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What is the most beneficial diet for patients with diverticulosis?
A diet high in fiber (particularly fruit and vegetable fiber) and low in fat and red meat may help to decrease the risk of symptomatic diverticular disease (strength of recommendation [SOR]: C, case-control studies and a large prospective cohort study). For people with diverticular disease, a diet high in fiber might decrease the risk of complications (SOR: C, case series). No studies have evaluated the effect of nut and seed avoidance.
Recommend natural sources of fiber for diverticulosis
David M. Schneider, MD
Sutter Santa Rosa Family Medicine Residency Program
“Conventional wisdom” dictates that physicians recommend a high-fiber diet to prevent symptoms in patients who are found to have diverticuli on endoscopic or radiographic studies, or who are diagnosed clinically with diverticulitis. Although there is a relative paucity of data, the clinical evidence, as set forth in this review, supports this practice. Insoluble fiber, and cellulose in particular, appears to be especially helpful.1
I tend to recommend natural dietary fiber in the form of vegetables and whole grains (primarily insoluble fiber), as well as legumes (soluble fiber to help reduce cholesterol and blunt glucose absorption). No studies are available to endorse the advice to avoid seeds and nuts; a survey of colorectal surgeons showed that half believed eating these foods made no difference in the disease course.2
It is noteworthy that acute diverticulitis is treated with clear liquids and a low-fiber diet during the exacerbation. This therapy is based on experience and conventional wisdom, and while there is no convincing evidence to support it, I still adhere to this recommendation.
Evidence summary
Approximately 60% of people living in Westernized countries who are older than 60 years will develop diverticulosis of the colon. Colonic diverticuli are thought to develop from an increase in intraluminal pressure. This pressure can be caused by colonic motility abnormalities, but a low-fiber diet can also result in a smaller stool mass and a less distended colon, thereby increasing intraluminal pressure.3
Because of strong epidemiological evidence that people from cultures with high-fiber diets are far less likely to develop diverticulosis than are people who live in cultures of low-fiber diets, it has been assumed that a diet high in fiber can prevent diverticulosis.4 Many small, uncontrolled studies have also investigated the effect of high-fiber diets and supplements on symptoms of diverticulosis and prevention of diverticulitis episodes.
One large, prospective study of 47,888 male health professionals gathered baseline dietary information in 1986. In 1990 and 1992, follow-up questionnaires asked the subjects if they had been diagnosed with diverticular disease in the interim, and whether they had symptoms of diverticulitis. The study showed a strong inverse relationship between fruit and vegetable fiber intake and risk of symptomatic diverticular disease. It also demonstrated a direct relationship between fat intake, particularly red meat, and symptomatic diverticular disease. For men in the highest quintile of total fat intake and lowest quintile of total fiber intake, the relative risk (RR) of diverticular disease was 2.35 (95% confidence interval [CI], 1.38–3.98) compared with men in the highest quintile of total fiber intake and lowest quintile of total fat intake. Men in the highest group of red meat intake and lowest quintile of fiber intake had a RR of 3.22 (95% CI, 1.46–7.54) compared with men with the lowest red meat intake and highest dietary fiber intake. In this study, cereal fiber did not reduce the risk of symptomatic diverticular disease.1
Two small randomized crossover studies evaluated the benefit of dietary fiber supplementation on symptomatic diverticular disease, with conflicting results (TABLE).5,6 One study found that sterculia gum with an antispasmodic, a high roughage diet, and bran tablets all improved symptomatic diverticular disease, with bran tablets associated with the greatest improvement.5 Another study found no significant differences between psyllium, bran, and placebo in reducing symptomatic diverticular disease.6 However, the amount of total fiber supplementation for each treatment regimen was less than in other studies.
A small randomized trial of lactulose vs dietary fiber showed both treatments to be effective in alleviating symptoms of diverticular disease.7 Two small case series of adults treated with dietary fiber found that fiber alleviated symptoms of diverticular disease,8,9 and possibly reduced complications of diverticulosis.9
We found no studies that investigated the common medical advice to avoid small nuts and seeds, which are thought to cause obstruction of the diverticuli and lead to diverticulitis.
TABLE
Studies on dietary fiber for diverticulosis
| TRIAL DESCRIPTION | INTERVENTION/COMPARISON | RESULTS |
|---|---|---|
| 20 adults with symptomatic diverticular disease diagnosed by barium enema. Randomized crossover trial5 | Bran tablets (18 g of fiber total) vs high roughage diet (HRD, amount of fiber unspecified) vs sterculia gum and antispasmodic | 20% were symptom free with a HRD, 40% with sterculia gum and antispasmodic, and 60% with bran tablets |
| 58 adults with uncomplicated symptomatic diverticular disease double-blind, crossover RCT, treated for 16 weeks with each intervention6 | Bran crispbread (6.99 g/d fiber), ispaghula (psyllium) husk drink (9.04 g/d fiber), and placebo (2.34 g/d fiber) | No significant difference among treatments for composite symptom scores. Stools were softer, more frequent, and straining with bowel movements was less with fiber supplements (P<.001) |
| 43 adults with symptomatic diverticular disease. Randomized trial7 | Lactulose 15 mL bid vs high-fiber diet (30–40 g/d) for 12 weeks | Pain frequency with a bowel movement was reduced with lactulose (P=.017). Pain severity was reduced with lactulose (P=.028) and high fiber diet (P=.043). Abdominal pain frequency was decreased with lactulose (P=.0015) and with a high fiber diet (P=.022). Abdominal pain severity was decreased with lactulose (P=.009) and with a high fiber diet (P=.028) |
| 40 adults with symptomatic diverticular disease diagnosed by barium enema. Case series8 | Wheat bran 24 g/d for at least 6 months | The 40 patients had 391 total symptoms, and 60% were abolished, 28% relieved |
| 100 adults with a history of symptomatic diverticular disease. Case series9 | High-fiber diet (40 g/d) | 91% of patients remained asymptomatic over 5 to 7 years, although only 75% adhered to their high-fiber diet |
Recommendations by others
The American College of Gastroenterology states that it is reasonable to recommend a diet high in fruit and vegetable fiber to patients with uncomplicated diverticulosis.10
1. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC, Willett WC. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr 1994;60:757-764.
2. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42:470-475.
3. Floch M, Bina I. The natural history of diverticulitis: fact and theory. J Clin Gastroenterol 2004;38(Suppl 1):S2-S7.
4. Aldoori W, Ryan-Harshman M. Preventing diverticular disease: review of recent evidence on high-fibre diets. Can Fam Physician 2002;48:1632-1637.
5. Taylor I, Duthie HL. Bran tablets and diverticular disease. Br Med J 1976;1(6016):988-990.
6. Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox AG. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981;282:1353-1356.
7. Smits BJ, Whitehead AM, Prescott P. Lactulose in the treatment of symptomatic diverticular disease: A comparative study with high-fibre diet. Br J Clin Pract 1990;4:314-318.
8. Brodribb AJ, Humphreys DM. Diverticular disease: Three studies. part II—treatment with bran. Br Med J 1976;1(6007):425-428.
9. Hyland JM, Taylor I. Does a high fibre diet prevent the complications of diverticular disease? Br J Surg 1980;67:77-79.
10. Stollman N, Raskin J. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:3111-3112.
A diet high in fiber (particularly fruit and vegetable fiber) and low in fat and red meat may help to decrease the risk of symptomatic diverticular disease (strength of recommendation [SOR]: C, case-control studies and a large prospective cohort study). For people with diverticular disease, a diet high in fiber might decrease the risk of complications (SOR: C, case series). No studies have evaluated the effect of nut and seed avoidance.
Recommend natural sources of fiber for diverticulosis
David M. Schneider, MD
Sutter Santa Rosa Family Medicine Residency Program
“Conventional wisdom” dictates that physicians recommend a high-fiber diet to prevent symptoms in patients who are found to have diverticuli on endoscopic or radiographic studies, or who are diagnosed clinically with diverticulitis. Although there is a relative paucity of data, the clinical evidence, as set forth in this review, supports this practice. Insoluble fiber, and cellulose in particular, appears to be especially helpful.1
I tend to recommend natural dietary fiber in the form of vegetables and whole grains (primarily insoluble fiber), as well as legumes (soluble fiber to help reduce cholesterol and blunt glucose absorption). No studies are available to endorse the advice to avoid seeds and nuts; a survey of colorectal surgeons showed that half believed eating these foods made no difference in the disease course.2
It is noteworthy that acute diverticulitis is treated with clear liquids and a low-fiber diet during the exacerbation. This therapy is based on experience and conventional wisdom, and while there is no convincing evidence to support it, I still adhere to this recommendation.
Evidence summary
Approximately 60% of people living in Westernized countries who are older than 60 years will develop diverticulosis of the colon. Colonic diverticuli are thought to develop from an increase in intraluminal pressure. This pressure can be caused by colonic motility abnormalities, but a low-fiber diet can also result in a smaller stool mass and a less distended colon, thereby increasing intraluminal pressure.3
Because of strong epidemiological evidence that people from cultures with high-fiber diets are far less likely to develop diverticulosis than are people who live in cultures of low-fiber diets, it has been assumed that a diet high in fiber can prevent diverticulosis.4 Many small, uncontrolled studies have also investigated the effect of high-fiber diets and supplements on symptoms of diverticulosis and prevention of diverticulitis episodes.
One large, prospective study of 47,888 male health professionals gathered baseline dietary information in 1986. In 1990 and 1992, follow-up questionnaires asked the subjects if they had been diagnosed with diverticular disease in the interim, and whether they had symptoms of diverticulitis. The study showed a strong inverse relationship between fruit and vegetable fiber intake and risk of symptomatic diverticular disease. It also demonstrated a direct relationship between fat intake, particularly red meat, and symptomatic diverticular disease. For men in the highest quintile of total fat intake and lowest quintile of total fiber intake, the relative risk (RR) of diverticular disease was 2.35 (95% confidence interval [CI], 1.38–3.98) compared with men in the highest quintile of total fiber intake and lowest quintile of total fat intake. Men in the highest group of red meat intake and lowest quintile of fiber intake had a RR of 3.22 (95% CI, 1.46–7.54) compared with men with the lowest red meat intake and highest dietary fiber intake. In this study, cereal fiber did not reduce the risk of symptomatic diverticular disease.1
Two small randomized crossover studies evaluated the benefit of dietary fiber supplementation on symptomatic diverticular disease, with conflicting results (TABLE).5,6 One study found that sterculia gum with an antispasmodic, a high roughage diet, and bran tablets all improved symptomatic diverticular disease, with bran tablets associated with the greatest improvement.5 Another study found no significant differences between psyllium, bran, and placebo in reducing symptomatic diverticular disease.6 However, the amount of total fiber supplementation for each treatment regimen was less than in other studies.
