UBC Faculty Research and Publications

Very high vitamin D supplementation rates among infants aged 2 months in Vancouver and Richmond, British… Crocker, Barbara; Green, Tim J; Barr, Susan I; Beckingham, Bridgid; Bhagat, Radhika; Dabrowska, Beata; Douthwaite, Rachel; Evanson, Carmen; Friesen, Russell; Hydamaka, Kathy; Li, Wangyang; Simmons, Kelly; Tse, Lillian Dec 7, 2011

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RESEARCH ARTICLE Open AccessVery high vitamin D supplementation ratesamong infants aged 2 months in Vancouver andRichmond, British Columbia, CanadaBarbara Crocker1, Tim J Green2*, Susan I Barr2, Bridgid Beckingham1, Radhika Bhagat1, Beata Dabrowska1,Rachel Douthwaite1, Carmen Evanson1, Russell Friesen2, Kathy Hydamaka3, Wangyang Li2, Kelly Simmons1 andLillian Tse1AbstractBackground: Vitamin D deficiency during infancy may lead to rickets and possibly other poor health outcomes.The World Health Organization recommends exclusive breastfeeding for the first 6 months. Breast milk is the bestfood for infants but does not contain adequate vitamin D. Health Canada recommends all breastfed infants receivea daily vitamin D supplement of 400 IU; however, there appears to be limited current Canadian data as to whetherparents or caregivers are following this advice. The aim of this study was to determine the rates of vitamin Dsupplementation among 2-month old infants in Vancouver and Richmond, British Columbia, Canada.Methods: Mothers of all healthy infants born between April and May 2010 were approached to participate.Telephone surveys were conducted with 577 mothers (response rate 56%) when their infants turned 2 months.Results: Over half of the infants received only breast milk in the week prior to the survey. One third received amixture of breast milk and infant formula and 10% received only formula. About 80% of the infants weresupplemented with vitamin D at 2 months. Infants who received only breast milk were most likely to besupplemented with vitamin D (91%). Over 60% of the infants had a total vitamin D intake of 300- < 500 IU/d fromsupplements and formula and only 5% did not receive any vitamin D. Most parents were advised to give vitaminD supplement by health professionals, such as public health nurses, midwives, and doctors.Conclusions: About 90% of the infants received breast milk at 2 months of age. The vitamin D supplementationrate was 80%. Future studies are needed to monitor breastfeeding duration and vitamin D supplementation ratesas infants get older.BackgroundWorldwide public health authorities recommend exclu-sive breastfeeding for the first 6 months of life forhealthy term infants [1-3]. Breast milk is the best foodfor optimal growth of the infant and breastfeeding hasbeen associated with improved health outcomes formother and infant [1]. While breast milk is the idealfood for infant, it does not generally supply adequateamounts of vitamin D [4]. As such, breastfed infants areat risk of vitamin D deficiency [5]. In its most seriousform vitamin D deficiency in infancy leads to rickets, acondition characterized by weakened bones, resultingfrom poor mineralization of newly formed bone tissue[6]. Additionally, there is emerging evidence that lack ofvitamin D during infancy, is associated with altered cal-cium metabolism [7], early childhood tooth decay [8],and increased risk of Type 1 Diabetes [9], and asthmalater on [10].While infant formula is fortified with vitamin D,breastfed infants are reliant on skin synthesis of vitaminD through the action of sunlight or supplemental vita-min D. Due to the risk of skin cancer it is generallyrecommended that infants under 1 year be kept out ofdirect sunlight [11]. Owing to concerns about vitamin D* Correspondence: tim.green@ubc.ca2Food, Nutrition and Health, University of British Columbia, 2205 East Mall,Vancouver V6T 1Z4, CanadaFull list of author information is available at the end of the articleCrocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905© 2011 Crocker et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.deficiency, Health Canada [4], the American Academy ofPediatrics [3], as well as several European countries[12-14] recommend that breastfed infants receive a dailyvitamin D supplement, usually 400 IU. In Canada thisrecommendation has been in place