At what age should a breastfed or partially breastfed infant be started on Tri‑Vi‑Sol (multivitamin) supplementation?

Vitamin Supplementation for Breastfed Infants

Start Tri-Vi-Sol (multivitamin supplementation containing vitamins A, C, and D) at hospital discharge or within the first few days of life for breastfed infants, primarily to provide the required 400 IU of vitamin D daily.

Vitamin D Supplementation: The Primary Indication

All breastfed infants should receive 400 IU of vitamin D supplementation daily beginning at hospital discharge, regardless of whether they are exclusively or partially breastfed. 1 This recommendation addresses the critical gap between breast milk vitamin D content and infant requirements:

• Breast milk alone does not provide adequate vitamin D to meet the Dietary Reference Intake (DRI), creating the most significant vitamin deficiency risk in breastfed infants 2
• Vitamin D deficiency and rickets have increased in all infants due to decreased sunlight exposure from lifestyle changes, clothing practices, and sunscreen use 1
• Continue vitamin D supplementation at 400 IU daily throughout the entire breastfeeding period 1

Evidence for Early Initiation

Research demonstrates that vitamin D deficiency develops rapidly in exclusively breastfed infants without supplementation:

• In one study, 24% of exclusively breastfed infants aged 2-3 months had serum 25(OH)D concentrations below 27.5 nmol/L (deficient range) 3
• Winter-born infants showed median vitamin D levels of only 21 nmol/L at 2-3 months, compared to 75 nmol/L for summer-born infants 3
• These findings support immediate supplementation rather than waiting weeks or months 3

Iron Supplementation Timing

The timing for iron supplementation in Tri-Vi-Sol depends on the infant's gestational age and birth weight:

Term, Healthy Infants

For exclusively breastfed term infants, American guidelines recommend starting iron supplementation at 4 months of age at a dose of 1 mg/kg/day. 1 However, note the following:

• During the first 6 months, dietary iron requirements for exclusively breastfed term infants are extremely low (approximately 0.27 mg/day) 1
• Healthy term infants are initially almost independent of additional external iron until they have doubled their birth weight 1
• WHO and European guidelines recommend iron-rich foods or supplements after 6 months, citing insufficient evidence for routine supplementation at 4-6 months in low-prevalence populations 1

High-Risk Infants Requiring Earlier Iron

Start iron supplementation between 2-6 weeks of age for: 1

• Preterm infants born <32 weeks gestation: 2-3 mg/kg/day
• Low birth weight infants <2000 g: 2-3 mg/kg/day
• Marginally low birth weight infants 2000-2500 g: 1-2 mg/kg/day
• Small for gestational age infants needing catch-up growth
• Continue supplementation at least until 6 months of age 1

High-Risk Populations

In populations with low socioeconomic status or high anemia prevalence, iron supplementation from 4-6 months has demonstrated reduced anemia rates 1

Vitamin K: Critical First Dose

Administer intramuscular vitamin K1 (phytonadione) 0.5-1.0 mg on the first day of life to all infants. 1 This is separate from Tri-Vi-Sol:

• Give at birth to reduce the risk of vitamin K deficiency bleeding 1
• The dose may be delayed until after the first breastfeeding 1
• Oral vitamin K is not recommended due to variable absorption and inadequate stores 1
• Standard multivitamin preparations like Tri-Vi-Sol do not contain vitamin K 2

Other Vitamin Considerations

For healthy breastfed infants of well-nourished mothers, deficiencies of vitamins other than D and K are rare 2:

• Water-soluble vitamins (thiamin, pyridoxine, niacin) in breast milk correlate with maternal intake 2
• Standard multivitamin preparations contain large amounts of both water-soluble and fat-soluble vitamins that exceed the RDA 2

Practical Implementation Algorithm

For a standard term, healthy, breastfed infant:

1. Day 1 of life: Intramuscular vitamin K 0.5-1.0 mg 1
2. At hospital discharge: Begin Tri-Vi-Sol (or equivalent vitamin D 400 IU preparation) daily 1
3. At 4 months: Add iron supplementation 1 mg/kg/day if exclusively breastfed 1
4. Continue vitamin D: Throughout entire breastfeeding duration 1

For preterm or low birth weight infants:

1. Day 1: Intramuscular vitamin K 1
2. At discharge: Vitamin D 400 IU daily 1
3. At 2-6 weeks: Iron 2-3 mg/kg/day (dose based on birth weight category) 1
4. Continue both: At least until 6 months 1

Common Pitfalls to Avoid

• Do not delay vitamin D supplementation waiting for signs of deficiency—deficiency develops rapidly, particularly in winter months 3
• Do not assume sunlight exposure is adequate for vitamin D synthesis in modern lifestyles with sunscreen use and indoor activities 1
• Do not use oral vitamin K as a substitute for the intramuscular newborn dose 1
• Do not overlook iron needs in preterm infants—they require earlier and higher-dose supplementation than term infants 1
• Remember that standard Tri-Vi-Sol does not contain vitamin K—this must be given separately at birth 2