A small randomized trial of lactulose vs dietary fiber showed both treatments to be effective in alleviating symptoms of diverticular disease.7 Two small case series of adults treated with dietary fiber found that fiber alleviated symptoms of diverticular disease,8,9 and possibly reduced complications of diverticulosis.9
We found no studies that investigated the common medical advice to avoid small nuts and seeds, which are thought to cause obstruction of the diverticuli and lead to diverticulitis.
TABLE
Studies on dietary fiber for diverticulosis
| TRIAL DESCRIPTION | INTERVENTION/COMPARISON | RESULTS |
|---|---|---|
| 20 adults with symptomatic diverticular disease diagnosed by barium enema. Randomized crossover trial5 | Bran tablets (18 g of fiber total) vs high roughage diet (HRD, amount of fiber unspecified) vs sterculia gum and antispasmodic | 20% were symptom free with a HRD, 40% with sterculia gum and antispasmodic, and 60% with bran tablets |
| 58 adults with uncomplicated symptomatic diverticular disease double-blind, crossover RCT, treated for 16 weeks with each intervention6 | Bran crispbread (6.99 g/d fiber), ispaghula (psyllium) husk drink (9.04 g/d fiber), and placebo (2.34 g/d fiber) | No significant difference among treatments for composite symptom scores. Stools were softer, more frequent, and straining with bowel movements was less with fiber supplements (P<.001) |
| 43 adults with symptomatic diverticular disease. Randomized trial7 | Lactulose 15 mL bid vs high-fiber diet (30–40 g/d) for 12 weeks | Pain frequency with a bowel movement was reduced with lactulose (P=.017). Pain severity was reduced with lactulose (P=.028) and high fiber diet (P=.043). Abdominal pain frequency was decreased with lactulose (P=.0015) and with a high fiber diet (P=.022). Abdominal pain severity was decreased with lactulose (P=.009) and with a high fiber diet (P=.028) |
| 40 adults with symptomatic diverticular disease diagnosed by barium enema. Case series8 | Wheat bran 24 g/d for at least 6 months | The 40 patients had 391 total symptoms, and 60% were abolished, 28% relieved |
| 100 adults with a history of symptomatic diverticular disease. Case series9 | High-fiber diet (40 g/d) | 91% of patients remained asymptomatic over 5 to 7 years, although only 75% adhered to their high-fiber diet |
Recommendations by others
The American College of Gastroenterology states that it is reasonable to recommend a diet high in fruit and vegetable fiber to patients with uncomplicated diverticulosis.10
A diet high in fiber (particularly fruit and vegetable fiber) and low in fat and red meat may help to decrease the risk of symptomatic diverticular disease (strength of recommendation [SOR]: C, case-control studies and a large prospective cohort study). For people with diverticular disease, a diet high in fiber might decrease the risk of complications (SOR: C, case series). No studies have evaluated the effect of nut and seed avoidance.
Recommend natural sources of fiber for diverticulosis
David M. Schneider, MD
Sutter Santa Rosa Family Medicine Residency Program
“Conventional wisdom” dictates that physicians recommend a high-fiber diet to prevent symptoms in patients who are found to have diverticuli on endoscopic or radiographic studies, or who are diagnosed clinically with diverticulitis. Although there is a relative paucity of data, the clinical evidence, as set forth in this review, supports this practice. Insoluble fiber, and cellulose in particular, appears to be especially helpful.1
I tend to recommend natural dietary fiber in the form of vegetables and whole grains (primarily insoluble fiber), as well as legumes (soluble fiber to help reduce cholesterol and blunt glucose absorption). No studies are available to endorse the advice to avoid seeds and nuts; a survey of colorectal surgeons showed that half believed eating these foods made no difference in the disease course.2
It is noteworthy that acute diverticulitis is treated with clear liquids and a low-fiber diet during the exacerbation. This therapy is based on experience and conventional wisdom, and while there is no convincing evidence to support it, I still adhere to this recommendation.
Evidence summary
Approximately 60% of people living in Westernized countries who are older than 60 years will develop diverticulosis of the colon. Colonic diverticuli are thought to develop from an increase in intraluminal pressure. This pressure can be caused by colonic motility abnormalities, but a low-fiber diet can also result in a smaller stool mass and a less distended colon, thereby increasing intraluminal pressure.3
Because of strong epidemiological evidence that people from cultures with high-fiber diets are far less likely to develop diverticulosis than are people who live in cultures of low-fiber diets, it has been assumed that a diet high in fiber can prevent diverticulosis.4 Many small, uncontrolled studies have also investigated the effect of high-fiber diets and supplements on symptoms of diverticulosis and prevention of diverticulitis episodes.
One large, prospective study of 47,888 male health professionals gathered baseline dietary information in 1986. In 1990 and 1992, follow-up questionnaires asked the subjects if they had been diagnosed with diverticular disease in the interim, and whether they had symptoms of diverticulitis. The study showed a strong inverse relationship between fruit and vegetable fiber intake and risk of symptomatic diverticular disease. It also demonstrated a direct relationship between fat intake, particularly red meat, and symptomatic diverticular disease. For men in the highest quintile of total fat intake and lowest quintile of total fiber intake, the relative risk (RR) of diverticular disease was 2.35 (95% confidence interval [CI], 1.38–3.98) compared with men in the highest quintile of total fiber intake and lowest quintile of total fat intake. Men in the highest group of red meat intake and lowest quintile of fiber intake had a RR of 3.22 (95% CI, 1.46–7.54) compared with men with the lowest red meat intake and highest dietary fiber intake. In this study, cereal fiber did not reduce the risk of symptomatic diverticular disease.1
Two small randomized crossover studies evaluated the benefit of dietary fiber supplementation on symptomatic diverticular disease, with conflicting results (TABLE).5,6 One study found that sterculia gum with an antispasmodic, a high roughage diet, and bran tablets all improved symptomatic diverticular disease, with bran tablets associated with the greatest improvement.5 Another study found no significant differences between psyllium, bran, and placebo in reducing symptomatic diverticular disease.6 However, the amount of total fiber supplementation for each treatment regimen was less than in other studies.