since 1967 [4], yet,other than in the province of Quebec [15,16], there arefew data as to whether parents or caregivers are follow-ing this advice. As part of the Canadian CommunityHealth Survey 2007-2008 [17], Statistics Canadareported that among women who had given birth in thepast 5 years and exclusively breastfed their infant, 67%provided a vitamin D supplement to the infant. How-ever, this survey did not consider the frequency, dose,or form of supplement, nor were supplementation prac-tices assessed among women who fed their infants acombination of breast milk and formula. Further, thissurvey included women who gave birth as early as 2002and there may now be greater awareness about theimportance of vitamin D. Indeed, Gallo et al. [18]reported that in one Montreal hospital 98% of exclu-sively breastfeeding mothers who gave birth in 2007-2008 supplemented their infants at some point prior to6 months of age.As part of British Columbia’s (BC) publicly fundedmedical system, public health nurses provide breastfeed-ing support including advice on vitamin D supplementa-tion within the first few days postpartum. To assess theeffectiveness of this health promotion strategy, we con-ducted a survey in 2010 to determine the rates ofbreastfeeding and vitamin D supplementation among 2-month old infants in Vancouver and Richmond, BC. Wealso wanted to determine the type and dose of vitaminD supplementation given, examine the association ofsocio-demographic factors and vitamin D supplementa-tion and determine barriers to infant vitamin Dsupplementation.MethodsSampling frameEthical approval to conduct the study was obtained fromthe University of British Columbia Behavioural ResearchEthics Board. The survey was conducted in Richmondand five of six Community Health Areas in Vancouver.Vancouver (population 578,041; 2006) and Richmond(population 174,461; 2006) are the largest and fourthlargest cities, respectively, in BC, Canada. All parents orcaregivers whose infant was born between April andMay of 2010 were invited to participate in the survey.Parents or caregivers were ineligible: if they moved outof the catchment area or were involved in a programthat provided care to high-risk mothers (i.e. substance-abuse); or if their infant was adopted, in foster-care, orunder the care of a neonatal intensive care unit. Aninfant age of 2 months was chosen because we wantedto survey women who had established breastfeeding andbefore the breastfeeding rates decline. Initial recruitmenttook place through public health nurses who asked theparent at an early postpartum contact whether theywould be willing to participate in a short telephoneinterview. At an infant age of 2 months (range = 7-10weeks) a research assistant phoned the parent to com-plete the survey after again obtaining verbal consent toparticipate.SurveyThe survey questionnaire was designed to obtain infor-mation on infant feeding practices; vitamin D supple-mentation including the form, frequency, and dose; whorecommended that the infant be supplemented and (ifappropriate) the reasons for not supplementing; andbasic socio-demographic questions. The questionnairewas initially developed by the study investigatorsthrough face-to face meetings and through consultationand focus testing with relevant stakeholders. We pilotedthe questionnaire with ten new parents and revised itaccordingly. The questionnaire was administered in Eng-lish or when required in Mandarin, Cantonese, Punjabi,Vietnamese, or Spanish.Data analysisIn our study, we defined “All breast milk” as infants whohad received only breast milk (vitamins, minerals, andmedicines permitted) in the week prior to the survey[2]. “Mixed breast milk and formula” was used to defineinfants who had received a mixture of breast milk andinfant formula in the week prior to the survey. “Infantformula” was used to define infants who had receivedonly formula in the week prior to the survey. Based ondata indicating that 2-month old infants are fed an aver-age of 8 times per day [3], we further divided the“mixed breast milk and formula” group into: “≥75% ofbreast milk” defined as ≤2 feedings of other liquids/foodper day; “50- < 75% breast milk” as 3-4 feedings ofother liquids/food per day; and “ < 50% breast milk” as> 4 feedings of other liquids/food per day. Average