to take extra care of her diet. She must eat healthily so that the fetus receives the nourishment it needs to grow. This includes having well-balanced meals and the recommended nutritional supplements. A gastric band may prevent these essential nutrients from reaching the mother and baby and has been shown to induce the unpleasant side effect of nausea.

“Pregnant women who have had bariatric surgery should therefore inform their doctors and midwives so that an assessment could be made and further action taken.”

The Royal College of Obstetricians and Gynaecologists 8th International Scientific Meeting is taking place in Abu Dhabi, the United Arab Emirates, from Monday 7 to Wednesday 9 December 2009. The meeting is held in collaboration with the Abu Dhabi Health Services Co. (SEHA) and sponsored by the Abu Dhabi Tourism Authority. For more information about the meeting, please click here.

Source
Royal College of Obstetricians and Gynaecologists

The Vitamin D Newsletter

More Vitamin D Studies of Interest

December 3, 2009.


This is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. If you want to unsubscribe, go to the end of this newsletter. If you are not subscribed, you can do so on the Vitamin D Council’s website.

This newsletter may be reproduced as long as you properly and prominently attribute it source. Please reproduce it, post it on Internet sites, and forward it to your friends.


Five million dollar randomized controlled trial sponsored by Thrasher Research Fund and NIH

Scientists around the world presented their work at the recent Vitamin D conference in Brugge, Belgium. Many, but not all, of the scientists opined that we have to wait for randomized controlled trials (RCT) before recommending Vitamin D. In a future newsletter, I will review many of these presentations.
However, one was extraordinary. Professor Bruce Hollis presented findings from his and Carol Wagner’s five million dollar Thrasher Research Fund and NIH sponsored randomized controlled trials of about 500 pregnant women. Bruce and Carol’s discoveries are vital for every pregnant woman. Their studies had three arms: 400, 2,000, and 4,000 IU/day.
1. 4,000 IU/day during pregnancy was safe (not a single adverse event) but only resulted in a mean Vitamin D blood level of 27 ng/ml in the newborn infants, indicating to me that 4,000 IU per day during pregnancy is not enough.
2. During pregnancy, 25(OH)D (Vitamin D) levels had a direct influence on activated Vitamin D levels in the mother’s blood, with a minimum Vitamin D level of 40 ng/ml needed for mothers to obtain maximum activated vitamin D levels. (As most pregnant women have Vitamin D levels less than 40 ng/ml, this implies most pregnant women suffer from chronic substrate starvation and cannot make as much activated Vitamin D as their placenta wants to make.)
3. Complications of pregnancy, such as preterm labor, preterm birth, and infection were lowest in women taking 4,000 IU/day, Women taking 2,000 IU per day had more infections than women taking 4,000 IU/day. Women taking 400 IU/day, as exists in prenatal vitamins, had double the pregnancy complications of the women taking 4,000 IU/day.
What does this huge randomized controlled trial mean?
We have long known that blood levels of activated Vitamin D usually rise during very early pregnancy, and some of it crosses the placenta to bathe the fetus, especially the developing fetal brain, in activated vitamin D, before the fetus can make its own. However, we have never known why some pregnant women have much higher activated Vitamin D levels than other women. Now we know; many, in fact most, pregnant women just don’t have enough substrate, the 25(OH)D building block, to make all the activated Vitamin D that their placenta wants to make.
Of course fetal tissues, at some time in their development, acquire the ability to make and regulate their own activated Vitamin D. However, mom’s activated Vitamin D goes up very quickly after conception and supplies it to baby, during that critical window when fetal development is occurring but the baby has yet to acquire the metabolic machinery needed to make its own activated Vitamin D.
The other possibility, that this is too much activated Vitamin D for pregnancy, cannot stand careful scrutiny. First, the amount of activated vitamin D made during pregnancy does not rise after the mother’s 25(OH)D reaches a mean of 40 ng/ml, so the metabolism is controlled. Second, levels above 40 ng/ml are natural, routinely obtained by mothers only a few short decades ago, such as President Barack Obama’s mom probably did, before the sun scare. (President Obama was born in Hawaii in late August before the sun-scare to a mother with little melanin in her skin) Third, higher blood levels of Vitamin D during pregnancy reduce risk of infection and other pregnancy complications, the opposite may be expected if 25(OH)D levels above 40 ng/ml constituted harm.
It is heartening to see the Thrasher Research Fund and NIH support such a large randomized controlled trial. In fact the Thrasher Research Fund has already funded a three year follow up and the NIH request for a follow up grant is pending. Nevertheless, a large number of medical scientists keep saying, “We need even more science before recommending Vitamin D.” What are they really saying?
First they said we need randomized controlled trials (RCT) before we do anything. Well here is a big one. Then they say, as they did in Brugge, “We don’t believe this RCT, we need more money for more RCTs.” If you think about it, they are saying pregnant women should remain Vitamin D deficient until scientists get all the money for all the RCTs they want, which may take another ten years. How many children will be forever damaged in that ten years?

