The Milk Transition/ Calcium requirements

 

What is calcium and why is it important

Let’s start with the basics: calcium is one of those behind-the-scenes nutrients that doesn’t get much hype, but it’s doing a ton of essential work for our body. Most people think of calcium as “the bone stuff,” and that’s true; it’s a major building block for strong bones and teeth. But calcium also helps your muscles move, your nerves send signals, and your heart to beat normally. In other words, it’s not just about skeletons. It’s about keeping the whole system running smoothly.

For babies and kids, calcium is especially important because their bodies are growing at warp speed. They’re literally building bones from scratch, and that early foundation matters for the rest of their lives. Getting enough calcium in infancy and childhood helps support healthy growth now and stronger bones later on. The reassuring part? Nature and modern nutrition make this pretty doable. Breast milk and formula are designed to meet babies’ needs early on, and as kids grow and their diets expand, calcium just becomes one more important piece of the overall nutrition puzzle.

Calcium Needs for infants

The calcium requirement for 0-6 month olds is 200 mg/day; for 6-12 month olds it bumps up slightly to 260 mg/day.

Very little thought or effort is needed to make sure they get enough at those ages. Babies who are growing well and feeding within the normal range will have no trouble getting their calcium needs met. The calcium in breast milk is quite ‘bioavailable’ meaning that it absorbs very well. Formula also has enough calcium to meet these needs.

A note on Cow’s Milk Protein Allergy

A small subset of babies will show signs of a cow’s milk protein allergy in the first few months of life, often around 2–4 months, but sometimes even earlier. This can look like persistent fussiness or pain with feeds, lots of spit-up or vomiting, blood or mucus in the stool, eczema or rashes, and sometimes poor weight gain. For breastfed babies, symptoms can still show up because tiny amounts of cow’s milk protein can pass through breast milk if a parent is consuming dairy; for formula-fed babies, it may become obvious soon after starting a standard cow’s-milk–based formula. If you’re seeing these patterns, it’s worth flagging for your pediatrician so you can make a plan together.

The really reassuring news - most babies with cow’s milk protein allergy outgrow it. The vast majority tolerate dairy again by late infancy or toddlerhood as their gut and immune system mature. In the meantime, there are great options (like hypoallergenic formulas or temporary dairy elimination) that keep babies comfortable and growing. This is one of those early-baby bumps in the road that feels huge in the moment, but for most families, it’s temporary.

4-7 months

At this age milk is still key. Until your little one is 6 months old, the only thing they technically really need is milk. Offering solids at this age is just for fun and exploration. The exception is a situation when allergens are recommended for some infants before 6 months due to risk of allergies. If you have more questions about solid foods, we did a huge post about this last year.

While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, cow’s milk lacks the correct balance of nutrients to be an appropriate substitute for formula or breast milk for kids under a year. To emphasize: limited cow’s milk products are fine, it just shouldn’t be the main nutritional source at this age.

When you do offer dairy products for the first time, watch carefully to make sure they don’t have any reactions (such as diarrhea or hives).

From 7-12 months ideally your baby has a mix of milk (breastmilk or formula) plus solids

We recognize that many parents stress about the exact balance of milk and food. The truth is, while milk is much more important for the first six months, at this age, there are no exact ratio requirements between milk and solids. Some kids are so excited by real food and others still prefer their milk. Your job is to offer both.

There are some simple common sense strategies.

Does your little one strongly prefer milk? Offer some solids first, before they fill up on the milk.

Are they only interested in solids? Offer the milk first.

But don’t let this drive you too crazy. As long as the baby is happy, growing, sleeping, pooping and peeing you can likely trust them. If your baby isn’t growing well then at that point it is worth checking in with your pediatrician to make a firm plan.

Blink and they are a year old! Calcium recruitment jumps up from 260 mg to 700 mg/day. At this age it is fine to expand your milk options.

Here are a few common questions and talking points

Are you still nursing? Great! There is nothing like breastmilk. Don’t be in a rush to stop. For those moms who are able to continue to breastfeed beyond the first year, that magical breast milk feels like a godsend if your child doesn’t feel well. Not only is nursing a comfort, but breastmilk is great for tummy bugs, eye issues and all sorts of stuff.

Do you have a huge stash of formula left over?

Great! Feel free to use it up. The only downside to formula at this age is the expense.

Do you need a toddler formula? We don’t think so. Toddler formulas are designed to help bridge the gap between infant formula and regular milk. We have never really seen the need for this step and many kids get constipated from some of the brands. If you do opt to go in that direction, make sure you keep an eye on the poops.

Dairy Milk Choices and Considerations

A lot of parents ask us, at one-year-old, “ok, so now that they’re one we have to switch to regular cow’s milk, right?”