dailyformula intake was calculated by multiplying frequencyof consumption in 24 hours by the amount of formulareceived in each bottle feed. The amount of vitamin Dprovided by formula was calculated assuming infant for-mula contains 40 IU vitamin D/100 ml, and the averageintake of vitamin D provided by supplements was calcu-lated based on the amount per dose and the frequencyof administration. These two sources were summed todetermine daily vitamin D intake. Descriptive statisticswere used to describe breastfeeding and vitamin D sup-plementation rates (proportion with 95% confidenceinterval). Chi Square tests were used to determine differ-ences in vitamin D supplementation by feeding practice.Crocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 2 of 8Rates were also stratified by socio-demographic variablessuch as ethnicity. The proportion of infants receiving atotal vitamin D intake of < 300 IU from supplementsand/or formula was also examined by feeding practiceusing Chi-square. A cut-point of 300 IU was selectedbecause in order to achieve 400 IU per day a caregiverof breastfed infant would need to be 100% compliantwith daily supplementation during the week surveyed.Further, the evidence base for infant requirements ispoor [19] and recent trials suggest that 400 IU vitaminD exceeds requirements [20]. Multiple logistic regres-sion was used to determine significant predictors (fromamong age, ethnicity, parity, income, and education) ofreceiving vitamin D supplements in two separate mod-els; one in women whose infants had only receivedbreast milk in the week prior to the survey and theother in those providing at least 50% of feeds frombreast milk.ResultsOf the 1028 women eligible to participate, 577 com-pleted the survey giving a response rate of 56% (Figure1). Participant characteristics are given in Table 1. Themajority of the mothers were over 31 y. One third ofthe infants were of European ethnicity and another onethird was Chinese. Among those who responded to theannual family income question (n = 454), almost halfhad an income greater than $80,000. Participants weregenerally well educated with 87% having completedsome post-secondary education.The breastfeeding initiation rate was 99% (n = 570)and by 2 months of age over 40% of women were exclu-sively breastfeeding, using the WHO definition (2).Table 2 displays feeding practices and vitamin D supple-mentation practices at 2 months of age. Nearly 90% ofinfants were still receiving some breast milk. Over halfreceived only breast milk in the past week; about onethird received a mixture of breast milk and formula ran-ging from ≤2 to > 4 feedings of other liquids/food perday; and about 10% received only infant formula. Of the577 infants, about 80% were supplemented with vitaminD at the time mothers were surveyed. Rates of vitaminD supplementation were significantly higher in thosereceiving only breast milk in the past week than thosewho received both breast milk and formula, which inturn were higher than exclusively formula fed babies.Within the mixed breast milk and formula group,infants receiving < 50% breast milk were less likely to besupplemented with vitamin D than those receiving 50%or more breast milk (P < 0.001). The proportion ofFigure 1 Participant flow and follow-up.Crocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 3 of 8infants receiving less than 300 IU vitamin D per day(supplement and/or formula) was higher among infantsreceiving only breast milk than among those fed mixedbreast milk and formula. However, within this groupthere was no difference in the percentage of infantsreceiving less than 300 IU per day.About 5% of the infants did not receive any vitamin Dfrom supplements and/or infant formula and 61% had atotal vitamin D intake of 300- < 500 IU/d (Figure 2).Approximately 10% received 500 IU or more per daywith the highest intake being 1130 IU/d (1000 IU fromthe supplement). Of those infants who were given vita-min D supplements, 80% received D-Drops® (a concen-trated formula that provides 400 IU in a single drop)and 16% received D-Vi-Sol® (a formula that provides400 IU per 1 mL). As shown in Table 3, over 90% ofparticipants recalled receiving one or more recommen-dations to give their infant a vitamin D supplement.Public health nurses and physicians were the most