Amazing study just presented at American Heart Association meeting
Dr. Tami Bair and Dr. Heidi May, of the Intermountain Medical Center in Utah, report yet another study showing that your risk of heart attack, stroke, congestive heart failure and death are dramatically increased by Vitamin D deficiency. In a presentation at the American heart Association meeting, they found that people with low levels (< 15 ng/ml) had a 45% increased risk for cardiovascular disease, 78% greater risk of stroke and double the risk for congestive heart failure, not to mention a 77% increased risk of death, compared to people with Vitamin D levels > 30 ng/ml. All that disease and death occurred in only 13 months of follow up for the 27,000 people in the study.
So how many Americans died this last year from Vitamin D deficiency? Ten thousand? A hundred thousand? More? How many will die next year? Someone is responsible. Medical scientists who want more money before recommending that Vitamin D deficiency be treated have to assume responsibility. I am all for more studies but we have to act now, like we did with cigarettes. Remember, no human randomized controlled trials exist showing cigarettes are dangerous, so we have much more and better science than we did when we warned about smoking. If we fail to act on the dangers of Vitamin D deficiency, someone will end up with blood on their hands.

The Great Disappearing Act
We are currently witnessing one of the great mysteries of the natural world. The H1N1 outbreak is rapidly disappearing, despite a wealth of potential victims without antibodies to the virus, and yes, in spite of plummeting Vitamin D levels. In several weeks, the CDC will announce that perhaps one-third of Americans were infected in the last nine months and now have Swine flu antibodies, leaving the majority of the population still susceptible.
But this H1N1 virus is rapidly refusing the invitation to infect the two-third of Americans who are mostly immunological virgins and will soon recede until the next widespread outbreak, which may come this spring or next fall and winter. When H1N1 returns again, I predict it will cause more illness and death than it did this fall despite the fact it will attack a population with more H1N1 specific antibodies. Measles, another virus thought to transmit via respiratory secretions, would never forego the opportunity to infect so many virgins.
Influenzologists have no idea why this Disappearing Act happens. Dr. Edgar Hope-Simpson believed the reason lay in the mode of transmission; the current outbreak is ending despite a wealth of potential victims because the people transmitting the flu are suddenly no longer contagious. I recommend Hope-Simpson’s book:
I also believe that only a small population was transmitting, not all those infected. If these good transmitters – and not all the sick – usually spread the virus, and their transmission period is limited, the epidemic would end shortly after the good transmitters lose their infectivity. Why they lose their infectivity is yet another mystery, but a mystery that fits the epidemiology of influenza.
Another incredible Disappearing Act, one that usually follows the introduction of a pandemic virus, is the rapid and usually complete replacement of seasonal flu with the pandemic one. It is as if the pandemic virus murders the seasonal flu. We will have to wait to see if that happens worldwide with this pandemic, but in the USA it has already happened. Last week the CDC reported that more than 99% of all influenza viruses identified in the USA were Swine flu. Only 1 of 1,874 influenza A viruses identified last week was seasonal flu. Where did the seasonal flu virus go?

Thanks to those who volunteered!
If your email address begins with A through E, you may have gotten my email asking for volunteers to help give feedback on our new website. We were overwhelmed with the response, ten times more than we needed. Thank you.
The reason for the request is that the Vitamin D Council has contracted with Minervation Ltd for $40,000 to build a new website over the next several years. We can only afford $1,000 per month so it take three and a half years to pay them, however; the first version of the new site is scheduled to go up in the late fall of 2010.
We decided to make our site more accessible, so if you only want to know about Vitamin D and pregnancy, you will be able to pull up the information quickly. Our new website will also update Vitamin D articles in the press and scientific studies from the National Library of Medicine automatically every day.
We also want to clearly separate fact from opinion, so readers can easily see what the science is and what our opinion is. Finally, as you know, the Vitamin D Council unfortunately has to market products, like the in-home Vitamin D blood test, to stay in business. The new website will prominently display all of our potential conflicts so readers will know them up front.
If you want our new website up and running sooner than 12 months, consider making a dedicated donation, either by using the snail mail address below or via PayPal on our website. We are now going on our seventh year of operation and plan on 20 more years, in spite of the fact that all 15 of our requests for grants were recently turned down.
Did you know that when you Google “Vitamin D,” you will get more than 12 million hits? Our current website is usually ranked either number 1 or 2 of those 12 million, beating out the NIH, Mayo Clinic and Wikipedia on most days? This is almost entirely due to our webmaster Dana Clark. However, we believe we can dramatically improve our website, with your help.