Wrong.

Humans didn’t evolve a dependence on the bovine species. We have a need for calcium, vitamin D, fats and proteins. Whole fat cow’s milk just so happens to be an easy way to get those things, but it’s not the only way. Some kids skip milk altogether in favor of cheese and yogurt, or vegan options, and that’s fine.

Most kids who were on a milk-based formula have no trouble moving on to cow’s milk. It is fine to do it gradually so that they get used to the taste (add a few ounces to the formula and see how they do). Intolerance will likely show up as tummy aches, poop changes or rashes. Nurse Judy’s older daughter got a terrible flare up of eczema when she first switched her over to cow’s milk. They put her back on her formula for a couple of months and when they tried the milk again, she seemed to tolerate it just fine. We don’t have any clinical understanding for why this happened, but we have seen it happen with other patients over the years.

Do you need to offer whole milk?

This society is so conditioned to think that fat is bad, but your child actually needs all of that fat for their brain development. But if they are getting fat from other sources like full fat yogurt and cheese, it is fine to compromise and do 2% so that your fridge isn’t overrun with so many milk options.

The AAP has historically suggested moving all kids to reduced fat milk at 2 years, but this isn’t a hard and fast rule and can be assessed based on your child’s growth and needs.

Do you need to spring for Organic?

Our bias leans toward organic (we are skeptical of the hormones and antibiotics in non-organic milks), but there’s no good consistent evidence that organic milk leads to better health outcomes for kids.

What about raw milk?

Big NO From Us

Here, the studies are clear. Raw milk comes along with health risks. We would avoid it. The purported health benefits have not been consistently shown, they are theoretical and not worth the risk of E. Coli and Listeria.

Vat pasteurization seems to be safe.

What on earth is A2 Milk?

If you thought that the main choices about cow’s milk were organic or fat content, think again. Along comes the choice between A1 and A2. Huh???

It turns out that there are indeed two kinds of cows out there (don’t worry, there won’t be a test on the following paragraph). A1 and A2 beta-casein are genetic variants of the beta-casein milk protein. The A1 beta-casein type is the most common type found in cow’s milk in Europe (excluding France), the USA, Australia and New Zealand. This is what most of us have grown up drinking. African and Asian cows are predominantly A2 cows. Milk from goats and humans contains only the A2 beta-casein.

There was a lot of buzz about this when we first wrote this post several years ago. The claim is that folks who have trouble with our common (A1) milk may in fact be able to tolerate A2 milk without any issues. Nurse Judy rolled her eyes when it first came around, but she confessed that she has had some patients with milk intolerance who seem to do better on the A2 milk. In the past years, A2 milk has become more widely available at many grocery stores and doesn’t seem to be all that more expensive. For those of you with milk issues, it is worth checking out. https://www.a2milk.com/our-story

Non dairy milk alternatives

The array of plant based dairy alternatives has exploded over the last several years. Although the dairy industry did some grumbling about sharing the name, the FDA ruled that they are indeed allowed to call themselves milk. Fortunately, they are simultaneously mandated clearer labeling.

Below is a good guide to some of the popular options out there. There are big variations among the choices and these numbers vary by brand. If you decide to skip cow’s milk altogether, you won’t get a lecture from us as long as you are paying attention to the nutritional components. The key is making sure that your kids are getting adequate amounts of protein and calcium.

As you are reading those labels, watch out to make sure you aren’t getting a sweetened version that is adding all sorts of extra sugar.

Lets dive a little deeper into some of the nutritional considerations

Protein:

It is important to note that not all proteins are created equal.

Cows milk contains essential amino acids – the “building blocks” of protein – that our bodies need.

Except for soy milk, the protein in most nut or plant-based milk substitutes is incomplete, meaning it’s lacking in some of these essential amino acids. Since your body can’t produce essential amino acids on its own, it has to come from the choices you make in your daily diet - like dairy or soy milk. If you have a hard time getting your children to drink milk, it is important to make sure they are meeting those nutritional needs through other sources.

If you choose to use a milk alternative such as goat, soy, rice, almond, coconut or pea protein, read the labels and see how they compare.

Vitamin D

After age 1, kids need 600 IU of Vitamin D per day. In general: having the milk fortified with vitamin D is a bonus, but many kids either need a multivitamin supplement or a lot of high vitamin D foods. Milk fortified with vitamin D has 100-150 IU per cup, so if you’re sticking to 3 cups of milk per day as a maximum (see above) you’re only getting 300-450 IU daily. The rest needs to come from elsewhere. The best source is a bit of sunshine, but that comes with its own risks. The Vitamin D Post here has a chart with the amount of vitamin D from different foods.

