Vitamin D Supplementation in Pregnancy - Essay Example

?Vitamin D Supplementation in Pregnancy Introduction Vitamin D deficiency in pregnancy and in babies of vitamin D deficient mothers has been found ina number of populations, including isolated northern Canadian aboriginal people ( Scroth et al 2004). However, as Hollis and Wagner point out ( 2004), there has been relatively little research into this topic until recently. As low levels of vitamin D can have negative implications upon maternal and fetal health, in particular on bone density and strength , treatment with multivitamins is usually considered a requirement until the child reaches 12 months of age, even if breastfeeding takes place. . This paper will consider the scientific data available form various studies in order to determine why Vitamin D supplementation is so advantageous for the development of embryo and then fetus as well as the mother involved. The aim is to discuss and consider best practice according to both the patient’s medical history and after researching the best practice of supplementation of vitamin D according to the patient’s clinical records and available empirical studies. The paper will deal with an understanding of why it is important to treat women with vitamin D, its safety, efficacy and best practice regarding its safety, optimum levels of vitamin D level during pregnancy and the way in which the literature reflects this . Background In pregnancy each individual’s medical history should be taken carefully and clearly. Also various tests will need to be performed, and this should include checking levels of vitamin D using the 25 hydroxyvitamin D blood test ( Med Line Plus 2010) . After this a well prepared clinical plan can be followed, which includes the introduction of vitamin D to any vitamin D deficient women in pregnancy. Although it was widely believed that breast milk alone contained sufficient antirachitic nutritional components if a women exposed herself to sufficient sunlight this isn’t always so (Hollis & Wagner, 2004). For this reason it has been realized that there is often a need for supplements of this important vitamin. Naturally produced vitamin D cannot cause difficulties as the body stops producing it once optimal levels are reached, but if it is used as a dietary supplement it should be borne in mind that overdosing can cause difficulties, especially in the long term as ‘spare’ vitamin D is stored in fatty tissues and may reach levels which are toxic. This can have a number of side effects, not all clearly understood as yet and during pregnancy toxicity can cause retardation of infants. ( American Pregnancy Association 2000) Vitamin D affects many organ systems and the level of vitamin D needed for optimal function in many tissues is not yet defined. (Dawson-Hughes & Harris, 2010, p. 1861). Because of such factors it is therefore necessary that levels for each women should be checked so that a dosage regime can be decided upon. Low levels are not just a factor in areas with low sunlight levels. The Royal Women’s Hospital, Victoria, states that among dark skinned women and Muslims who cover their skin Vitamin D deficiency can be a problem ( 2011) citing a number of studies such as Mason and Diamond 2001. As reported by Litonjua & Weiss (2007):- Coupled with inadequate intake from foods and supplements, this then leads to vitamin D deficiency, particularly in pregnant women. (p. 1031). It should be noted that sufficient vitamin D cannot be obtained from diet, especially in vegetarians.( Office of Dietary Supplements , 2011) and in pregnancy women may avoid such sources of Vitamin D as eggs which precipitates more problems. This is because vitamin D is “both a nutrient and a hormone” (Litonjua & Weiss, 2007, p. 32). Developing a Question According to Courtney & McCutcheon (2010) the PICO (Patient, Intervention, Comparison and Outcome) model defines the meaning of nursing practice following research questions as consisting of 4 definite parts, namely: Patient – All vitamin D deficient women in pregnancy. Intervention – Performing assessment of different studies dealing both past and present experience in treating pregnant women deficient in vitamin D. Comparison – Providing a measured and clear-cut differentiation between practices used today and those documented to be the best thereafter i.e. future practice Outcome – This should consist in up-to-date, clear and arguments on the necessity of treating women with vitamin D before, during, and after pregnancy with arising from good medical practice related to discovering the need for and uses of vitamin D. Research Question Should all women be treated with vitamin D for their health and health of the fetus and infants afterwards? Rationale For the sake of the patients involved, and their infants, it is necessary to consider evidence in order to decide which practice is the best for all pregnant women , especially those deficient in vitamin