fre-quent sources of this recommendation. Women who diduse a supplement were asked to respond to an openquestion on why they chose to do so. The most com-mon reasons were related to the inadequate amounts ofvitamin D in breast milk, that a supplement had beenrecommended, that vitamin D had health benefits forthe infant, and that lack of sunlight exposure meantsupplementation was needed. Women who did not pro-vide a supplement were asked to choose from a list onwhy they did not. Among those providing a response,the most common reasons were that the infant wasbeing given formula, or that they did not think supple-mentation was necessary.In multiple regression analysis of infants receivingonly breast milk in the week prior to the survey (n =331), only parity was associated with vitamin D supple-mentation. Primiparas were more likely to supplementtheir infants than multiparas (95% versus 84%; P =0.03). Table 4 shows the results of the logistic regressionof selected variables associated with vitamin D supple-mentation in infants who received greater than 50% oftheir feeds from breast milk (n = 517). None of the vari-ables studied was significantly associated with supple-mentation, although there was a tendency for a higherrate of vitamin D supplementation in infants fromfamilies in the two higher income categories than thosein the lowest income category.DiscussionIn this study we build on previous Canadian observa-tions indicating high rates of breastfeeding and vitaminD supplementation, and provide new informationregarding the dose of vitamin D provided, and mothers’reasons for choosing to supplement or not supplement.Almost 60% of infants had received only breast milk inthe week prior to the survey and of these greater than90% had received vitamin D supplements. This is muchhigher than the 67% vitamin D supplementation ratereported in a 2007-2008 survey for Canadian womenTable 1 Participant characteristicsCharacteristic % (n)Maternal Age< 31 33.3(192)≥31 66.7(385)Baby’s ethnicityEuropean 36.7(212)Chinese 31.2(180)Other1 32.1(185)Annual family income<$40,000 19.6(113)$40,000-59,000 11.3 (65)$60,000-80,000 10.4 (60)>$80,000 37.4(216)Unknown2 21.3(123)Education< High school 0.3 (2)Some and completed high school 12.5 (72)Some trade/vocational training and college/university 8.8 (51)Completed trade/vocational training and college/university78.3(452)ParityPrimipara 52.0(300)Multipara 48.0(277)Baby’s genderMale 50.6(292)Female 49.4(285)Marital statusSingle 4.9 (28)Married 85.6(494)Common-law 8.5 (49)Other 1.0 (6)1South Asian 42.0% (63), South East Asian 42.7% (64), Korean 6.0% (9),Japanese 9.3% (14), Aboriginal 25.7% (9), Black 22.9% (8), Middle Eastern42.9% (15), Iranian 2.9% (1), Afghan 2.9% (1), Turkish 2.9% (1)2Do not know and do not want to sayCrocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 4 of 8who had exclusively breastfed an infant in the past 5years [17]. In that study, the supplementation rate in BCwas marginally higher than the national average (70%),but still well below the rate in our study. Our rates ofvitamin D supplementation are comparable to thosereported more recently in one Montreal hospital where98% of exclusively breastfed (WHO definition) infantshad been supplemented with vitamin D at some pointduring the first 6 months [18]. Data from the InfantFeeding Practices Study II (2005-2007) suggest that USvitamin D supplementation rates are markedly lowerthan in Canada; 43% of infants were breastfed at 2months and of these only 10% were receiving vitamin D[21]. However, the American Academy of Pediatricsonly began recommending infant supplementation inNovember 2008, whereas the Canadian recommendationhas been present in some form since 1967. Further,breastfeeding rates have been historically higher inCanada than in the US and Canada’s higher latitudemay have created a greater impetus for infant supple-mentation in this country. As expected infant supple-mentation at 2 months was lower amongst thosereceiving mixed feeds (79%) and lower still in infantsreceiving only infant formula (20%). In Montreal, anapparently higher 88% of mixed feeders had receivedsupplemental vitamin D; however, this was anytime dur-ing the first 6 months [18]. In the US study, amongstmixed feeders, only 5% were receiving vitamin D supple-ments