Keep in mind that calcium absorbs better with Vitamin D so if you chose to supplement with vitamins try to take them together.

Iron and Milk

Iron isn’t something that you are going to be getting from most milk sources, but it is so important that we want to include some considerations in this post.

Cow’s milk does not have as much iron as formula, so it is important to make sure your little one is getting iron from other sources. In fact, as we discuss below, cow’s milk is notorious for actually blocking the absorption of iron. Iron is such an important but tricky nutrient. It absorbs much better with high vitamin C foods. Take a moment to review the Iron Post from several years ago.

If your little one is a picky eater, some physicians like to see a blood test result showing that the baby has an adequate hemoglobin level( a proxy for iron) before leaving the formula behind.

Is there such a thing as too much milk?

It is not uncommon for our little patients who are ‘milkaholics’ to be anemic. Due to its high casein and calcium content, excessive cow’s milk can block the absorption of the iron in the gut. This is even more of an issue for a vegetarian diet. At the same time, kids who fill up on milk instead of eating other foods with wider nutritious content can become even more anemic. This is why, with your toddlers, ideally keep milk intake under 24 ounces per day.

One more reason to pay attention to this? Anemic kids often have sleep issues. Cutting back on the milk can be an easy fix.

Dr. Ted’s Tidbit

The 24 oz per day milk limit is a tough concept. Every gut is different, and kids have wildly different needs based on their diet. What’s with all the fuss?

To add some scare to your milk motivation: I’ve seen milk-induced anemia in action. I’ve had patients that have wound up in the pediatric ICU with dangerously low hemoglobins that needed blood transfusions. Why does this happen?

In the child that I’m thinking of, they subsisted on essentially only milk (far over 36 oz per day), every day, with very little other food sources, except bread. There are a couple of theories as to why this happens. It’s known that cow’s milk can lead to increased intestinal blood loss (we all bleed a little into our guts, milk just makes us do it more). That blood takes iron with it. At the same time, studies have shown that unmodified casein protein in cow’s milk, as well as calcium, have the potential to bind with iron and limit its absorption, but mostly for none-heme iron (aka iron that’s not from meats or animals).

There’s still some ambiguity in these guidelines, but use the above science to direct how you approach nutrition. If you have a total milkaholic, the occasional 30oz day is ok if you pair it with hamburger meat. If you have a picky carb-atarian who skips meat, it might make sense to stick to the 24oz or under guidelines.

From Bottle to Cup

We personally don’t feel the need to be completely off of the bottle at 12 months. Until 18 months or so, we are perfectly fine with a snuggle bottle when first waking up or going to sleep.

But please keep this important rule:

NEVER leave a bottle of anything other than water in bed. If a child falls asleep and keeps the milk bottle in their mouth it will risk tooth decay.

After a year, try to transition most of the fluid intake to a cup. Once you start moving away from the bottle and transitioning to a cup you may find that your child doesn’t take in nearly as much milk. We couldn’t tell you why, but we have seen it over and over again. Milk in a cup just isn’t as comforting.

Some parents like to hold on to that bottle option just to make sure that their kids are getting at least some milk every day. In any case, once you lose the reliable amounts of milk that you used to count on from the bottle, it becomes even more important to pay attention to other sources of calcium.

If your little one is two and has managed to convince you that the bottle is essential, it is time for an intervention. It is time for that bottle to disappear. Consider making a big production about “gifting” all of your bottles to someone else’s baby. At the same time go out and pick out a special ‘big kid’ cup.

Sippy cups are not the best option. Straw cups are preferred.

Extra little tricks

If you are trying to encourage your child to drink the milk from a cup:

• Try adding a few drops of vanilla.

• Experiment with the temperature. Some kids might like it better warm.

• You can also try frothing it.

• Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender.

What about Calcium Supplements? Tums?

For most adults, the goal is to meet calcium needs through food first, with supplements used only to fill in the gaps if diet falls short. If you do supplement, smaller doses (like 500mg - 600mg per dose) work better than one big dose, and pairing calcium with enough vitamin D helps with absorption.

Specifically, we recommend against the regular use of Tums for calcium supplementation. While Tums does have calcium in it, it also suppresses stomach acid. If done regularly, it can cause rebound acid production in the stomach (ouch).

With a little planning, getting enough calcium should be reasonably easy.

Reference Section

High-Calcium Foods (per typical serving)

Note the spike during the growing years. If you have a teenage boy who seems to need a new pair of pants every 3 weeks, this will make perfect sense to you.

A snippet from my book/Keep the repair man off the roof

 As some of you know, several years ago I toyed with the idea of turning my collection of blog posts into a book. I certainly had plenty of content.

I was inspired by some of the people who told me that the posts have been something they counted on.