A small randomized trial of lactulose vs dietary fiber showed both treatments to be effective in alleviating symptoms of diverticular disease.7 Two small case series of adults treated with dietary fiber found that fiber alleviated symptoms of diverticular disease,8,9 and possibly reduced complications of diverticulosis.9
We found no studies that investigated the common medical advice to avoid small nuts and seeds, which are thought to cause obstruction of the diverticuli and lead to diverticulitis.
TABLE
Studies on dietary fiber for diverticulosis
| TRIAL DESCRIPTION | INTERVENTION/COMPARISON | RESULTS |
|---|---|---|
| 20 adults with symptomatic diverticular disease diagnosed by barium enema. Randomized crossover trial5 | Bran tablets (18 g of fiber total) vs high roughage diet (HRD, amount of fiber unspecified) vs sterculia gum and antispasmodic | 20% were symptom free with a HRD, 40% with sterculia gum and antispasmodic, and 60% with bran tablets |
| 58 adults with uncomplicated symptomatic diverticular disease double-blind, crossover RCT, treated for 16 weeks with each intervention6 | Bran crispbread (6.99 g/d fiber), ispaghula (psyllium) husk drink (9.04 g/d fiber), and placebo (2.34 g/d fiber) | No significant difference among treatments for composite symptom scores. Stools were softer, more frequent, and straining with bowel movements was less with fiber supplements (P<.001) |
| 43 adults with symptomatic diverticular disease. Randomized trial7 | Lactulose 15 mL bid vs high-fiber diet (30–40 g/d) for 12 weeks | Pain frequency with a bowel movement was reduced with lactulose (P=.017). Pain severity was reduced with lactulose (P=.028) and high fiber diet (P=.043). Abdominal pain frequency was decreased with lactulose (P=.0015) and with a high fiber diet (P=.022). Abdominal pain severity was decreased with lactulose (P=.009) and with a high fiber diet (P=.028) |
| 40 adults with symptomatic diverticular disease diagnosed by barium enema. Case series8 | Wheat bran 24 g/d for at least 6 months | The 40 patients had 391 total symptoms, and 60% were abolished, 28% relieved |
| 100 adults with a history of symptomatic diverticular disease. Case series9 | High-fiber diet (40 g/d) | 91% of patients remained asymptomatic over 5 to 7 years, although only 75% adhered to their high-fiber diet |
Recommendations by others
The American College of Gastroenterology states that it is reasonable to recommend a diet high in fruit and vegetable fiber to patients with uncomplicated diverticulosis.10
1. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC, Willett WC. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr 1994;60:757-764.
2. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42:470-475.
3. Floch M, Bina I. The natural history of diverticulitis: fact and theory. J Clin Gastroenterol 2004;38(Suppl 1):S2-S7.
4. Aldoori W, Ryan-Harshman M. Preventing diverticular disease: review of recent evidence on high-fibre diets. Can Fam Physician 2002;48:1632-1637.
5. Taylor I, Duthie HL. Bran tablets and diverticular disease. Br Med J 1976;1(6016):988-990.
6. Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox AG. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981;282:1353-1356.
7. Smits BJ, Whitehead AM, Prescott P. Lactulose in the treatment of symptomatic diverticular disease: A comparative study with high-fibre diet. Br J Clin Pract 1990;4:314-318.
8. Brodribb AJ, Humphreys DM. Diverticular disease: Three studies. part II—treatment with bran. Br Med J 1976;1(6007):425-428.
9. Hyland JM, Taylor I. Does a high fibre diet prevent the complications of diverticular disease? Br J Surg 1980;67:77-79.
10. Stollman N, Raskin J. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:3111-3112.
1. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC, Willett WC. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr 1994;60:757-764.
2. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42:470-475.
3. Floch M, Bina I. The natural history of diverticulitis: fact and theory. J Clin Gastroenterol 2004;38(Suppl 1):S2-S7.
4. Aldoori W, Ryan-Harshman M. Preventing diverticular disease: review of recent evidence on high-fibre diets. Can Fam Physician 2002;48:1632-1637.
5. Taylor I, Duthie HL. Bran tablets and diverticular disease. Br Med J 1976;1(6016):988-990.
6. Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox AG. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981;282:1353-1356.
7. Smits BJ, Whitehead AM, Prescott P. Lactulose in the treatment of symptomatic diverticular disease: A comparative study with high-fibre diet. Br J Clin Pract 1990;4:314-318.
8. Brodribb AJ, Humphreys DM. Diverticular disease: Three studies. part II—treatment with bran. Br Med J 1976;1(6007):425-428.
9. Hyland JM, Taylor I. Does a high fibre diet prevent the complications of diverticular disease? Br J Surg 1980;67:77-79.