John Cannell, MD
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I bring this up because RNY and DS’ers are more likely to become D deficient.. but the US as a whole is popping up deficient.  Hubby, my skinny ass, non-rerouted gutted husband who drinks Mt. Dew all day husband, is D deficient.  Point is — this is something we need to be adding to prenatal blood workups, postop or not.  While many of my readers may not be currently pregnant, it can (and has) happened and should be noted as important.  I mean, I’m living proof as I sit here watching my two little vikings color.

Directly from the Vitamin D Council’s newsletter:

Pregnancy and Gestational Vitamin D Deficiency

In the last 3 years, an increasing amount of research suggests that some of the damage done by Vitamin D deficiency is done in-utero, while the fetus is developing. Much of that damage may be permanent, that is, it can not be fully reversed by taking Vitamin D after birth. This research indicates Vitamin D deficiency during pregnancy endangers the mother’s life and health, and is the origin for a host of future perils for the child, especially for the child’s brain and immune system. Some of the damage done by maternal Vitamin D deficiency may not show up for 30 years. Let’s start with the mother.

Incidence of Gestational Vitamin D Deficiency

Dr. Joyce Lee and her colleagues at the University of Michigan studied 40 pregnant women, the majority taking prenatal vitamins. Only two had blood levels >50 ng/mL and only three had levels >40 ng/mL. That is, 37 of 40 pregnant women had levels below 40 ng/mL, and the majority had levels below 20 ng/mL. More than 25% had levels below 10 ng/mL. Lee JM, Smith JR, Philipp BL, Chen TC, Mathieu J, Holick MF. Vitamin D deficiency in a healthy group of mothers and newborn infants. Clin Pediatr (Phila). 2007 Jan;46(1):42–4.

Dr. Lisa Bodnar, a prolific Vitamin D researcher, and her colleagues at the University of Pittsburg studied 400 pregnant Pennsylvania women; 63% had levels below 30 ng/mL and 44% of the black women in the study had levels below 15 ng/mL. Prenatal vitamins had little effect on the incidence of deficiency. Bodnar LM, Simhan HN, Powers RW, Frank MP, Cooperstein E, Roberts JM. High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates. J Nutr. 2007 Feb;137(2):447–52.

Dr. Dijkstra and colleagues studied 70 pregnant women in the Netherlands, none had levels above 40 ng/mL and 50% had levels below 10 ng/mL. Again, prenatal vitamins appeared to have little effect on 25(OH)D levels, as you might expect since prenatal vitamins only contain 400 IU of Vitamin D. Dijkstra SH, van Beek A, Janssen JW, de Vleeschouwer LH, Huysman WA, van den Akker EL. High prevalence of vitamin D deficiency in newborns of high-risk mothers. Arch Dis Child Fetal Neonatal Ed. 2007 Apr 25.

Thus, more than 95% of pregnant women have 25(OH)D levels below 50 ng/mL, the level that may indicate chronic substrate starvation. That is, they are using up any Vitamin D they have very quickly and do not have enough to store for future use. Pretty scary.

Effects on the Mother

Caesarean section

The rate of Caesarean section in American women has increased from 5% in 1970 to 30% today. Dr. Anne Merewood and her colleagues at Boston University School of Medicine found women with levels below 15 ng/mL were four times more likely to have a Cesarean section than were women with higher levels. Among the few women with levels above 50 ng/mL, the Caesarean section rate was the same as it was in 1970, about 5%. Merewood A, Mehta SD, Chen TC, Bauchner H, Holick MF. Association between vitamin D deficiency and primary cesarean section. J Clin Endocrinol Metab. 2009 Mar;94(3):940–5.