I organized my years worth of blog posts and wrote up a book proposition. That was as far as I got. The pandemic came along and I got caught up with the start-up world (Shout out to Oath Care; I miss you)

The inclination to put together a ‘Nurse Judy’ book simply got placed on the ‘back burner’.

But the urge to keep writing stayed with me and I am grateful to all of the readers out there who stuck with me.

My standard health related posts got peppered with more and more of the personal stories….and some of those stories are admittedly a bit bizarre.

I realized that those were the ones I wanted to write more of, so that’s exactly what I did.

I now have a completely different book that I am just about wrapping up.

The following is a random, tiny snippet:

Keep the repair man off the roof

Many buildings in San Francisco don’t have air conditioning. The hot days when it is really needed are generally limited. (That is one of the reasons I can never move.)

But some neighborhoods are warmer than others. Noe Valley, where I worked for so many years, is one of the sunnier neighborhoods and we were fortunate to have a building that actually had air conditioning. But it was an old building and the creaky heating and cooling system went on the fritz every so often.

In October 2009 (I know the date because I had jotted this anecdote down in my journal) the cooling system wasn’t working and the weather was HOT.

A repair man was called. When he finally showed up, he sought me out. My car was blocking his access to the roof. He needed to get up there in order to figure out exactly what was going on. He asked if I could quickly move my car to another spot.

“Sure”.

I finished up my call… which was likely giving phone advice about heat rash.

I got into my car, turned the key and found that the car wouldn’t start.

Of course the repairman had to try for himself. Then my boss needed to try but neither of them were able to get it started. It turned out that having a penis was not going to make a difference.

The repair man wasn’t going to wait around. He rescheduled for the following day. In the meantime, I had a dead car. Sandy volunteered to come after work to jump it in case it was the battery. In any case I was likely to need a ride home.

Shortly before I was done for the day Alana called to check in. At the time she was a student down in Santa Cruz. I mentioned the car situation.

There was a pause.

“Did the man make it onto the roof?”

“No, he is coming back tomorrow.”

“Good, he wasn’t supposed to get on the roof. The car should start now”

Excuse me?

I went out to the parking lot. Got into my car. I turned the key. The car started right up.

For the record, Alana has no idea why she said that.

The book is full of odd stories like this.

The next step is figuring out what to do with it.

Vitamin D/ The Sunshine Vitamin. Diving into the recent headlines

 

Food superstars come and go. One minute something is going to cure all of your ills and the next minute it might be considered poison (lets just hope that chocolate and wine stay on the beneficial foods list)!

Vitamin D has been on the ‘hero’ list for years, but has been all over the headlines recently.

You might have seen the teasers:

“Low levels of this vitamin are tied to more severe respiratory infections…tune in at 6 to learn which one.”

With recent studies being touted, we thought this would be a good time to take a deep dive into this important vitamin.

For many years, vitamin D deficiency was most associated with Rickets (a disease that causes very soft bones.) But recent studies found that vitamin D levels are also very important well beyond good bone health.

Deficiencies are associated with multiple illnesses including diabetes, cancer, heart disease…. It’s important to note that we are talking about associations, not causations. It’s not yet been shown, for example, that vitamin d supplementation could actually change your heart disease or cancer risk.

Researchers are exploring the link between low levels of D and obesity. There are ongoing studies underway to see if there is a link between low vitamin D levels and increased allergies. Other studies are associating vitamin D deficiency with insomnia and mood disorders. There have also been studies linking vitamin D and cognitive health in older folks. This list goes on and on.

Dr. Nayana Anne, a board certified Integrative Medicine Doctor at Getzwell Pediatrics in San Francisco is a big fan. She highlights that it has been explored as a possible adjunct in some patients with ADHD, particularly those with deficiency. Vitamin D has the potential to improve neurotransmitter regulation, cognitive function and treatment response to other ADHD medications.

She also uses it for her patients who suffer from migraines. Anecdotally they appear to have a reduced number of attacks with lower severity when supplementing with vitamin D.

Dosing and Recommendation

Vitamin D is measured in international units (IU). The American Academy of Pediatrics recommends that all babies start getting 400 IU daily.

Note: there are 2 forms of vitamin D - D2 and D3. Most experts are in favor of focusing on D3, which is the more natural form. D2 is less stable and less clinically useful in humans.

American infant formulas are fortified to include vitamin D3. Babies who get 32 ounces of formula per day have their needs covered. So, as long as they are on full formula you don’t need to worry about it, but combo feeding with breastmilk and formula might not be enough to meet daily needs.

If your baby is breastfed, that is a different story. Unfortunately, the segment of the population who often test the lowest for vitamin D are pregnant and breastfeeding women.

