Pozdravljeni,

Pred kratkom so mi diagnosticirali revmatoidni artritis. Zraven medrola mi je moja revmatologinja (,ki ve da dojim in da želim nadaljeva ti z dojenjem) predpisala tudi vitamin D – alpha D3. Doma sem na listku prebrala, da ob jemenju teh zdravil ne smem dojiti, ker lahko škoduje dojenčkovemu presnavljanju kalcija. Sedaj ne vem kaj naj naredim. Ali naj jem tablete, ali zaupam zdravnici?

Že v naprej se vam zahvaljujem za odgovor.

Lp, Maša

Pozdravljeni! Mi lahko zaupate še predpisano doziranje? Dojenja običajno ni treba prekiniti, vam pojasnim podrobno v nadaljevanju, le še na strokovni forum pogledam.

V navodilih k zdravilom se proizvajalci praviloma želijo izogniti tožbi, če bi prišlo do kakršnihkoli stranskih učinkov pri “kritičnih” skupiah, tako da odsvetujejo uporabo med dojenjem, tudi ko to morda ni potrebno oz. zdravnik zdravilo kljub temu predpiše.

Povzemam s foruma dr. Tomasa W. Halea, torej iz prve roke, od strokovnjaka za zdravila in njihovo prehajanje v materino mleko (avtor priročnika Medication and Mothers’ Milk). Spodaj originalni odgovori na nekaj podobnih vprašanj vašemu. Lahko prevedem, če želite.

Na kratko, opozorila glede varnosti jemanja vitamina D med dojenjem izvirajo iz ene raziskave, v kateri je bila zaznana hiperkalcemija pri dojenem otroku, katerega mati je zaužila 100.000 enot analoga D2 dnevno. To je zelo zelo visok odmerek, dr. Hale meni, da dojenja ob normalnih odmerkih ni treba prekinjati: “Ne nazadnje je mogoče otrokove morebitne simptome spremljati in ga umakniti z dojke ob prvih znakih težav.” Otroka bi spremljal pediater.

Spodaj je sprva govora o vit. D2, ki je bolj problematičen glede vsrkanja in uporabnosti, nato pa o D3, ki je manj problematičen; danes smo celo skoraj vsi deficitarni, ko gre za D3. Nekateri menijo, da je doziranje D3 materam celo boljši način kot doziranje kapljic D3 otrokom, a so o tem mnenja deljena, saj ni raziskano, kako vit. D prehaja v materino mleko oz. ali sploh prehaja v znatni količini, ko gre za prehraske dodatke. Dr. Hale v večini primerov pravi, da je prehajanje v mleko verjetno tako majhno, da ne bi moglo priti do kliničnih znakov pri doječem se otroku. Smiselno bi bilo omeniti vaše jemanje pediatru in se pogovoriti, ali nadaljevati z jemanjem AD3 pri otroku ali morda ne, odvisno morda tudi od vaše doze. Vprašajte še na pediatričnem forumu,

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September 19, 2003 – 08:15 am
The only good data we have is from Greer (2001) in which they found infantile hypercalcemia in a breastfed infant whose mother was ingesting 100,000 IU vitamin D “per day”. Will 50,000 IU per week do the same thing, perhaps, but I sort of doubt it. The infant could easily be followed for symptoms of hypercalcemia and withdrawn from the breast at first symptoms if the mom wants to continue to breastfeed.
Tom Hale, PH.D.

Reference: J Pediatr. 1984 Jul;105(1):61-4. High concentrations of vitamin D2 in human milk associated with pharmacologic doses of vitamin D2. Greer FR, Hollis BW, Napoli JL.

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April 12, 2004 – 10:11 am
From MMM2004: Vitamin D typically undergoes a series of metabolic steps to become active. Calcitriol (1,25 dihydro cholecalciferol) is believed to be the active metabolite of vitamin D metabolism. Calcitriol is the most potent of the synthetic vitamin D analogs. It is indicated for treatment of hypocalcemia in patients undergoing chronic renal dialysis and renal osteodystrophy. Calcitriol is also indicated in patients with severe liver dysfunction and who are unable to hydroxylate dihydrotachysterol to its active form. Because calcitriol works more quickly, it is useful in treatment of patients with severe hypocalcemia. Calcitriol is well absorbed from the GI tract with a peak at 3-6 hours. It is 99.9% protein bound to a specific alpha-globulin vitamin D binding protein. The elimination half-life is about 5-8 hours in adults and 27 hours in pediatric age patients. However, plasma levels are quite low, averaging approximately 40 picograms/mL. No data are available on the transfer of calcitriol into human milk. It is not likely that normal doses of this vitamin D analog would lead to clinically relevant levels in human milk, particularly since vitamin D transfers only minimally into human milk anyway. While plasma levels of vitamin D are normally quite low in human milk (< 20 IU/L), at least one study now suggests that supplementing a mother with high levels of vitamin D2 can significantly elevate milk levels and subsequently lead to hypercalcemia in a breastfed infant. Some caution is recommended.
Tom Hale Ph.D.

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May 19, 2009 – 09:26 am
Calcitriol is the active form of Vitamin D. It is virtually all bound to plasma protein and is unlikely to ever reach the milk compartment (99.9% bound). Milk levels of Calcitriol reported by the manufacturer are only 2.2 picograms/ml. In essence virtually none of the calcitriol gets to milk. I do not think it would ever reach levels in milk to produce clinical effects on the infant.
Tom Hale Ph.D.

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Monday, November 30, 2009 – 08:46 am
wouldn’t worry about this product very much…although 5000 units of vitamin D is a little high for daily use. Perhaps every other day would be safer. Do not assume that this will elevate the vitamin D levels in her milk…it will only slightly. The infant needs supplementation itself.
Tom Hale Ph.D

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We have encountered a handful of breastfeeding mothers who are being tx for postpartum depression and low Vit D levels with 50,000IU Vit D daily for 4-8 weeks. Are their breastfeeding infants at risk for hypercalcemia and should our pediatricians be monitoring infant in some way? Thank you. Christy, RNMS

Wednesday, December 16, 2009 – 03:39 pm
Christy, I doubt these levels 50 K IU for only 4-8 weeks would be hazardous, because so little of vitamin D really passes into milk. In some studies, 10,000 IU only marginally elevated the amount in milk. But it would be a fun study, if someone were to determine these levels in mom and infants. We definitely need to know this.
Tom Hale

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What about the info in the Academy of Breastfeeding Medicine protocols section on Vitamin D supplementation? This is showing supplementation of mothers with Vitamin D3 in the 6000 range as bringing baby’s levels up to normal, even better than supplementing baby directly. Do you think this is valid? Could some of the variations in findings have to do with the type of Vitamin D used in the various studies?
Anonymous posted on Monday, March 01, 2010 – 05:25 pm

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The mother of our 4 months old exclusively breastfed infant was just diagnosed with severe vitamin D deficiency and will start regimen of oral vitamin D 50,000 IU a week for 12 weeks, followed by 2,000 IU PO daily. Is it safe for the baby to stay on the breast milk while his mother is being treated? If so, should the baby be monitored for hypercalcemia (clinically or labs) and how frequently?
Nadia Tomarev, MD-general pediatrician from Maryland.

March 03, 2010 – 09:47 am
Nadia, I checked with a colleague who is an expert in Vitamin D. She says not to worry. We are probably soon going to recommend doses as high as 6400 IU per day in the future for breastfeeding mothers, which is 44,800 IU per week in order to drive up levels in milk to a therapeutic range for infants. Monitoring the infants plasma calcium levels and even vitamin D levels is advisable however.
Tom Hale PhD