Preeclampsia

Preeclampsia is a common obstetrical condition in which hypertension is combined with excess protein in the urine. It greatly increases the risk of the mother developing eclampsia and then dying from a stroke. Dr. Lisa Bodnar and her colleagues found women with 25(OH)D levels less than 15 ng/mL had a five-fold (5 fold) increase in the risk of preeclampsia. Bodnar LM, Catov JM, Simhan HN, Holick MF, Powers RW, Roberts JM. Maternal vitamin D deficiency increases the risk of preeclampsia. J Clin Endocrinol Metab. 2007 Sep;92(9):3517–22.

Gestational Diabetes

Diabetes during pregnancy affects about 5% of all pregnant women, is increasing in incidence, and may have deleterious effects on the fetus. Dr. Cuilin Zhang and colleagues at the NIH found women with low 25(OH)D levels were almost 3 times more likely to develop diabetes during pregnancy. Zhang C, Qiu C, Hu FB, David RM, van Dam RM, Bralley A, Williams MA. Maternal plasma 25-hydroxyvitamin D concentrations and the risk for gestational diabetes mellitus. PLoS ONE. 2008;3(11):e3753.

Bacterial Vaginitis

Dr. Lisa Bodnar and her colleagues found pregnant women with the lowest 25(OH)D level are almost twice as likely to get a bacterial vaginal infection during their pregnancy. Bodnar LM, Krohn MA, Simhan HN. Maternal Vitamin D Deficiency Is Associated with Bacterial Vaginosis in the First Trimester of Pregnancy. J Nutr. 2009 Apr 8.

Effects on the child

Seventeen experts—many of them world-class experts—recently recommended:

“Until we have better information on doses of vitamin D that will reliably provide adequate blood levels of 25(OH)D without toxicity, treatment of vitamin D deficiency in otherwise healthy children should be individualized according to the numerous factors that affect 25(OH)D levels, such as body weight, percent body fat, skin melanin, latitude, season of the year, and sun exposure. The doses of sunshine or oral vitamin D3 used in healthy children should be designed to maintain 25(OH)D levels above 50 ng/mL. As a rule, in the absence of significant sun exposure, we believe that most healthy children need about 1,000 IU of vitamin D3 daily per 11 kg (25 lb) of body weight to obtain levels greater than 50 ng/mL. Some will need more, and others less. In our opinion, children with chronic illnesses such as autism, diabetes, and/or frequent infections should be supplemented with higher doses of sunshine or vitamin D3, doses adequate to maintain their 25(OH)D levels in the mid-normal of the reference range (65 ng/mL) — and should be so supplemented year-round (p. 868).” Cannell JJ, Vieth R, Willett W, Zasloff M, Hathcock JN, White JH, Tanumihardjo SA, Larson-Meyer DE, Bischoff-Ferrari HA, Lamberg-Allardt CJ, Lappe JM, Norman AW, Zittermann A, Whiting SJ, Grant WB, Hollis BW, Giovannucci E. Cod liver oil, vitamin A toxicity, frequent respiratory infections, and the vitamin D deficiency epidemic. Ann Otol Rhinol Laryngol. 2008 Nov;117(11):864–70.

That’s right. Healthy children need about 1,000 IU per 25 pounds of body weight and their 25(OH)D levels should be >50 ng/mL, year-round.

Eight years before the above recommendations, Professor John McGrath of the Queensland Centre for Mental Health Research theorized that maternal Vitamin D deficiency adversely “imprinted” the fetus, making infants more liable for a host of adult disorders. Research since that time has supported McGrath’s theory. Consider, for a minute, what it must be like for John McGrath, to know that maternal Vitamin D deficiency is causing such widespread devastation, to know it could be so easily treated, but to also know he must wait the decades that will be required to deal with the problem. McGrath J. Does ‘imprinting’ with low prenatal vitamin D contribute to the risk of various adult disorders? Med Hypotheses. 2001 Mar;56(3):367–71.

Schizophrenia

Dr. Dennis Kinney and his colleagues at Harvard published a fascinating paper last month on the role of maternal Vitamin D deficiency in the development of schizophrenia, in support of Dr. McGrath’s theory. As they point out, the role of inadequate Vitamin D during brain development appears to “overwhelm” other effects, explaining why schizophrenia has so many of the footprints of a maternal Vitamin D deficiency disorder, such as strong latitudinal variation, excess winter births, and skin color. Kinney DK, Teixeira P, Hsu D, Napoleon SC, Crowley DJ, Miller A, Hyman W, Huang E. Relation of schizophrenia prevalence to latitude, climate, fish consumption, infant mortality, and skin color: a role for prenatal vitamin d deficiency and infections? Schizophr Bull. 2009 May;35(3):582–95.