It would be nice to believe that breast milk is a “complete source” for all of your baby’s needs, but with vitamin D this is not necessarily the case. If you are a nursing mom and you are deficient, your baby is simply not getting the amount that they need from your milk. If mom has a good level, her milk might be adequate but there are no good reasons to take a chance.

There are some studies that claim that if a nursing mom takes 6,400 IU/daily, this can adequately fortify the milk and ensure that the baby is getting the suggested amount of 400 IU.

But be careful because 6,400 IU daily is much higher than the recommended daily dose, so make sure you’re calculating where else you’re getting it from. It can add up if you are getting it from multiple sources. If you get close to 10,000 IU daily, you may be approaching toxic levels, enough to cause calcium overload and kidney dysfunction.

Giving vitamin D drops directly to the baby can take the guesswork out of this and remains the AAP recommendation.

Vitamin D Brands

There are many different brands available for your baby. If you are giving your baby a multivitamin supplement like Poly-Vi-Sol, that already has the D in it. If you are giving the D alone, one of the most common brands is the Enfamil D-Vi-SOL. One dropper is 1 ml; this gives the daily dose of 400 IU. Babies seem to tolerate this well.

There are some other forms out there that give 400 IU in each drop! That is quite a difference. It is essential that you be a careful label reader! Dr. Ted likes Wellements or Baby D drops because they’re organic, and it’s easier to use one drop that you can put right on the nipple prior to putting the baby on the breast.

Yes, we have gotten calls from parents absolutely freaking out because they don’t recall being told about this when their babies were newborn.

There is a lot that goes on during the first couple of visits and it is easy enough for things to get overlooked.

If you are just hearing about this for the first time and your baby missed the first few months, please don’t stress. Vitamin D crosses the placenta and hangs around for 2-3 weeks after birth, so if you were on a prenatal vitamin, your baby likely did get some from that.

Because vitamin D is fat-soluble and stored in the body, it’s important not to megadose with supplements—but the amounts typically recommended are very safe.

On the other hand, be assured that you cannot get “too much” from natural sources such as the sun or diet.

It’s not just babies who need it

Getting Vitamin D is not just a recommendation for newborns; it is a lifelong health issue.

Children over the age of one, and all adults, should make sure they are at the very least getting 600 IU daily. The recommendation increases to 800 IU for adults over 70 to support bone health and reduce fracture risk.

Dr Anne likes Pure vit D. One drop is 1,000 IU. It has excellent absorption compared to other forms because it bypasses the GI tract. Take after a fatty meal for best results.

There are also yummy gummies that are 1,000 units if that is the easiest way to get your kid to cooperate.

Although the recommendation is for 600 IU daily, we have no concerns of bumping the dose up to 1,000 IU, as this is still well within the tolerable safety window for 6 months and older.

Why are so many of us deficient?

At the same time that scientists were recognizing the importance of Vitamin D, they were also discovering that many folks are deficient without even being aware of it.

Historically much of our vitamin D is/was from sun exposure.

Honestly the biggest shift is that human no longer live outside like our earlier ancestors! It turns out that roofs are more convenient (they block the rain, etc…) but they also block our access to the optimal amount of sun exposure.

The rays of natural sunlight that produce vitamin D in your skin cannot penetrate glass. This means you can’t get vitamin D from indirect sunlight in your car or at home.

Folks who live in sunny climates generally have higher levels. Darker pigmented skin has a harder time absorbing it. Some dermatologists think that being out in the sun unprotected for 30 minutes, 2 or 3 times a week, would probably give most people the amount they need, but this depends a lot on latitude, season, how much skin is covered by clothing, time of day, etc.

What impact does sunscreen have? Not as much as you might think. If sunscreen were applied *perfectly* it would in fact block the skin’s ability to produce vitamin D. To apply it appropriately, you need to apply liberally, evenly, and reapply every 2 hours. However, most real-world observational studies of this in humans show that we are too ineffective at thoroughly applying sunscreen to make a clinically meaningful difference in vitamin D production.

Some exposure is healthy, but overdoing it is problematic. It is hard to find a balance. Sunburn and an elevated risk of skin cancer don’t seem like a sensible answer, when there are so many easy ways to take a supplement.

Checking Vitamin D Levels

It isn’t a bad idea to know what your level is. The next time you are getting routine blood work, consider asking your doc to add an order for the vitamin D level. The recommended test usually ordered is a 25-hydroxy vitamin D level. There is some debate about what the proper level should actually be, but most people seem to agree that:

• < 12ng/mL is severely deficient (measurement is nanograms/milliliter)

• 12-20 ng/mL is still not adequate

• 20-50ng/mL is a reasonable range of normal

• >75ng/mL is the level where many naturopaths recommend you to aspire to. There might be something to this. Some of the recent studies on vitamin D and respiratory tract infections (referenced above) show a significantly lower risk of severe disease at this level when compared to people with less than 15 ng/mL

Be aware! 40% of folks tested in this country are low!! Please make sure that you and your baby are not one of those.