D. It incorporates the idea of a critical review of many academic sources in order to arrive at the optimal method of treatment. Literature Review on Best Practice The literature review has been generated through the use of the following keywords, namely: vitamin D; deficiency; dose; practice; pregnant women; 25-Hydroxyvitamin D3 (25(OH)D); nutrition, etc. A total of 23 articles were considered :- 2 related articles, 1 comment, 3 sets of guidelines , 8 systematic reviews and 9 research articles. In this case, studies reported by Hollis & Wagner (2004) and Litonjua & Weiss (2007) have already identified an obligatory exposure of pregnant women to the sun in order to get more vitamin D using the body’s natural ability to synthesize it, using melanotic pigment under the influence of the sun’s ultraviolet rays. This is the most efficient and safe method of obtaining vitamin D on a day-by-day basis. Several researchers considered possible risk to children whose mothers were given administered more or less 25(OH)D . Their aim was to discover whether organisms are harmed from the time of impregnation onwards., Gale, et al. (2008)considered at length the problem of the child outcomes as a result of less or more dosage of vitamin D for pregnant women. They concluded:- Children whose mothers had a 25(OH)-vitamin D concentration in pregnancy 475 nmol/l had an increased risk of eczema on examination at 9 months (OR 3.26, 95% CI 1.15– 9.29, Pј0.025) and asthma at age 9 years (OR 5.40, 95% CI, 1.09–26.65, Pј0.038) compared to children whose mothers had a concentration of o30 nmol/l (p. 68). It seems then that Vitamin D deficiency affects much more than bone density levels. Because of such findings, and other related research, it is important that nurses and other medical staff are knowledgeable about the relationship needed between Vitamin D and antenatal care. Sharma, et al. (2009) outline the increase in vitamin D deficiency due to inefficient instructions and care on the part of the medical units in both the UK and Australia. According to these researchers in June 2008 no =. London National Health Service antenatal units had departmental guidelines on vitamin D, and therefore presumably no best practice protocols. .They go on to describe findings which it is claimed are directly due to low maternal vitamin D levels in late pregnancy. These were associated with:- higher incidence of hypocalcaemia in the neonate, a decreased knee– heel length at birth and reduced whole body and lumbar spine bone mineral content in the child/offspring at age of 9 years. ( Sharma et al 2009) As well as having staff who are knowledgeable on the subject, it will take careful questioning to discover a pregnant woman’s diet and other life style choices, but, as described above, these will have an effect upon her need for Vitamin D supplementation. Contact between a doctor or a midwife and a pregnant woman should include some focus on the dietary and leisure (sun exposure) factors, and be aiming at fetal well-being throughout pregnancy and beyond. (Three Center Consensus 2001). Adequate antenatal care must therefore include : The development of a method of assessing pregnant women to identify those for whom additional care is necessary (the ‘Antenatal assessment tool’) Giving information to pregnant women. Lifestyle considerations: a) Vitamin D supplementation b) Alcohol consumption Screening for the baby: Screening for the pregnant woman (NICE Clinical Guidelines, 2008). These are all necessary steps which are widely accepted as general practice needed in order to keep pregnant women safe and to preventing them from the loss of their infant or bad health effects later. As regards Vitamin D supplementation modern research questions revolve round two points - Firstly defining “normal” vitamin D status and secondly the potential physiological impact of vitamin D-insufficiency (Grayson & Hewison, 2011). On the other hand, Specker (2004) outlines the fact that fetal growth, as well as bone development, are not dependent upon the amount of vitamin D deficiency. In this regard it is potential hypocalcemia is what makes nurses get anxious about women getting through ante- and neonatal care safely. Barrett & McElduff (2010) considered a number of arguments as to what is makes the best practice when comes to Vitamin D supplementary treatment in clinical conditions. The researchers touch upon the idea of historical obstetric practice, treating women with a deformed pelvis and rickets caused by vitamin D deficiency as compared to those treated correctly with vitamin D. They argue that “the “normal” range of vitamin D is difficult to define, but suggest as a minimum level it should probably be >50 nmol/L” Barrett & McElduff (2010, p. 536). This assumption all but coincides with the frames which Gale, et al. (2008) set to identify the extreme measures of vitamin D in a pregnant woman. Stevenson , ( 2006 )considers seasonal factors and their influence