Autism

I will say not more, other than to point out that Scientific American ran a lengthy article last month on my autism theory but the editors insisted that the author not cite me, nor my paper, because I am “not a scientist.” Gabrielle Glaser. What If Vitamin D Deficiency Is a Cause of Autism? 2009 April 24. Scientific American.

Mental Retardation

The only evidence that Vitamin D deficiency is a common cause of mental retardation is from researchers at the CDC who found mild mental retardation is twice as common among African Americans as whites, and that the politically correct explanation—socioeconomic factors—cannot explain it. If latitudinal studies of mild mental retardation exist, I am unable to locate them. Yeargin-Allsopp M, Drews CD, Decoufle P, Murphy CC. Mild mental retardation in black and white children in metropolitan Atlanta: a case-control study. Am J Public Health 1995;85(3):324–8. Drews CD, Yeargin-Allsopp M, Decoufle P, Murphy CC. Variation in the influence of selected sociodemographic risk factors for mental retardation. Am J Public Health 1995;85(3):329–34.

Of course, it is claimed you are a racist if you believe these studies. In fact, a number of writers have told me their editors will not allow writers to discuss these studies in their stories. I am glad these studies were conducted by researchers at the CDC. Although, I worry about their political longevity at the CDC after reporting such findings.

I will mention one other fact (at my peril) and that is the fact that a very smart man, President Barack Obama, was born in the late summer (August) and has a brain that developed in a womb covered in white skin, during the spring and summer, in the subtropics (Latitude 21 degrees North), during an age before sun-avoidance was the mantra (1961). Make what you want to of that fact. My point is that whites living at temperate latitudes may have a huge developmental advantage over blacks, an advantage that begins immediately after conception, an advantage that has nothing to do with innate genetic ability and everything to do with environment.

Newborn Lower Respiratory Tract Infection

Newborn babies are vulnerable to infections in their lungs and women with the lowest 25(OH)D level during pregnancy were much more likely to have their newborn in the ICU being treated for lower respiratory tract infections. Drs. Walker and Modlin at UCLA recently presented reasons why viral pneumonia is probably only one of many pediatric Vitamin D deficient infections. Karatekin G, Kaya A, Salihoğlu O, Balci H, Nuhoğlu A. Association of subclinical vitamin D deficiency in newborns with acute lower respiratory infection and their mothers. Eur J Clin Nutr. 2009 Apr;63(4):473–7. Walker VP, Modlin RL. The Vitamin D Connection to Pediatric Infections and Immune Function. Pediatr Res. 2009 Jan 28.

Birth weight

While conflicting results exist on the effects of maternal Vitamin D deficiency and birth weight, the majority of the studies find an effect. Furthermore, the studies are comparing women who have virtually no intake to women who have minuscule intakes. For example, women who ingested around 600 IU per day were more likely to have normal weight babies compared to women whose intake was less than 300 IU per day. One can only wonder what would happen if pregnant women had adequate intakes? Drs. Scholl and Chen, at the Department of Obstetrics at the University of Medicine and Dentistry of New Jersey, concluded pregnant women need 6,000 IU per day, not the 400 IU/day contained in prenatal vitamins. Scholl TO, Chen X. Vitamin D intake during pregnancy: association with maternal characteristics and infant birth weight. Early Hum Dev. 2009 Apr;85(4):231–4.

Diabetes

My old nemesis, cod liver oil, when given during pregnancy resulted in children who were three times less likely to develop juvenile diabetes before the age of 15. Of course, this was back when cod liver oil had meaningful amounts of Vitamin D (these Norwegian mothers were taking cod liver oil in the 1980s). Stene LC, Ulriksen J, Magnus P, Joner G. Use of cod liver oil during pregnancy associated with lower risk of Type I diabetes in the offspring. Diabetologia. 2000 Sep;43(9):1093–8.