Special Considerations for Bone Surgery

Dr. Nicole Cates is an amazing podiatrist in San Francisco. Because she deals with bones and fractures, she takes vitamin D very seriously and checks the levels of all of her pre-op patients. She also checks their parathyroid hormone and calcium, as they’re closely related to vitamin D and bone health.

She was kind enough to share the following slide:

It’s worth noting that the vitamin D level needed for elective bone surgery here may be higher than the average person needs in everyday life.

So here is a public service announcement, if you are having any upcoming orthopedic procedures, or dental implants, it may be even more important to pay attention to your vitamin D levels.

Natural sources

As you can see from the chart below, milk that has D added, some fatty fish, and cod liver oil are on the short list of good dietary sources for vitamin D, but a person would have to drink four tall glasses of vitamin D fortified milk each day just to get minimum levels of vitamin D into their diet, which is still a lot of milk.

Other foods like some mushrooms and eggs will get you a bit, but not enough to begin to make a dent in the daily requirement:

Note: some farmed mushrooms can be intentionally exposed to UV light to increase vitamin D levels, but mushrooms produce the less useful D2 form of Vitamin D, making it not as reliable when compared to other sources.

Without exposing yourself to sunshine it isn’t so easy to get adequate amounts without the help of a supplement!

But what about the recent headlines? Is there actually anything new?

Yes. Kind of.

The conclusion from the recent research is that higher vitamin D levels are indeed associated with a lower risk of severe acute respiratory tract infections. The study was a large-scale meta-analysis using more than 36,000 participants.

Bottom line, to no one’s surprise, low levels are associated with worse outcomes. High levels are associated with better outcomes. There isn’t robust data for outcomes with “normal” levels, such as those from 20-75, as described above, so we don’t know either way.

But there is so much tantalizing research going on about Vitamin D as an option for immune system health, that we couldn’t stop ourselves from going down lots of rabbit holes (other people get coffee, we look at data).

There was a lot there.

Why Might Vitamin D Be So Helpful, Molecularly?

At a cellular level, vitamin D seems to play a quiet but meaningful role in how our immune system responds to respiratory infections.

Studies show that immune cells lining the airways convert vitamin D into its active form. When vitamin D is present and activated, these cells increase production of antimicrobial chemicals which can directly disrupt viruses and bacteria.

Vitamin D also seems to help fine-tune the immune response, dialing down excessive inflammation while preserving the parts of the immune system needed to clear infection.

Together, these effects have led researchers to hypothesize that adequate vitamin D levels may not prevent respiratory infections outright, but could help reduce their severity by strengthening first-line defenses and limiting the kind of runaway inflammation that makes illnesses like the flu or RSV feel so miserable.

It looks promising. We speculate that future headlines may tout more definitive benefits.

Concluding Thoughts

While the study making the headlines only looks at correlation, it certainly doesn’t hurt to make sure our babies and families are getting enough, especially with flu and other respiratory illnesses circulating.

Of course Vitamin D is no magic bullet! (Both of us still do take it daily) But if taken in safe doses it is associated with good health with very little downside.

Feeling overwhelmed? Here are some useful tips for identifying and managing stress

 Feeling stressed out? Welcome to the club!

These days many people are experiencing a lot of anxiety/stress/guilt (fill in your pesky emotion of choice here). We often don’t need to look very hard to find triggers. Just turn on the news.

If you have moments of feeling overwhelmed, you are not alone. Let me assure you that you are, in fact, in the large majority. It is actually the rare being who is sailing along without a care in the world.

My daughter Alana is a mental health therapist here in San Francisco. Her advice is to give yourself permission to feel all of your emotions to the fullest. As she puts it, invite those feelings in for tea, just don’t let them overstay their welcome. At this little tea party, when you are ready, request the presence of your problem solving brain to join you at the table.

The first thing I will have you do is to remind yourself that there are some things that are within your control and some that are not. It is essential to be able to identify which is which:

Things Out of our control

• Others being kind

• Others being honest

• Others forgiving us

• Who likes us

• The family we were born into

• The color of our skin

• Past mistakes

• Pandemics

• Natural disasters

• Death

• Taxes

• Power hungry dictators

• Other people making poor choices

• Family members who believe in conspiracy theories

Things that are in our control

• Being kind

• Being honest

• Being grateful for the good things in our lives

• Friends we choose

• Taking care of ourselves

• Working hard

• Apologizing

• Asking for help

• How we respond to others

• What we do in our free time

• Volunteering our time (if you have a surplus)

• Donating to a worthy cause (if your own needs are met)

• Seeking out joy

• Voting

• Taking common sense health precautions

• Problem solving your situation. Identifying and taking that first step.