10. Stollman N, Raskin J. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:3111-3112.
Evidence-based answers from the Family Physicians Inquiries Network
What vitamins and minerals should be given to breastfed and bottle-fed infants?
Breastfed and formula-fed infants should receive intramuscular vitamin K soon after birth to prevent classic hemorrhagic disease of the newborn (strength of recommendation [SOR]: A, systematic review of controlled trials).
Routine iron supplementation for all term, healthy, breastfed infants is not proven to be safe or necessary. Formula-fed infants should be consuming formula that contains 10 to 12 mg/L of iron (SOR: A, 2 small randomized controlled trials).
Healthy, term infants at the highest risk for vitamin D deficiency are those who are breastfeeding and have dark skin or little sun exposure (SOR: B, 2 case series). Infants consuming at least 500 mL of fortified formula each day do not need additional supplementation. A recommendation of vitamin D supplementation of 200 IU/day should be explained to all families, particularly those at highest risk for nutritional rickets (SOR: C, expert opinion). Infants older than 6 months should receive an oral fluoride supplement of 0.25 mg if they consume fluids with a water fluoride level less than 0.3 ppm (SOR: B, poor-quality randomized controlled trials).
Encourage breastfeeding; keep vitamin D and iron needs in mind
Julia Fashner, MD
Piqua, Ohio
Physicians can help mothers give the best nutrition to their children by encouraging breastfeeding. In most cases, no supplements are required. From this information, I will keep in mind the shorter hours of daylight in the winter and the skin tone of the child, as this may warrant discussion of vitamin D supplementation in infants who are exclusively breastfed. Knowing the recommendations for iron supplementation will help physicians when counseling parents regarding formula choices. Lastly, vitamin K has become part of the routine protocol at delivery and should not be a factor for any child.
Evidence summary
Vitamin K. The Cochrane Database of Systematic Reviews looked at randomized trials to determine the effectiveness of vitamin K prophylaxis in preventing classic hemorrhagic disease of the newborn.1 Two trials demonstrated that a single dose of intramuscular vitamin K reduced clinical bleeding at 1 to 7 days. Oral vitamin K has been studied for its effects on biochemical indices of coagulation status, but not for its clinical effects on bleeding. A single oral vitamin K dose at birth resulted in lower vitamin K levels at 2 weeks and 1 month, compared with a single dose of intramuscular vitamin K at birth.
Iron. The iron status of exclusively breastfed infants vs formula-fed infants was evaluated in a nonrandomized cohort study.2 Twenty-five healthy, breastfed infants and 15 healthy infants fed high-iron formula were followed for 9 months. No differences in mean hemoglobin values were seen at any age between the 2 groups.
A randomized controlled trial investigated the efficacy of daily and weekly iron supplementation on iron status in 67 exclusively breastfed infants.3 At age 4 months the infants were randomized into 3 groups: daily iron, weekly iron, and no iron. No significant differences were detected in the mean weight, height, and head circumference among the groups. The mean values of hemoglobin, mean corpuscular volume, serum iron, and transferrin saturation were similar among all the groups at ages 5, 6, and 7 months.
A randomized, double-blind, placebo-controlled iron supplementation trial involved 214 exclusively breastfed infants from 4 to 9 months of age in Sweden and Honduras.4 Iron supplementation did not affect weight gain in the groups, but length gain from ages 4 to 9 months was less in the iron-supplemented groups than in the placebo group (P<.05 for placebo vs Fe). This effect was greater in Sweden, and only existed in Honduras for infants aged 4 to 6 months with initial mean Hgb of at least 11 mg/dL. The researchers conclude that iron supplementation may pose risks in iron-replete infants.
Vitamin D. A case review of nutritional rickets in North Carolina between 1990 and 1999 found that all 30 patients identified were breastfed African American infants.5 Among the 166 published cases of rickets in the US from 1986 to 2003, 83% were categorized as African American or black. Ninety-six percent of cases were breastfed.6
Fluoride. No infant under 6 months of age should receive fluoride supplementation to prevent dental caries because of the risk of enamel fluorosis.7 A systematic review that evaluated fluoride for preventing dental caries in primary teeth in children aged <5 years found 6 small clinical trials. Although the studies were not of high quality, they consistently showed that the incidence of caries was reduced by 32% to 72%.8
Recommendations from others
The American Academy of Pediatrics (AAP) recommends that:
- All newborns receive vitamin K as an intramuscular dose of 0.5 to 1 mg9
- All full-term appropriate-for-gestational-age breastfed infants receive a supplemental source of iron starting at 4 to 6 months of age, preferably from iron-enriched complementary foods. Infants should only receive formula fortified with 10 to 12 mg/L for weaning or supplementing breastmilk10
- All infants, including those exclusively breastfed, should have a minimum intake of 200 IU of vitamin D per day starting in the first 2 months of life.
The National Academy of Sciences recommends 200 IU of vitamin D daily for all normal infants, children, and adolescents.11
The US Preventative Services Task Force (USPSTF) states evidence is insufficient to recommend for or against the routine use of iron supplements for healthy infants.12
The USPSTF, AAP, and the American Academy of Pediatric Dentistry recommends 0.25 mg/d of fluoride supplement for children ages 6 months to 3 years if the fluoride concentration in the community drinking water is less than 0.3 ppm. Older children may benefit from supplements if the fluoride concentration is between 0.3 and 0.6 ppm.13
1. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database Syst Rev 2000;(4):CD002776.-
2. Calvo EB, Galindo AC, Aspres NB. Iron status in exclusively breastfed infants. Pediatrics 1992;90:375-379.
3. Yurdakok K, Temiz F, Yalcin SS, Gumruk F. Efficacy of daily and weekly iron supplementation on iron status in exclusively breastfed infants. J Pediatr Hematol Oncol 2004;26:284-288.