at 2 months of age [21]. Despite a high propor-tion of breastfed infants receiving vitamin Dsupplements, one third were not receiving at least 300IU/d; mainly because of less than daily supplementadministration. Although we report less frequent vita-min D supplementation rates among infants who werereceiving mixed breast milk and formula in the weekbefore the survey than among those fed only breast milkTable 2 Feeding practices and vitamin D supplementation of infants aged two monthsFeeding practice Feeding Practice Vitamin D Supplement < 300 IU/d Vitamin D5% (n) % yes (n) % (n)Total 100.0 (577) 79.9 (461) 28.9 (167)All breast milk1 57.4 (331) 91.2 (302)a* 33.5 (111)aMixed breast milk and formula 32.2 (186) 79.0 (147)b 22.0 (41)b≥75% breast milk2 53.8 (100) 86.0 (86) 21.0 (21)50- < 75% breast milk3 20.4 (38) 84.2 (32) 26.3 (10)< 50% breast milk4 25.8 (48) 60.4 (29) 20.8 (10)Infant formula 10.4 (60) 20.0 (12)c 25.9 (15)ab1Only breast milk in the past week2 ≤2 feedings of other liquids/food per day33-4 feedings of other liquids/food per day4 > 4 feedings of other liquids/food per day5Total daily vitamin D intake from supplement and formula*Rows showing different superscripts are significantly different from each other; c2 P < 0.0010 10 20 30 40 50 60 70 0 1-<300 300-<500 500 % of Infants at 2 Months Vitamin D (IU/d) n = 577 Figure 2 Daily total vitamin D intake from supplements and infant formula at two months of age.Crocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 5 of 8(79% versus 91%), fewer of the infants receiving mixedfeeding had vitamin D intakes below 300 IU/d vitaminD (22%, versus 33.5% in the fully breastfed group).Further, within the group receiving mixed feeds, as theamount of formula increased infant supplementationdropped; however, the percentage of those receiving lessthan 300 IU/d remained constant at around 20%. Thiswas not unexpected as formula is fortified with vitaminD and it would take about 700 ml of formula to achievean intake of 300 IU/d. Consuming less than 700 ml/dalso explains why 25% of formula fed infants failed toachieve this intake. Using a stricter cut-point of 400 IU/d, the Montreal researchers reported that 74% of exclu-sively breastfed infants and 51% receiving mixed feedsachieved an intake of 400 IU/d at 6 months [18].Up to a third of infants not achieving 300 IU/d vita-min D and even less achieving the recommendation of400 IU/d may appear high. However, only 5% of infantswere receiving no vitamin D. Further, it is acknowledgedthat the evidence base used to derive the infant recom-mendation is limited. Serum 25-hydroxyvitamin D(25OHD) concentration is the best indicator of vitaminD status. Although controversial the US Institute ofMedicine recently affirmed a 25OHD of 50 nmol/L asdesirable in all age groups including infants [19]. Greeret al. [22] showed that breastfed infants (n = 9) receiving400 IU had mean 25-hydroxyvitamin D concentrationsof 95 nmol/L after 12 weeks. More recently, infants ran-domized to 250 or 500 IU per day (n = 20 per group) atbirth achieved mean (95% CI) 25OHD concentrations of139 (114-164) and 151 (126-176) nmol/L, respectivelyafter 6 weeks [20]. Thus, it appears that the recom-mended intake of 400 IU exceeds the requirements ofalmost all infants, perhaps by a considerable margin.There have been reports of infant overdosing with vita-min D in the US resulting in the Food and DrugAdministration issuing a warning of the potential risk ofoverdosing infants with liquid vitamin D [23]. In ourstudy only one infant was receiving greater than theupper limit for vitamin D of 1000 IU suggesting thiswas not a problem.Among caregivers there was generally good awarenessof the need to supplement and why it was important.For example, caregivers indicated that they used a sup-plement because vitamin D was not present in adequateamounts in breast milk and/or that sunlight exposurewas limited or not recommended; and many womenwho used formula appeared to be aware that supple-mentation wasn’t required. Over 90% of caregiversrecalled receiving advice primarily from public healthnurses and doctors to supplement with vitamin D,which may explain the high rates of supplementation. Ina Seattle study [24], parents who reported that theirchild’s pediatrician recommended vitamin D were 8times more