Of course feel free to add to either list. The key is to shift your focus to the things where you have some agency.

Second, let’s evaluate your stress level.

My kids grew up having to deal with all of mom’s theories. This ‘stress theory’ is one of the classics. It is loosely based on something called the Holmes and Rahe stress measurement tool

Is there a water bottle or tea cup nearby? Take a look at it; imagine that you are that container. It is not transparent so you can not easily see how much liquid is inside.

Now imagine that elements of your life are varying amounts of fluid. Every aspect of your life adds liquid to the bottle. Good things and bad things can all contribute to the amount of stress.

There are 3 levels that would correspond to mild, moderate or high stress. Obviously the more fluid in the bottle, the higher the stress level.

Some amount of stress is perfectly normal and it just means you are living!

Certain things may add a few ounces, others only a tiny drop (drops can add up!) Being chronically short staffed at work? An illness in the family? Planning a wedding? Moving? Considering a job change? Having a baby? These big ones can fill your container right up before you notice.

We generally don’t pay too much attention to how full our bottle is until it is near the top. As I mentioned, the smallest drop, something that normally you could handle with no problem, can move you from one level to the next.

If you are near the top, it may make the entire bottle overflow.

This is the proverbial straw that broke the camel’s back. Are you crying because you burnt your toast? Your partner left dishes in the sink? You got honked at for sitting an extra second once the light turned green? A co-worker directed their grumpiness at you?

Take a moment to figure out what is going on that has your bottle so full that the littlest thing can set you off. Make a mental list of all the things that are filling up your bottle. Write them down if that is helpful.

There is often some validation when you recognize how much all the things you are dealing with pile up. This can help make sense of why you feel like you want to curl up and ‘ugly cry’ on the shower floor.

Alana shares this exercise with her clients. One of them really took it to heart and came up with the term “dump the cup.” In other words, are there things that can lower the level (don’t underestimate the power of those tears in the bathroom) ?

What can you do to dump out your container a bit? Arrange a little time for yourself? Take a walk? Find a pet to snuggle? Have the perfect cup of tea? Communicate what you are feeling to your support system? Sometimes just getting things down in writing is a good start.

Everyone who you interact with has their own stress level. It is good to keep that in mind when someone seems to be ‘overreacting’. If someone is in pain, or frustrated about something going on in their life, they are going to have a harder time staying calm.

Toddlers might just be hungry!

You may be running with the pack if you are experiencing extra stress, but you are quite unique in how different things might impact you. People react to different stressors in different ways. Something that drives you nuts, might slide right off of the back of your partner and vice versa.

As this old saying goes:

“The same boiling water that softens the potato will harden an egg”

Some people are much more sensitive to lack of sleep or being constantly interrupted while others just roll with it.

Some people are frantic if the house hasn’t been vacuumed, while others couldn’t care less and will get to it when they get to it.

The key is figuring out how YOU tick. What adds stress and what eases things.

The third aspect

Try to stay grounded in the present.

Is part of your stress from guilt or regret from recent decisions or actions?

Did you decide to go out to dinner with friends and now you have covid? Is your toddler parroting some colorful language that they picked up from your frustrating drive home yesterday?

Here is an important public service announcement (and one of my husband’s favorite pieces of wisdom he would regularly impart to his employees):

“You can’t manage the past”

Rather than doing the woulda shoulda coulda dance, don’t spend your energy there. Instead learn any lessons and move on.

In closing, one of my mom’s favorite adages was:

“It is what it is and you do the best you can” In other words, don’t be too hard on yourself!

She also had the premise that when she was feeling blue, she would get up, brush her hair and put on some lipstick. Just those simple actions could change the trajectory and give her a better outlook.

I hope one or all of these little tools can help you find your footing.