4. Dewey KG, Domellof M, Cohen RJ, Landa Rivera L, Hernell O, Lonnerdal B. Iron supplementation affects growth and morbidity of breastfed infants: results of a randomized trial in Sweden and Honduras. J Nutr 2002;132:3249-3255.
5. Kreiter SR, Schwartz RP, Kirkman HN, Jr, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breastfed infants. J Pediatr 2000;137:153-157.
6. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. J Clin Nutr 2004;80:1697S-1705S.
7. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50:1-59.
8. Bader JD, Rozier G, Harris R, Lohr KN. Dental Caries Prevention: The Physician’s Role in Child Oral Health. Systematic Evidence Review no. 29. Rockville, Md: Agency for Healthcare Research and Quality, 2004. Available at: www.ahrq.gov/downloads/pub/prevent/pdfser/dentser.pdf. Accessed on November 15, 2005.
9. American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics 2003;112:191-192.
10. Gartner LM, Greer FR. Section on Breastfeeding and Committee on Nutrition, American Academy of Pediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003;111:908-910.
11. Institute of Medicine, Food and Nutrition Board, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Vitamin D. In: Dietary Reference Intakes: For Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997;250-287.
12. DiGuiseppi C. Screening for iron deficiency anemia-including iron prophylaxis. In: US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 1996:231–246. Available at: www.ahrq.gov/clinic/2ndcps/anemia.pdf. Accessed on November 15, 2005.
13. American Academy of Pediatric Dentistry. Special issue: reference manual 1994-95. Pediatric Dent 1995;16:1-96.
Breastfed and formula-fed infants should receive intramuscular vitamin K soon after birth to prevent classic hemorrhagic disease of the newborn (strength of recommendation [SOR]: A, systematic review of controlled trials).
Routine iron supplementation for all term, healthy, breastfed infants is not proven to be safe or necessary. Formula-fed infants should be consuming formula that contains 10 to 12 mg/L of iron (SOR: A, 2 small randomized controlled trials).
Healthy, term infants at the highest risk for vitamin D deficiency are those who are breastfeeding and have dark skin or little sun exposure (SOR: B, 2 case series). Infants consuming at least 500 mL of fortified formula each day do not need additional supplementation. A recommendation of vitamin D supplementation of 200 IU/day should be explained to all families, particularly those at highest risk for nutritional rickets (SOR: C, expert opinion). Infants older than 6 months should receive an oral fluoride supplement of 0.25 mg if they consume fluids with a water fluoride level less than 0.3 ppm (SOR: B, poor-quality randomized controlled trials).
Encourage breastfeeding; keep vitamin D and iron needs in mind
Julia Fashner, MD
Piqua, Ohio
Physicians can help mothers give the best nutrition to their children by encouraging breastfeeding. In most cases, no supplements are required. From this information, I will keep in mind the shorter hours of daylight in the winter and the skin tone of the child, as this may warrant discussion of vitamin D supplementation in infants who are exclusively breastfed. Knowing the recommendations for iron supplementation will help physicians when counseling parents regarding formula choices. Lastly, vitamin K has become part of the routine protocol at delivery and should not be a factor for any child.
Evidence summary
Vitamin K. The Cochrane Database of Systematic Reviews looked at randomized trials to determine the effectiveness of vitamin K prophylaxis in preventing classic hemorrhagic disease of the newborn.1 Two trials demonstrated that a single dose of intramuscular vitamin K reduced clinical bleeding at 1 to 7 days. Oral vitamin K has been studied for its effects on biochemical indices of coagulation status, but not for its clinical effects on bleeding. A single oral vitamin K dose at birth resulted in lower vitamin K levels at 2 weeks and 1 month, compared with a single dose of intramuscular vitamin K at birth.
Iron. The iron status of exclusively breastfed infants vs formula-fed infants was evaluated in a nonrandomized cohort study.2 Twenty-five healthy, breastfed infants and 15 healthy infants fed high-iron formula were followed for 9 months. No differences in mean hemoglobin values were seen at any age between the 2 groups.
A randomized controlled trial investigated the efficacy of daily and weekly iron supplementation on iron status in 67 exclusively breastfed infants.3 At age 4 months the infants were randomized into 3 groups: daily iron, weekly iron, and no iron. No significant differences were detected in the mean weight, height, and head circumference among the groups. The mean values of hemoglobin, mean corpuscular volume, serum iron, and transferrin saturation were similar among all the groups at ages 5, 6, and 7 months.
A randomized, double-blind, placebo-controlled iron supplementation trial involved 214 exclusively breastfed infants from 4 to 9 months of age in Sweden and Honduras.4 Iron supplementation did not affect weight gain in the groups, but length gain from ages 4 to 9 months was less in the iron-supplemented groups than in the placebo group (P<.05 for placebo vs Fe). This effect was greater in Sweden, and only existed in Honduras for infants aged 4 to 6 months with initial mean Hgb of at least 11 mg/dL. The researchers conclude that iron supplementation may pose risks in iron-replete infants.