on more or less vitamin D in pregnant wome. There is usually less sunlight available in colder weather, and also peoeple wear more clothes, so that only tiny areas of their bodies are exposed to ultraviolent rays.In a longitudinal study over a ten year period it became clear that children born in summer months, when their mothers had more exposure to UV-B radiation favors higher bone mineral content (Stevenson, 2006). Lewis, Lucas, Halliday, & Ponsonby (2010) recommend maintaining vitamin D and calcium levels as a prerequisite for the decrease of pre-eclampsia and gestational diabetes mellitus, so yet more conditions associated with low levels of Vitamin D. Given that the practical emphasis on additional supplements of vitamin D in winter, and exposure to the sun in summer, help women have high bone mineral content, Balasubramanian (2011) speculates as to the appropriate amount of UV-B light required for synthesizing enough vitamin D in the organism during the antenatal period. It depends on many factors, such as: the amount of hours spent outdoors in summertime, the amount of skin exposed, the darknes or otherwise of that skin and the level of air pollution present. .He also points out however that, exposure to the sun is inappropriate for infants younger than 6 months of age. (Balasubramanian, 2011). Dror & Allen (2010) consider the practical evidence as to why vitamin D is important. They deal with its metabolism, beginning with 25(OH)D converted by the mitochondrial enzyme through 1,25(OH)2D and the important organs, the liver and the kidneys, which are involved in the metabolism and catalysis of the vitamin. A nurse who take into consideration the findings of these researchers will be able to make recommendations to her patients as to whether they should use supplements or UV-B light. It seems , according to researchers such as Hollis, ( 2007, ) that with modernization and the growth of city populations , pregnant women are becoming more likely to stay indoors, which means that will be a resultant dietary requirement for vitamin D intake during both the ante- and neonatal periods . Another factor is the effect on neonatal calcium homeostasis, which is directly dependent upon the adequate maternal vitamin D stores in order to allow perinatal intake of calcium, and so prevent childhood rickets (Delvin, Salle, Glorieux, Adeleine, & David, 1986). Historically, especially in the northern regions where it is cold and sun light levels may be low , people were likely to use cod-liver oil from the neonatal period onwards and up to adolescence, thus maintaining such necessary stores. . However, according to Ansary, Palacios, De-Regil, & Pena-Rosas (2010), there is a need for not just vitamin D alone, but in combination with calcium as a precursor of better metabolism in the organism of a pregnant woman. Also as shown by studies carried out by Taylor, Wagner, & Hollis (2008) the intake of vitamin D should go on in the neonatal period due to the fact that if a mother has a low store of vitamin D then a child will have it in the same amount. They claim that ‘the majority of humans, including lactating mothers, subsist in a vitamin D insufficient state.’ Best Practice On looking closely at the literature review and picking out the pivotal facts and findings produced by the researchers, it is obvious that pregnant women should be advised of the following based on the best possible nursing practice according to current knowledge:- Making healthy lifestyle choices; Spending an appropriate amount of time outdoors; Taking additional vitamin D supplements according to the months (seasons) when the pregnancy takes place; Ensure they attend clinics when requested to do so, in order that current levels of Vitamin D at any one time can be accurately assessed. Conclusion The information taken from the above review can be used as the basis for further research on the need for vitamin D intake in pregnancy in order to protect children from rickets, asthma, eczema and similar conditions. There is also sufficient evidence within the paper to serve as a detailed justification as to why vitamin D intake is needed throughout pregnancy, thus answering the research question in a positive way. The research has also revealed a widespread interest among contemporary experts in pediatrics, midwifery, and nutrition in the adequate supervision of current and potential vitamin D-deficient women in pregnancy. The positive results of such supplementation will far outweigh any costs in time and money involved. The articles reviewed also considered the possible consequences of Vitamin D overdose and toxicity . It is therefore important that staff receive proper instruction on this topic and that a best practice protocol be decided upon and followed, allowing for individual differences in such things as life styles, skin tones etc. The result will be healthier infants and mothers. 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