likely to provide the supplementation thanparents whose child’s pediatrician did not. However,only a third of parents recalled receiving any recommen-dation and of these under half supplemented with vita-min D. In contrast to our study, where < 5% ofcaregivers thought supplementation was unnecessary,67% of parents in the Seattle study believed that supple-mentation was unnecessary because breast milk has allneeded nutrition.Multivariate regression revealed little in the way ofpredictors of supplement use. There was a non-signifi-cant tendency for family incomes less than $40,000 tobe associated with lower rates of supplementation. How-ever, vitamin D supplements cost less than $40 for 6months and cost of the supplements was not given as areason for not supplementing. Interestingly 80% of care-givers reported giving their infants D-Drops® versusTable 3 Advice and decisions on vitamin Dsupplementation% (n)Did anyone ever recommend a vitamin D supplement?Yes 92.2 (532)No 7.8 (45)Who recommended the supplement? (n = 532)aPublic health nurse 80.2 (426)Doctor 69.7 (370)Midwife 9.6 (51)Dietitian/pharmacist 5.1 (27)Family member or friend 19.4 (103)Other1 7.7 (46)Reasons for providing a vitamin D supplement (n = 452)aNot in breast milk/I am breastfeeding 43.6 (197)It was recommended 30.3 (137)Health benefits for infant 28.3 (128)Lack of sunlight/northern climate 21.0 (95)Other2 13.1 (59)Reasons for not supplementing vitamin D (n = 116)aBaby is being fed formula 35.3 (41)I didn’t know to give 10.3 (12)I don’t think the baby needs it 19.0 (22)Forgot to give 3.4 (4)Baby did not tolerate (vomit/spit up) 0.9 (1)Other3 5.2 (6)No response 28.4 (33)aMultiple responses possible1Reading, television, internet, South Community Birth Program, Baby’s BestChance, prenatal class, lactation clinic, natural path, doula, specialist, from firstchild2Knew from first baby, read about it, did not know why, it is important3Confused with the recommended dose, will purchase later, will ask doctor,first baby did not tolerate, had not started yetCrocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 6 of 8only 16% who supplemented with D-Vi-Sol® . The rea-son for the popularity of D-Drops® may be their ease ofadministration requiring only a single drop that can beplaced on the mother’s breast prior to nursing, versusthe need to use a dropper to administer D-Vi-Sol® [25].A strength of our study was that we had access to adatabase that contained the names of nearly all infantsborn in Vancouver and Richmond over the study period.Also, we sampled an ethnically diverse population wherebreastfeeding rates are high relative to the rest of NorthAmerica. Finally, data were collected prospectively at 2months rather than relying on recall of up to 5 years inone study. In studies of this type, selection bias is alwaysan important consideration. For example, people whochoose to participate versus those who do not, may bemore educated and of higher socioeconomic status andthus more likely to breastfeed and supplement with vita-min D. Thus a limitation of our study is that we had onlya moderate response rate of 56%. Unfortunately, we donot have any data on our non-responders and there are norepresentative data on pregnant women in Vancouver andRichmond to compare our results with. However, withrespect to ethnicity [26], education [27] and family income[28] our sample compares well with 2006 census data forwomen from Vancouver and Richmond. Further, only halfof the non-responders refused participation, while theother half could not be contacted initially or at follow-up.Because the survey was conducted in the summer monthsit appeared that many women were away on vacations orstaying with family outside the area. We acknowledge thatour findings cannot be extrapolated to the rest of Canadaor even BC. Breastfeeding rates are higher in BC than else-where and Vancouver and Richmond have a unique ethnicmix not present in the rest of the province or Canada. Sec-ond, we only sampled at 2 months; this was an intentionaldecision but more data are needed on older infants. In theUS, supplementation rates remained relatively constantout to 12 months; however, in this study both breastfeed-ing rates and infant supplementation were much lowerthan ours [21]. In Montreal, of all supplemented breastfedinfants