Vitamin D. A case review of nutritional rickets in North Carolina between 1990 and 1999 found that all 30 patients identified were breastfed African American infants.5 Among the 166 published cases of rickets in the US from 1986 to 2003, 83% were categorized as African American or black. Ninety-six percent of cases were breastfed.6
Fluoride. No infant under 6 months of age should receive fluoride supplementation to prevent dental caries because of the risk of enamel fluorosis.7 A systematic review that evaluated fluoride for preventing dental caries in primary teeth in children aged <5 years found 6 small clinical trials. Although the studies were not of high quality, they consistently showed that the incidence of caries was reduced by 32% to 72%.8
Recommendations from others
The American Academy of Pediatrics (AAP) recommends that:
- All newborns receive vitamin K as an intramuscular dose of 0.5 to 1 mg9
- All full-term appropriate-for-gestational-age breastfed infants receive a supplemental source of iron starting at 4 to 6 months of age, preferably from iron-enriched complementary foods. Infants should only receive formula fortified with 10 to 12 mg/L for weaning or supplementing breastmilk10
- All infants, including those exclusively breastfed, should have a minimum intake of 200 IU of vitamin D per day starting in the first 2 months of life.
The National Academy of Sciences recommends 200 IU of vitamin D daily for all normal infants, children, and adolescents.11
The US Preventative Services Task Force (USPSTF) states evidence is insufficient to recommend for or against the routine use of iron supplements for healthy infants.12
The USPSTF, AAP, and the American Academy of Pediatric Dentistry recommends 0.25 mg/d of fluoride supplement for children ages 6 months to 3 years if the fluoride concentration in the community drinking water is less than 0.3 ppm. Older children may benefit from supplements if the fluoride concentration is between 0.3 and 0.6 ppm.13
Breastfed and formula-fed infants should receive intramuscular vitamin K soon after birth to prevent classic hemorrhagic disease of the newborn (strength of recommendation [SOR]: A, systematic review of controlled trials).
Routine iron supplementation for all term, healthy, breastfed infants is not proven to be safe or necessary. Formula-fed infants should be consuming formula that contains 10 to 12 mg/L of iron (SOR: A, 2 small randomized controlled trials).
Healthy, term infants at the highest risk for vitamin D deficiency are those who are breastfeeding and have dark skin or little sun exposure (SOR: B, 2 case series). Infants consuming at least 500 mL of fortified formula each day do not need additional supplementation. A recommendation of vitamin D supplementation of 200 IU/day should be explained to all families, particularly those at highest risk for nutritional rickets (SOR: C, expert opinion). Infants older than 6 months should receive an oral fluoride supplement of 0.25 mg if they consume fluids with a water fluoride level less than 0.3 ppm (SOR: B, poor-quality randomized controlled trials).
Encourage breastfeeding; keep vitamin D and iron needs in mind
Julia Fashner, MD
Piqua, Ohio
Physicians can help mothers give the best nutrition to their children by encouraging breastfeeding. In most cases, no supplements are required. From this information, I will keep in mind the shorter hours of daylight in the winter and the skin tone of the child, as this may warrant discussion of vitamin D supplementation in infants who are exclusively breastfed. Knowing the recommendations for iron supplementation will help physicians when counseling parents regarding formula choices. Lastly, vitamin K has become part of the routine protocol at delivery and should not be a factor for any child.
Evidence summary
Vitamin K. The Cochrane Database of Systematic Reviews looked at randomized trials to determine the effectiveness of vitamin K prophylaxis in preventing classic hemorrhagic disease of the newborn.1 Two trials demonstrated that a single dose of intramuscular vitamin K reduced clinical bleeding at 1 to 7 days. Oral vitamin K has been studied for its effects on biochemical indices of coagulation status, but not for its clinical effects on bleeding. A single oral vitamin K dose at birth resulted in lower vitamin K levels at 2 weeks and 1 month, compared with a single dose of intramuscular vitamin K at birth.
Iron. The iron status of exclusively breastfed infants vs formula-fed infants was evaluated in a nonrandomized cohort study.2 Twenty-five healthy, breastfed infants and 15 healthy infants fed high-iron formula were followed for 9 months. No differences in mean hemoglobin values were seen at any age between the 2 groups.
A randomized controlled trial investigated the efficacy of daily and weekly iron supplementation on iron status in 67 exclusively breastfed infants.3 At age 4 months the infants were randomized into 3 groups: daily iron, weekly iron, and no iron. No significant differences were detected in the mean weight, height, and head circumference among the groups. The mean values of hemoglobin, mean corpuscular volume, serum iron, and transferrin saturation were similar among all the groups at ages 5, 6, and 7 months.
A randomized, double-blind, placebo-controlled iron supplementation trial involved 214 exclusively breastfed infants from 4 to 9 months of age in Sweden and Honduras.4 Iron supplementation did not affect weight gain in the groups, but length gain from ages 4 to 9 months was less in the iron-supplemented groups than in the placebo group (P<.05 for placebo vs Fe). This effect was greater in Sweden, and only existed in Honduras for infants aged 4 to 6 months with initial mean Hgb of at least 11 mg/dL. The researchers conclude that iron supplementation may pose risks in iron-replete infants.