Seizures

Newborns frequently have seizures and those seizures are almost always due to low blood calcium. This problem is so common that many newborns are given a prophylactic injection of calcium. In 1978, researchers found such hypocalcemia can easily be prevented by giving Vitamin D. Sadly, standard treatment remains—not Vitamin D, but calcium and an analogue of activated Vitamin D. Such analogues do not correct Vitamin D deficiency. The fact that this was known in 1978 and has been routinely ignored by obstetricians since then should give you pause. Do not think science will solve the Vitamin D problem. Science simply points the way, activists must change the practice. Fleischman AR, Rosen JF, Nathenson G. 25-Hydroxycholecalciferol for early neonatal hypocalcemia. Occurrence in premature newborns. Am J Dis Child. 1978 Oct;132(10):973–7.

Heart Failure

Idiopathic infant heart failure is often fatal. Of course, idiopathic to whom? The uninformed cardiologists who do not recognize severe infantile Vitamin D deficiency? Luckily, for 16 infants, Dr. Maiya, Dr. Burch, and colleagues at the Great Ormand Street Hospital for Children are not among them. Maiya S, Sullivan I, Allgrove J, Yates R, Malone M, Brain C, Archer N, Mok Q, Daubeney P, Tulloh R, Burch M. Hypocalcaemia and vitamin D deficiency: an important, but preventable, cause of life-threatening infant heart failure. Heart. 2008 May;94(5):581–4.

Weak bones

Dr. Muhammad Javaid and colleagues at the University of Southampton found that children of Vitamin D deficient mothers were much more likely to have weak bones 9 years later. Dr. Adrian Sayers and Jonathan Tobias of the University of Bristol recently found the same thing when they looked at maternal sun-exposure. Javaid MK, Crozier SR, Harvey NC, Gale CR, Dennison EM, Boucher BJ, Arden NK, Godfrey KM, Cooper C; Princess Anne Hospital Study Group. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet. 2006 Jan 7;367(9504):36–43. Sayers A, Tobias JH. Estimated maternal ultraviolet B exposure levels in pregnancy influence skeletal development of the child. J Clin Endocrinol Metab. 2009 Mar;94(3):765–71.

Brain Tumors

John McGrath’s group discovered that children with astrocytomas and ependymomas (brain tumors you do not want your child to have) were more likely to be born in the winter. Ko P, Eyles D, Burne T, Mackay-Sim A, McGrath JJ. Season of birth and risk of brain tumors in adults. Neurology. 2005 Apr 12;64(7):1317.

Epilepsy

Three studies have found that epileptic patients are much more likely to be born in the winter. Dr. Marco Procopio of the Priory Hospital Hove in Sussex has written all three. Procopio M, Marriott PK, Davies RJ. Seasonality of birth in epilepsy: a Southern Hemisphere study. Seizure. 2006 Jan;15(1):17–21.

Craniotabes

Craniotabes is softening of the skull bones that occurs in 1/3 of “normal” newborns. Recent evidence indicates it is yet another sign and sequela of maternal vitamin D deficiency. Yorifuji J, Yorifuji T, Tachibana K, Nagai S, Kawai M, Momoi T, Nagasaka H, Hatayama H, Nakahata T. Craniotabes in normal newborns: the earliest sign of subclinical vitamin D deficiency. J Clin Endocrinol Metab. 2008 May;93(5):1784–8.

Cavities

Dr. Robert Schroth from the University of Manitoba reported that mothers of children who developed cavities at an early age had significantly lower vitamin D levels during pregnancy than those whose children were cavity-free. Megan Rauscher. Prenatal vitamin D linked to kids’ dental health. 2009. Reuters.

Asthma

The extant data here is conflicting. Two studies have found higher Vitamin D intakes during pregnancy decrease the risk of asthma in later childhood and one has found the opposite. The best review of the issue is by Drs. Augusto Litonjua and Scott Weiss, at Harvard, who conclude that the current epidemic of asthma among our children is related to both gestational and ongoing childhood vitamin D deficiency. Litonjua AA, Weiss ST. Is vitamin D deficiency to blame for the asthma epidemic? J Allergy Clin Immunol. 2007 Nov;120(5):1031–5.

Furthermore, a very recent study by Dr. John Brehm and the same Harvard group found low Vitamin D levels in asthmatic children were associated with hospitalization, medication use, and disease severity. Brehm JM, Celedón JC, Soto-Quiros ME, Avila L, Hunninghake GM, Forno E, Laskey D, Sylvia JS, Hollis BW, Weiss ST, Litonjua AA. Serum vitamin D levels and markers of severity of childhood asthma in Costa Rica. Am J Respir Crit Care Med. 2009 May 1;179(9):765–71.