Forwarded this email? Subscribe here for more The desire to treat things as naturally as possible, combined with data and a large dollop of common sense. Feeling overwhelmed? Here are some useful tips for identifying and managing stress Nurse Judy Jan 23   READ IN APP   Feeling stressed out? Welcome to the club! These days many people are experiencing a lot of anxiety/stress/guilt (fill in your pesky emotion of choice here). We often don’t need to look very hard to find triggers. Just turn on the news. Thanks for reading Nurse Judy’s Substack! Subscribe for free to receive new posts Pledge your support If you have moments of feeling overwhelmed, you are not alone. Let me assure you that you are, in fact, in the large majority. It is actually the rare being who is sailing along without a care in the world. My daughter Alana is a mental health therapist here in San Francisco. Her advice is to give yourself permission to feel all of your emotions to the fullest. As she puts it, invite those feelings in for tea, just don’t let them overstay their welcome. At this little tea party, when you are ready, request the presence of your problem solving brain to join you at the table. The first thing I will have you do is to remind yourself that there are some things that are within your control and some that are not. It is essential to be able to identify which is which: Things Out of our control Others being kind Others being honest Others forgiving us Who likes us The family we were born into The color of our skin Past mistakes Pandemics Natural disasters Death Taxes Power hungry dictators Other people making poor choices Family members who believe in conspiracy theories Things that are in our control Being kind Being honest Being grateful for the good things in our lives Friends we choose Taking care of ourselves Working hard Apologizing Asking for help How we respond to others What we do in our free time Volunteering our time (if you have a surplus) Donating to a worthy cause (if your own needs are met) Seeking out joy Voting Taking common sense health precautions Problem solving your situation. Identifying and taking that first step. Of course feel free to add to either list. The key is to shift your focus to the things where you have some agency. Second, let’s evaluate your stress level. My kids grew up having to deal with all of mom’s theories. This ‘stress theory’ is one of the classics. It is loosely based on something called the Holmes and Rahe stress measurement tool Is there a water bottle or tea cup nearby? Take a look at it; imagine that you are that container. It is not transparent so you can not easily see how much liquid is inside. Now imagine that elements of your life are varying amounts of fluid. Every aspect of your life adds liquid to the bottle. Good things and bad things can all contribute to the amount of stress. There are 3 levels that would correspond to mild, moderate or high stress. Obviously the more fluid in the bottle, the higher the stress level. Some amount of stress is perfectly normal and it just means you are living! Certain things may add a few ounces, others only a tiny drop (drops can add up!) Being chronically short staffed at work? An illness in the family? Planning a wedding? Moving? Considering a job change? Having a baby? These big ones can fill your container right up before you notice. We generally don’t pay too much attention to how full our bottle is until it is near the top. As I mentioned, the smallest drop, something that normally you could handle with no problem, can move you from one level to the next. If you are near the top, it may make the entire bottle overflow. This is the proverbial straw that broke the camel’s back. Are you crying because you burnt your toast? Your partner left dishes in the sink? You got honked at for sitting an extra second once the light turned green? A co-worker directed their grumpiness at you? Take a moment to figure out what is going on that has your bottle so full that the littlest thing can set you off. Make a mental list of all the things that are filling up your bottle. Write them down if that is helpful. There is often some validation when you recognize how much all the things you are dealing with pile up. This can help make sense of why you feel like you want to curl up and ‘ugly cry’ on the shower floor. Alana shares this exercise with her clients. One of them really took it to heart and came up with the term “dump the cup.” In other words, are there things that can lower the level (don’t underestimate the power of those tears in the bathroom) ? What can you do to dump out your container a bit? Arrange a little time for yourself? Take a walk? Find a pet to snuggle? Have the perfect cup of tea? Communicate what you are feeling to your support system? Sometimes just getting things down in writing is a good start. Everyone who you interact with has their own stress level. It is good to keep that in mind when someone seems to be ‘overreacting’. If someone is in pain, or frustrated about something going on in their life, they are going to have a harder time staying calm. Toddlers might just be hungry! You may be running with the pack if you are experiencing extra stress, but you are quite unique in how different things might impact you. People react to different stressors in different ways. Something that drives you nuts, might slide right off of the back of your partner and vice versa. As this old saying goes: “The same boiling water that softens the potato will harden an egg” Some people are much more sensitive to lack of sleep or being constantly interrupted while others just roll with it. Some people are frantic if the house hasn’t been vacuumed, while others couldn’t care less and will get to it when they get to it. The key is figuring out how YOU tick. What adds stress and what eases things. The third aspect Try to stay grounded in the present. Is part of your stress from guilt or regret from recent decisions or actions? Did you decide to go out to dinner with friends and now you have covid? Is your toddler parroting some colorful language that they picked up from your frustrating drive home yesterday? Here is an important public service announcement (and one of my husband’s favorite pieces of wisdom he would regularly impart to his employees): “You can’t manage the past” Rather than doing the woulda shoulda coulda dance, don’t spend your energy there. Instead learn any lessons and move on. In closing, one of my mom’s favorite adages was: “It is what it is and you do the best you can” In other words, don’t be too hard on yourself! She also had the premise that when she was feeling blue, she would get up, brush her hair and put on some lipstick. Just those simple actions could change the trajectory and give her a better outlook. I hope one or all of these little tools can help you find your footing.