Vitamin D. A case review of nutritional rickets in North Carolina between 1990 and 1999 found that all 30 patients identified were breastfed African American infants.5 Among the 166 published cases of rickets in the US from 1986 to 2003, 83% were categorized as African American or black. Ninety-six percent of cases were breastfed.6
Fluoride. No infant under 6 months of age should receive fluoride supplementation to prevent dental caries because of the risk of enamel fluorosis.7 A systematic review that evaluated fluoride for preventing dental caries in primary teeth in children aged <5 years found 6 small clinical trials. Although the studies were not of high quality, they consistently showed that the incidence of caries was reduced by 32% to 72%.8
Recommendations from others
The American Academy of Pediatrics (AAP) recommends that:
- All newborns receive vitamin K as an intramuscular dose of 0.5 to 1 mg9
- All full-term appropriate-for-gestational-age breastfed infants receive a supplemental source of iron starting at 4 to 6 months of age, preferably from iron-enriched complementary foods. Infants should only receive formula fortified with 10 to 12 mg/L for weaning or supplementing breastmilk10
- All infants, including those exclusively breastfed, should have a minimum intake of 200 IU of vitamin D per day starting in the first 2 months of life.
The National Academy of Sciences recommends 200 IU of vitamin D daily for all normal infants, children, and adolescents.11
The US Preventative Services Task Force (USPSTF) states evidence is insufficient to recommend for or against the routine use of iron supplements for healthy infants.12
The USPSTF, AAP, and the American Academy of Pediatric Dentistry recommends 0.25 mg/d of fluoride supplement for children ages 6 months to 3 years if the fluoride concentration in the community drinking water is less than 0.3 ppm. Older children may benefit from supplements if the fluoride concentration is between 0.3 and 0.6 ppm.13
1. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database Syst Rev 2000;(4):CD002776.-
2. Calvo EB, Galindo AC, Aspres NB. Iron status in exclusively breastfed infants. Pediatrics 1992;90:375-379.
3. Yurdakok K, Temiz F, Yalcin SS, Gumruk F. Efficacy of daily and weekly iron supplementation on iron status in exclusively breastfed infants. J Pediatr Hematol Oncol 2004;26:284-288.
4. Dewey KG, Domellof M, Cohen RJ, Landa Rivera L, Hernell O, Lonnerdal B. Iron supplementation affects growth and morbidity of breastfed infants: results of a randomized trial in Sweden and Honduras. J Nutr 2002;132:3249-3255.
5. Kreiter SR, Schwartz RP, Kirkman HN, Jr, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breastfed infants. J Pediatr 2000;137:153-157.
6. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. J Clin Nutr 2004;80:1697S-1705S.
7. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50:1-59.
8. Bader JD, Rozier G, Harris R, Lohr KN. Dental Caries Prevention: The Physician’s Role in Child Oral Health. Systematic Evidence Review no. 29. Rockville, Md: Agency for Healthcare Research and Quality, 2004. Available at: www.ahrq.gov/downloads/pub/prevent/pdfser/dentser.pdf. Accessed on November 15, 2005.
9. American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics 2003;112:191-192.
10. Gartner LM, Greer FR. Section on Breastfeeding and Committee on Nutrition, American Academy of Pediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003;111:908-910.
11. Institute of Medicine, Food and Nutrition Board, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Vitamin D. In: Dietary Reference Intakes: For Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997;250-287.
12. DiGuiseppi C. Screening for iron deficiency anemia-including iron prophylaxis. In: US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 1996:231–246. Available at: www.ahrq.gov/clinic/2ndcps/anemia.pdf. Accessed on November 15, 2005.
13. American Academy of Pediatric Dentistry. Special issue: reference manual 1994-95. Pediatric Dent 1995;16:1-96.
1. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database Syst Rev 2000;(4):CD002776.-
2. Calvo EB, Galindo AC, Aspres NB. Iron status in exclusively breastfed infants. Pediatrics 1992;90:375-379.
3. Yurdakok K, Temiz F, Yalcin SS, Gumruk F. Efficacy of daily and weekly iron supplementation on iron status in exclusively breastfed infants. J Pediatr Hematol Oncol 2004;26:284-288.
4. Dewey KG, Domellof M, Cohen RJ, Landa Rivera L, Hernell O, Lonnerdal B. Iron supplementation affects growth and morbidity of breastfed infants: results of a randomized trial in Sweden and Honduras. J Nutr 2002;132:3249-3255.
5. Kreiter SR, Schwartz RP, Kirkman HN, Jr, Charlton PA, Calikoglu AS, Davenport ML. Nutritional rickets in African American breastfed infants. J Pediatr 2000;137:153-157.
6. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. J Clin Nutr 2004;80:1697S-1705S.
7. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50:1-59.
8. Bader JD, Rozier G, Harris R, Lohr KN. Dental Caries Prevention: The Physician’s Role in Child Oral Health. Systematic Evidence Review no. 29. Rockville, Md: Agency for Healthcare Research and Quality, 2004. Available at: www.ahrq.gov/downloads/pub/prevent/pdfser/dentser.pdf. Accessed on November 15, 2005.
9. American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics 2003;112:191-192.
10. Gartner LM, Greer FR. Section on Breastfeeding and Committee on Nutrition, American Academy of Pediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003;111:908-910.
11. Institute of Medicine, Food and Nutrition Board, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Vitamin D. In: Dietary Reference Intakes: For Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997;250-287.
12. DiGuiseppi C. Screening for iron deficiency anemia-including iron prophylaxis. In: US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 1996:231–246. Available at: www.ahrq.gov/clinic/2ndcps/anemia.pdf. Accessed on November 15, 2005.
13. American Academy of Pediatric Dentistry. Special issue: reference manual 1994-95. Pediatric Dent 1995;16:1-96.
Evidence-based answers from the Family Physicians Inquiries Network