around a third had stopped taking the supplementby 6 months [18]. More data are needed on older infantsespecially around the time of introduction of solids and asbreastfeeding rates drop with age.ConclusionsBreastfeeding rate was high among this group of mothers.About 90% of the infants received breast milk and 57%were exclusively breastfed at 2 months. Over 60% of theinfants had a total vitamin D intake of 300- < 500 IU/dfrom supplements and formula. The vitamin D supple-mentation rate was 80%. There was good awareness of theneed to supplement with vitamin D and the reasons why.Most parents were advised to give their infants vitamin DTable 4 Percentages and multivariate adjusted odds ratio (and 95% CIs) for infant vitamin D supplementation ininfants receiving greater than 50% of feeds from breast milk by select characteristics (n = 420)Characteristic % (n) OR (95% CI) p-valueMaternal Age< 31 y 87.6 (134) 1.00≥31 y 89.9 (286) 1.28 (0.65, 2.50) 0.479Baby’s ethnicityEuropean 88.9 (160) 1.00Chinese 89.6 (129) 1.34 (0.62, 2.86) 0.456Other 89.1 (131) 1.32 (0.62, 2.80) 0.469Annual family income<$40,000 83.1 (74) 1.00$40,000-80,000 92.2 (95) 2.51 (0.98, 6.41) 0.054>$80,000 91.4 (170) 2.24 (0.94, 5.30) 0.068Non-responder1 87.1 (81) 1.35 (0.58, 3.14) 0.488EducationLess than completed trade/vocationaltraining and college/university87.0 (87) 1.00Completed trade/vocational training and college/university 89.8 (333) 0.99 (0.48, 2.04) 0.984ParityPrimipara 90.5 (219) 1.00Multipara 87.8 (201) 0.69 (0.37, 1.29) 0.244Note: CI confidence interval, OR multivariate adjusted odds ratio1Do not know and do not want to sayCrocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 7 of 8supplement by public health nurses and doctors. Overall itappears that the level of knowledge translation about theimportance of vitamin D is high. This points to the successof Vancouver Coastal Heath’s system of universal contactby public health nurses, especially for providing breastfeeding support and also for providing key public healthmessages such as the use of vitamin D. Future studies areneeded to monitor vitamin D supplement rates of olderinfants and toddlers.AcknowledgementsWe are grateful to all public health nurses who recruited participants. Wethank research assistants: Kathy Ho and Anita Rashidi for their roles incompleting surveys and data management. We are also grateful to theparticipants in this study. This study was supported with a grant from theVancouver Coastal Health Research Institute.Author details1Infant, Child and Youth Program, Vancouver Coastal Health, 1669 EastBroadway, Vancouver V5N 1V9, Canada. 2Food, Nutrition and Health,University of British Columbia, 2205 East Mall, Vancouver V6T 1Z4, Canada.3Healthy Babies and Families Program, Vancouver Coastal Health, 8100Granville Avenue, Richmond V6Y 3T6, Canada.Authors’ contributionsBC and TG were responsible for the conception of the study and obtainingfunds. All authors had a role in the design, acquisition of data, analysis andinterpretation of data. BC, TG, SB, and WL drafted the initial manuscript. Allauthors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 12 July 2011 Accepted: 7 December 2011Published: 7 December 2011References1. Health Canada: Exclusive breastfeeding duration - 2004 Health Canadarecommendation Ottawa; 2004.2. 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Statistics Canada: 2006 Census of Canada highlight tables, income andearnings tables: Median earnings and employment for full-year, full timeearners, all occupations, both sexes, for Canada, provinces andterritories, and census metropolitan areas and census agglomerationswith 5,000-plus population. Ottawa, Canada: Statistics Canada; 2006,Retrieved June 6, 2011, from http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/97-563/T801-eng.cfm?Lang=E&T=801&GH=6&GF=59&G5=1&SC=1&S=1&O=A.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/905/prepubdoi:10.1186/1471-2458-11-905Cite this article as: Crocker et al.: Very high vitamin D supplementationrates among infants aged 2 months in Vancouver and Richmond,British Columbia, Canada. BMC Public Health 2011 11:905.Crocker et al. BMC Public Health 2011, 11:905http://www.biomedcentral.com/1471-2458/11/905Page 8 of 8

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