In case you are wondering, black children are four times more likely than white children to be hospitalized or die from asthma. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002 Aug;110(2 Pt 1):315–22.

My experience, both at the hospital and via my readers, is that asthma improves—albeit sometimes slowly—when adequate doses of Vitamin D are taken. However, Vitamin D does not appear to be a cure, like it is in some other conditions. I suspect children with asthma have suffered both gestational and ongoing childhood Vitamin D deficiency that probably altered, perhaps permanently, their immune system.

The Vitamin D Council’s Effort

We recently ran a ¼ page announcement in OB/GYN News and the American Journal of Obstetrics and Gynecology (AJOG). Unfortunately, the editor of AJOG censored our announcement after its first month, but we were able to get the full, three-month run in OB/GYN News. We also sent a very similar email to 18,000 obstetricians in the United States. The total cost to the Vitamin D Council for this campaign was about $12,000.00.

The announcement simply pointed out that the American Academy of Pediatrics (AAP) recently recommended that all pregnant women have a 25(OH)D blood test because Vitamin D is important for normal fetal development (p. 1145):

“Given the growing evidence that adequate maternal vitamin D status is essential during pregnancy, not only for maternal well-being but also for fetal development, health care professionals who provide obstetric care should consider assessing maternal vitamin D status by measuring the 25-OH-D concentrations of pregnant women. On an individual basis, a mother should be supplemented with adequate amounts of vitamin D3 to ensure that her 25-OH-D levels are in a sufficient range (>32 ng/mL). The knowledge that prenatal vitamins containing 400 IU of vitamin D3 have little effect on circulating maternal 25-OH-D concentrations, especially during the winter months, should be imparted to all health care professionals.” Wagner CL, Greer FR; American Academy of Pediatrics Section on breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008 Nov;122(5):1142–52.

As the AAP recommendation came from an official medical body, to medical malpractice attorneys it represents evidence of a “standard of care” for future lawsuits. We also reminded obstetricians that the statute of limitations on malpractice suits does not toll (begin) until the injured party recognizes the injury. That is, the parents of a 5-year-old child diagnosed with autism five years in the future may bring suit against that obstetrician for how the child was treated during his time in the uterus, citing the 2008 AAP‘s recommendation as a standard of care. Obstetricians are already burdened with lawsuits, but they could decrease the number of suits significantly if they would just take the time to learn about Vitamin D.

Finally, we used our last $12,000 to produce and run a television announcement in the Washington, D.C. TV market, entitled Pregnancy and Vitamin D.

What can you do?

Most people want to do good—at least some good—in their lives. The endless pursuit of the God-almighty dollar, better clothes, better houses and better vacations than your neighbors eventually leaves a hole in your soul. Here is an opportunity to fill it.

If you don’t feel that soul hole, try a meditation I learned at Esalen Institute in the 1980s and have practiced ever since. Lie on the floor and pretend you are dead in your grave. Feel the worms, smell the rot, sense the finality. Then, when you really feel dead, visualize your gravestone above. What does it say? “Here lies Robert; he had a big fancy house.” “Here lies Vanessa; she wore beautiful clothes and had four face lifts.” Here lies Michael; he made a billion dollars.” Through this meditation, I realized I want my gravestone to say, “Here lies John, he did something good.”

One good thing you can do is simply tell every pregnant woman and women thinking of getting pregnant that she needs to take more Vitamin D, a lot more. Pregnant women need a minimum of 5,000 IU per day and even that dose will not achieve 25(OH)D levels of >50 ng/mL in all women. Why not buy a few bottles of 5,000 IU capsules and hand out the bottles to your pregnant friends? You can get 250 vitamin D capsules for 15 bucks. Or, forward this email to them. Show them our Pregnancy and Vitamin D public service announcement.

If you want to do more, why not get a copy of our Pregnancy and Vitamin D public service announcement by emailing our webmaster at webmaster@vitamindcouncil.org (the ad is not copyrighted) and then pay to run it on a TV station in your hometown? You can easily add a caption at the bottom saying this public service announcement is being sponsored by your company, combining a good deed with good business.

Alas, no glory will be yours, at least in this life. No woman will ever thank you for the schizophrenic child she never had, for the trips to the emergency room with a breathless child that she never made, for the repetitive moaning of the autistic child she never endured. Although, she may wonder why her pregnancy was so easy and why her infant is so healthy, alert, active, and smart.

John Jacob Cannell MD Executive Director


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